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Amongst nephron-sparing surgical options for treatment of renal cell carcinoma, partial nephrectomy (PN) is the standard of care. Two recently emerging phenomena in the field of PN surgery are driven by robotic surgery: (a) increased utilization of PN in the field and (b) recent technical innovations in the technical aspects of PN surgery. In this chapter, we discuss advanced techniques for PN surgery, such as tumor-specific super-selective clamping PN and minimal-margin zero-ischemia PN, as well as use of intraoperative imaging modalities, such as laparoscopic Doppler ultrasound and vascular fluorescence imaging with indigo-cyanine dye, that are used to propagate these advanced PN techniques.

Background Level II–III inferior vena cava (IVC) tumor thrombectomy for renal cell carcinoma is among the most challenging urologic oncologic surgeries. In 2015, we reported the initial series of robot-assisted level III caval thrombectomy. Objective To describe our University of Southern California technique in a step-by-step fashion for robot-assisted IVC level II–III tumor thrombectomy. Design, setting, and participants Twenty-five selected patients with renal neoplasm and level II–III IVC tumor thrombus underwent robot-assisted surgery with a minimum 1-yr follow-up (July 2011 to March 2015). Surgical procedure Our standardized anatomic-based "IVC-first, kidney-last" technique for robot-assisted IVC thrombectomy focuses on minimizing the chances of an intraoperative tumor thromboembolism and major hemorrhage. Outcome measurements and statistical analysis Baseline demographics, pathology data, 90-d and 1-yr complications, and oncologic outcomes at last follow-up were assessed. Results and limitations Robot-assisted IVC thrombectomy was successful in 24 patients (96%) (level III: n =11; level II: n =13); one patient was electively converted to open surgery for failure to progress. Median data included operative time of 4.5h, estimated blood loss was 240ml, hospital stay 4 d; five patients (21%) received intraoperative blood transfusion. All surgical margins were negative. Complications occurred in four patients (17%): two were Clavien 2, one was Clavien 3a, and one was Clavien 3b. All patients were alive at a 16-mo median follow-up (range: 12–39 mo). Conclusions Robotic IVC tumor thrombectomy is feasible for level II–III thrombi. To maximize intraoperative safety and chances of success, a thorough understanding of applied anatomy and altered vascular collateral flow channels, careful patient selection, meticulous cross-sectional imaging, and a highly experienced robotic team are essential. Patient summary We present the detailed operative steps of a new minimally invasive robot-assisted surgical approach to treat patients with advanced kidney cancer. This type of surgery can be performed safely with low blood loss and excellent outcomes. Even patients with advanced kidney cancer could now benefit from robotic surgery with a quicker recovery.