Robotic partial nephrectomy is inching toward the gold standard for small renal masses—a narrative review

Abstract

Background and Objective

Management of small renal masses has changed significantly since the concept of radical nephrectomy for kidney cancer was described in 1969. As improved imaging allowed the early detection of small renal masses, minimally invasive partial nephrectomies became the standard treatment to preserves kidney function. The DaVinci robotic platform allowed many of these surgeries to be performed robotically, with the aid of new technologies that refine dissection. The purpose of this review is to describe the progression of partial nephrectomy technique over time and its impact on patient outcomes.

Methods

PubMed was searched for all studies tracking the change in proportion of partial nephrectomies based on surgical approach from 2000–2026. The search was limited to English language studies. Studies that did not describe the proportion of robotic partial nephrectomies were excluded. A non-systemic literature review was then performed using keywords associated with associated advances in surgical approach and technology.

Key Content and Findings

Early partial nephrectomies were predominantly performed through open surgery. In the early 21st century there was a small growth in laparoscopic surgery, which was quickly overtaken by robotic partial nephrectomy after the introduction of the DaVinci robot in the early 2000s. Robotic partial nephrectomy would become the predominant surgical approach by the early 2010s in the United States. This trend would be mirrored internationally, albeit with slower adoption of the robotics. The predominance of robotic partial nephrectomy can be attributed to superior post-operative outcomes, mediated by the integration of new technology into the robotic platform.

Conclusions

Partial nephrectomy has become a guideline recognized standard for managing small renal masses. The robotic approach has become favored due to superior post-operative outcomes mediated by advances in technology and surgical technique. Further advances are expected to refine the robotic partial nephrectomy, inching it towards the clinical “gold standard”.

Introduction

The management of small renal masses has undergone significant change during the 21^st century on account of evolving technology. The initial standard of care for any renal mass was radical nephrectomy (1). However, improved imaging technology led to an increased detection of stage 1 disease, which was found to predict improved relative survival likely secondary to early treatment (2). Furthermore, nephron sparing surgery was found to reduce the risk of severe chronic kidney disease (CKD) compared to radical nephrectomy for localized tumors, while providing roughly equivalent oncologic results (3-5). A study by Thompson et al. found that partial nephrectomy was associated with better overall survival than radical nephrectomy in younger patients, possibly due to the avoidance of renal and cardiovascular morbidity (6). In 2009, the American Urological Association introduced guidelines advocating for partial nephrectomy to be the clinical standard for stage T1a renal masses to preserve renal function in this new clinical context (7). This corresponded with a significant increase in partial nephrectomies performed (8).

Alongside this shift in management, there was a corresponding evolution in surgical technology, with more kidney masses being treated with laparoscopic, and subsequently robotic surgery. When compared to open partial nephrectomy (OPN), minimally invasive partial nephrectomies have been shown to improve blood loss, hospital stay and rate of major complications (9). Laparoscopic partial nephrectomies (LPNs) improved blood loss and hospital stay compared to open nephrectomy, but unfortunately the technical difficulty of the procedure resulted in an overall increase in complication rates (10). On the other hand, robotic assisted partial nephrectomy (RAPN) has a lower complication rate alongside a shorter hospital stay and lower blood loss compared to open surgery (11). The introduction of the da Vinci Surgical System greatly improved the learning curve for RAPN, with its improved optics and ergonomics overcoming the difficulties of laparoscopy (12).

Given these advances, RAPN was swiftly adopted across urological practices. Ghani et al. performed the first analysis of practice patterns and outcomes for minimally invasive partial nephrectomy using the Nationwide Inpatient Sample, showing that RAPN had an annual increase of 45.4% in 2010 compared to 6.1% for LPN and 7.9% for OPN (13). The propagation of robotic surgery has also facilitated the integration of technology enabling more precise dissection, such as near infrared fluorescence imaging with indocyanine green (ICG) and intra-operative ultrasound (US) visualization of the renal mass. The purpose of this narrative review is to describe the changing management of small renal masses in response to the progression of surgical technology, with a focus on the benefit of these changes for patient outcomes. We present this article in accordance with the Narrative Review reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0239/rc).

Methods

A single author queried the PubMed database using the following query: “partial nephrectomy” AND (“robot” OR “robotic” OR “robot-assisted” OR “robot assisted”) AND (“trends” OR “utilization” OR “practice patterns” OR “use” OR “usage” OR “adoption”).

Studies were screened to include papers describing the relative proportion of OPN, LPN, and RAPN across all partial nephrectomies performed during a defined period. Articles from 1/1/2000 to 1/27/2026 were included. Exclusion criteria included a lack of evaluation on the prevalence of robotic partial nephrectomy and non-English papers. The references of the included articles were also screened to broaden the scope of the literature search.

Data regarding perioperative and long-term outcomes were extracted from the included articles when relevant. We performed non-systemic literature reviews of partial nephrectomy outcomes, costs, use of intra-operative ultrasound, and use of ICG with an emphasis on prior systemic reviews and meta-analyses. Articles with level 1–3 evidence were included in this review, with select case series included to discuss new concepts. The objective was to synthesize data on factors underlying the changing trends in surgical approach. An outline of our search strategy is displayed in Table 1.

Table 1. Literature review search strategy summary.

Items	Specification
Date of search	Up to 1/27/26
Database searched	PubMed
Search terms used	“Partial nephrectomy” AND (“robot” OR “robotic” OR “robot-assisted” OR “robot assisted”) AND (“trends” OR “utilization” OR “practice patterns” OR “use” OR “usage” OR “adoption”)
Timeframe	1/1/2000–1/27/2026
Inclusion criteria	Population level data that reported approach as proportion of total partial nephrectomies by year
Exclusion criteria	Lack of evaluation on prevalence of robotic partial nephrectomy; non-English language
Selection process	All articles were reviewed by first author M.X. prior to inclusion

A brief timeline of the development of robotic partial nephrectomy

The first successful nephrectomy and partial nephrectomy for cancer were performed in 1875 by Langenbuch and 1887 by Czerny, respectively (14). In 1969, Robson et al. described the modern radical nephrectomy with ipsilateral adrenalectomy as the gold standard surgery for kidney cancer (1). In 1993, Licht and Novick reported the first positive outcomes of partial nephrectomy sourced from the literature, as partial nephrectomy had only been sparingly used at that point (15). Partial nephrectomy became more widely accepted as a treatment for T1 disease in the late 1990s after clinical trials showed acceptable oncological outcomes and complications (16-18). Laparoscopic radical nephrectomy and partial nephrectomy were described in 1991 and 1992 respectively by Clayman’s group (19,20). Robotic partial nephrectomy was first described in a small case series by Gettman et al. in 2004, which showed feasible tumor removal through both the transperitoneal and retroperitoneal approach (21). Since then, RAPN has been enhanced by technological developments, including the first report of Tilepro intra-operative ultrasound in 2008 by Bhayani and the first use of near-infrared fluorescence with ICG to identify tumor in 2011 by Tobis (22,23). RAPN has even been integrated into telesurgery, with Yu et al. reporting successful remote partial nephrectomy in 2024 as part of a multicenter study on telesurgery in urology (24). A timeline of the progress of RAPN is included in Figure 1.

Figure 1.

Timeline of technological progression of partial nephrectomy (1,16,19-29). ICG, indocyanine green; RAPN, robotic assisted partial nephrectomy.

Growing use of minimally invasive partial nephrectomy for small renal masses

Partial nephrectomy became widely utilized for T1 masses at academic centers, though trends from national databases suggested underutilization in the 2000s (30). However, minimally invasive partial nephrectomy appears to have played a role in improving utilization. Kowalczyk et al. performed the first chronological study analyzing the uptake of minimally invasive partial nephrectomy, focusing on T1a masses immediately after the introduction of robotic surgery (31). 1682 patients were identified via the Surveillance, Epidemiology and End Results (SEER) database between 2005 and 2007, with 404 receiving open radical nephrectomy, 535 receiving minimally invasive radical nephrectomy, 330 receiving OPN, 160 receiving minimally invasive partial nephrectomy, 211 receiving ablation and 42 on surveillance. The use of minimally invasive (34.1% to 30.7%) and open radical nephrectomy (28.7% to 21.2%) decreased over the study period, while the rate of minimally invasive (8.4% to 9.9%) and OPN (20.7% to 20.2%) remained relatively stable. The authors did not differentiate between robotic and LPN due to the limitations of SEER database coding, but the time frame of data collection suggests that robotic surgery was not yet widely adopted.

Liu et al. then used the National Surgical Quality Improvement Program database to examine the adoption of minimally invasive partial nephrectomy from 2005 to 2011 amongst all surgeries for renal masses. Laparoscopic and robotic partial nephrectomies combined to account for 57% of all partial nephrectomies by 2011, whereas they were virtually unaccounted for prior to 2007 (32). Similar trends occurred with radical nephrectomy, though the minimally invasive approach showed earlier uptake in 2005, and the overall proportion of radical nephrectomies decreased through the study. Increased use of minimally invasive partial nephrectomy corresponded with a greater overall prevalence of partial nephrectomy over the study, suggesting that minimally invasive techniques may contribute towards increased utilization.

The trend of reduced radical nephrectomy for T1 masses would continue. Singh et al. reviewed the management T1 renal masses from 2000–2021 via the SEER database, finding that partial nephrectomy increased from 16% to 57% while radical nephrectomy decreased from 84% to 33% (33). Radical nephrectomy remained the predominant treatment choice for tumors over 4 cm. On multivariable regression, older age, larger tumors, rare histology, and non-white ethnicity were predictive of reduced likelihood of receiving partial nephrectomy compared to radical nephrectomy, with the older patients specifically more likely to receive ablation therapy. Higher income, metropolitan location, and a later year of diagnosis were predictive of increased likelihood of receiving partial nephrectomy. This data suggests that socioeconomic factors may continue to present barriers to receiving partial nephrectomy for T1 disease, though this effect may be mediated by the diffusion of RAPN and changing guidelines beginning in the mid to late 2000s.

The progression of minimally invasive surgery for localized renal cancer would ultimately shift towards robotics. Pietropaolo et al. reviewed the literature for publications in surgery and ablation for kidney cancer from 2000–2015, using the number of articles published for each treatment modality as a proxy for prevalence. From 2008 to 2015, there were 4600% more publications on RAPN compared to from 2000 to 2007 (34). This far outpaced the increase 189% and 69% increase in published articles for OPN and LPN respectively. In 2017, Mohapatra et al. performed a survey of 129 endourologists, finding that compared to 5 years prior, there was a significantly increased utilization of RAPN and a corresponding decrease in utilization of LPN and OPN, with a similar trend occurring for radical nephrectomy (35).

Progression towards RAPN in the United States

Utilization trends of partial nephrectomy were subject to more granular analysis as robotic surgery became more widespread in the United States, with the earliest data collected on a statewide level. Patel et al. performed a retrospective review of patients in Maryland receiving kidney cancer surgery from 2000–2011, finding that robotic technology facilitated an increase in partial nephrectomy via multivariate analysis (36). OPNs decreased by 33% while minimally invasive partial nephrectomies increased by 15%. At the end of the study, 47% of partial nephrectomies in the academic setting and 41% of partial nephrectomies in the community setting were performed via robot. Jabaji et al. examined the trend of surgical management of kidney cancer from 1999 to 2015 in Kaiser Permanente Southern California, which introduced the RAPN in 2011. RAPN quickly surpassed laparoscopic partial and radical nephrectomy in 2012 and 2014 respectively, with its relative use increasing by 125% the first year after adoption (37). Pak et al. examined the utilization trends of different partial nephrectomy modalities in New York state via the Statewide Planning and Research Cooperative system database from 2008 to 2012. They found that from 2009 to 2012, robotic partial nephrectomies increased from 17.7% to 39.8% while OPNs decreased from 66.8% to 50.3% and LPN decreased from 15.4% to 9.8% (38). National level data would eventually show some regional variation in the uptake of RAPN, which tended to be more prominent in the Midwest and mountain regions compared to the northeast and south (13,39). In general, there appears to have been widespread proliferation of RAPN across multiple states from 2009–2011. Notably, this data is limited by biases in coding, which underwent several changes during data collection. There is also limited data regarding tumor characteristics and outcomes, and the individual studies are restricted to particular regions. This data is summarized in Table 2.

Table 2. Regional trends in partial nephrectomy approach.

Study	Location	Study start	Study end	OPN at start (%)	OPN at end (%)	LPN at start (%)	LPN at end (%)	RAPN at start (%)	RAPN at end (%)
Patel et al. [2013]	Maryland	2000	2011	98	41	2	14	0	45
Pak et al. [2017]	New York	2009	2012	66.8	50.3	15.4	9.8	17.7	39.8
Jabaji et al. [2019]	Southern California	2011	2015	17	9	62	29	21	62

LPN, laparoscopic partial nephrectomy; OPN, open partial nephrectomy; RAPN, robotic assisted partial nephrectomy.

Later studies assessed the diffusion of robotic technology using national databases, summarized in Table 3. Cheung et al. used the Premier Hospital database to perform the first national study specifically examining RAPN adoption. When data collection began in 2004, RAPN cases accounted for 1.3% of partial nephrectomies while LPN accounted for 19% and OPNs accounted for 79.8% (40). By the end of data collection in 2013, RAPN accounted for 64.1% of partial nephrectomies while LPN accounted for 4.8% and open surgery accounted for 31.1%. Notably, Cheung et al. proposed a classification of RAPN adoption based on the Law of Diffusion, which defined innovator, early adopter and early majority as when 2.5%, 16%, and 50% of a population adopts a new technology. 2004–2005 corresponded with the innovator phase in which RAPN was performed 1.3–2.3% of the time, 2006–2008 was classified as the early adopter phase in which RAPN grew from 3.7–12.1% of partial nephrectomies, and 2009–2013 was the early majority phase in which over half of all partial nephrectomies became robotic. The authors also noted that the proliferation of RAPN was primarily driven by high volume centers via multivariable analysis. Given that earlier studies have shown that increased access to robotics increases usage of partial nephrectomy, the proliferation of RAPN may be due a cycle in which higher surgical volume facilitates technologic progress which in turn drives additional volume (32,36). Cheung et al. note hospital sampling bias, reliance on charge description master coding, and extrapolating the Law of Diffusion to a non-binary variable were key limitations.

Table 3. National trends in partial nephrectomy approach.

Study	Database	Study start	Study end	OPN at start (%)	OPN at end (%)	LPN at start (%)	LPN at end (%)	RAPN at start (%)	RAPN at end (%)
Cheung et al. [2017]	Premier Hospital	2004	2013	79.8	31.1	19	4.8	1.3	64.1
Bahler et al. [2018]	National Inpatient Sample	2009	2012	70.2	46.7	9.7	4.1	20.1	49.2
Xia et al. [2019]	National Cancer	2010	2015	49.5	25.3	15.3	11	35.2	63.7
Alameddine et al. [2019]	National Cancer	2010	2013	59	37	n/a	n/a	41	63
Mazzone et al. [2019]	National Inpatient Sample	2009	2015	71	40	8	2	21	58

LPN, laparoscopic partial nephrectomy; OPN, open partial nephrectomy; RAPN, robotic assisted partial nephrectomy.

Bahler et al. used the National Inpatient Sample database to assess the utilization trends of partial nephrectomy from 2009–2012, after coding for robotics was added in 2008. During this time frame the total number of partial nephrectomies increased by 93%, which was primarily driven by RAPN (41). At the beginning of 2009, RAPN, LPN and OPN respectively accounted for 20.1%, 9.7% and 70.2% of partial nephrectomies. By the end of 2012, RAPN, LPN and OPN respectively accounted for 49.2%, 4.1%, and 46.7% of partial nephrectomies. It should be noted that Bahler’s study lines up almost precisely with the early majority phase described by Cheung et al. in terms of both the timeline and rate of adoption of RAPN, despite drawing from different national databases. Mazzone et al. assessed the same database as Bahler et al. up to 2015, finding that RAPN had increased to 57.9% of partial nephrectomies by then (42). Limitations of the National Inpatient Sample include dependence on individual hospitals for accurate coding and costs, as well as not having access to patient and tumor characteristics.

Xia et al. and Alameddine et al. both used the National Cancer Database to examine patients receiving kidney surgery, with Alameddine et al. specifically examining robotic versus open partial nephrectomy. Xia et al. found that the proportion of RAPN increased from 35.2% in 2010 to 63.7% in 2015, while LPN decreased from 15.3% to 11.8% and OPN decreased from 49.5% to 25.3% in the same period (39). Alameddine found that RAPN increased from 41% to 63% of all partial nephrectomies from 2010-2013, surpassing OPN in 2011 (43). Both Xia and Alameddine found that black and Hispanic patients were less likely to receive RAPN alongside patients with Medicaid or no insurance (39,43). Key limitations include selection bias on the institutions participating in the National Cancer Database and limited tumor information outside of staging. This data suggests socioeconomic factors present a significant obstacle to the diffusion of robotic technology. In turn, similar socioeconomic factors were discussed as barriers to obtaining a partial nephrectomy by Singh et al. and Ghani et al. (13,33). Addressing disparities in access to robotic technology may be important for ensuring that partial nephrectomy becomes more appropriately utilized in indicated cases.

International trend towards RAPN

The transition from OPN to RAPN across the world had a similar trajectory to the transition to RAPN in the United States. Many studies examining this transition were performed in Europe, with almost identical results generally showing a slower diffusion of robotic technology than in the US. Schiavina et al. prospectively evaluated patients receiving kidney cancer treatment from 2009–2012 at 19 Italian urologic centers. There was a reduction in OPNs from 69.6% to 38.4% of cases, an increase in RAPNs from 0 to 36.2% and a relatively consistent rate of LPNs changing 30.4% to 25.4% (44). Marcus et al. assessed the diffusion of robotic surgery across England from 2006–2014. In 2006, there was only one RAPN while 13.5% of cases were LPN and 86.3% of cases were OPN (45). RAPN accounted for 27% of partial nephrectomies in 2014, while LPN accounted for 24.6% and OPN remained a plurality at 48.3%. Another English study using the British Association of Urological Surgeons nephrectomy register from 2008 to 2017 found that RAPN increased from none to 62.4% of all partial nephrectomies (46). Hjelle et al. assessed management of T1 kidney cancer in a Norwegian population from 2008–2013. RAPN grew from 6.5% to 35% of partial nephrectomies from 2008 to 2013, while LPN grew from 18.5% to 29% and OPN dropped from 69.4% to 35% in the same period (47).

Outside of Europe, population level data on partial nephrectomy utilization trends is scarcer. Kang et al. examined trends in renal mass treatment in Korea from 1988 to 2015, though minimally invasive surgery began in 2000. From 2000 to 2015, RAPN went from 6% to 38.2% of partial nephrectomies for renal masses 4cm or below, LPN from 19.4% to 22.7%, and OPN from 74.6% to 39% (48). Ali et al. assessed the changing trends in surgery for renal tumors in Australia from 2000–2016, finding an increase in surgical treatment from 25% to 41% across the study period, and a rapid increase in the proportion of RAPN from 4.7% of all partial nephrectomies in 2010 to 58% in 2016 (49). Muaddi et al. performed a population-based analysis of the evolution towards robotic surgery in Ontario from 2012–2018, including for partial nephrectomy. RAPN grew from 2.8% of partial nephrectomies in 2012 to 13.6% in 2018, while OPN fell from 67.9% to 52.2% and LPN grew from 29.3% to 34.2% (50). Notably, it can be difficult to generalize results from one country for another, and much of the data is drawn from administrative databases retrospectively risking selection and ascertainment bias. These databases, like those in the United States, often do not include many relevant tumor and patient characteristics. The British Nephrectomy register is more informative in this regard, but is subject to selection bias as it relies on data input from surgeons. Data regarding international trends in partial nephrectomy approach is summarized in Table 4.

Table 4. International trends in partial nephrectomy approach.

Study	Country	Study start	Study end	OPN at start (%)	OPN at end (%)	LPN at start (%)	LPN at end (%)	RAPN at start (%)	RAPN at end (%)
Schiavina et al. [2015]	Italy	2009	2012	69.6	38.4	30.4	25.4	0	36.2
Marcus et al. [2017]	England	2006	2015	86.3	48.4	13.5	24.6	0.2	27
Hjelle et al. [2018]	Norway	2008	2013	69.4	35	18.5	29	6.5	35
Kang et al. [2019]	South Korea	1988, 2000	2015	100 in 1998; 74.6 in 2000	39	0 in 1998; 19.4 in 2000	22.7	0 in 1998; 6 in 2000	38.2
Devlin et al. [2021]	England	2008	2017	57	24	33	14	0	62
Muaddi et al. [2023]	Canada (Ontario)	2012	2018	67.9	52.2	29.3	34.2	2.8	13.6

LPN, laparoscopic partial nephrectomy; OPN, open partial nephrectomy; RAPN, robotic assisted partial nephrectomy.

Though these international studies regarding are predominantly performed in wealthy and westernized countries, several important trends emerge. The robotic approach was noted to be associated with high volume practices by Hjelle et al. and Muaddi et al., with Muaddi et al. also noting a positive association between RAPN and higher income (47,50). There was a significant increase in partial nephrectomy volume across several of these studies, while radical nephrectomy volume decreased or remained stable (45,47,49). This stands in contrast to the reduced usage of radical nephrectomy in the US (32,33). Surgical intervention became more common in older patients as well, driving some of the increase in overall partial nephrectomy volume (48,49). Several studies noted inflection point in the rate of RAPN adoption around 2010, mirroring the time frame of rapid RAPN adoption in the US (47-49). Notably, only the Australian cohort described by Ali et al. showed RAPN becoming the predominant method of partial nephrectomy, suggesting that RAPN has not fully reached an early majority phase outside of the US (40,49).

Expansion of RAPN to larger renal masses and complex patients

As urologists became more proficient with the robot, there was a corresponding broadening of the indications for partial nephrectomy beyond small renal masses, further increasing the prevalence of RAPN. Several studies specifically examined the relationship between robotic technology and the use of partial nephrectomy for masses larger than the typical small renal mass cutoff of 4 cm. Reynolds et al. compared RAPN for T1b and T1a masses, finding equivalent oncologic and functional outcomes albeit with significant increases in operative time, ischemia time, blood loss, and complications (29). The authors assessed that the increased drawbacks of RAPN for T1b disease were relatively small, and that the procedure should be considered when feasible. Schiavana et al. found an increase in partial nephrectomies for stage T1b and T2 cancers from 2009 to 2012, corresponding to the diffusion of robotic technology (44). This corresponded to Hjelle et al. found that partial nephrectomy for tumors from 4–7 cm increased from 10% to 18% of cases, while partial nephrectomy became the primary surgery for tumors under 4cm, increasing from 43% to 63% of cases (47). Okhawere et al. queried the National Cancer Database from 2004 to 2019, finding that open radical nephrectomy began declining in use for T2 disease starting in 2010, when data on minimally invasive renal surgery was recorded in the database (51). From 2010 until the end of the study, RAPN increased from 1.11% to 25.51% and robotic radical nephrectomy increased from 7.86% to 25.84% of all surgical approaches to T2 disease. Suek et al. queried the same database from 2010 to 2016, finding similar outcomes with RAPN rates for T2 masses increasing by 346% without any significant increases in positive margins, readmission or perioperative mortality (52). Several studies have shown that RAPN has comparable oncologic outcomes to robotic radical nephrectomy for T2 disease, without a significant increase in complications or readmissions (53,54).

RAPN also presents a compelling option to treat patients functional and anatomic differences such as CKD and solitary kidneys. A multicenter study found that RAPN was superior to OPN in patients with CKD with respect to blood loss and hospital stay, with equivalent oncologic and functional outcomes (55). RAPN in patients with CKD was explored in a study comparing outcomes in patients with estimated glomerular filtration rate (GFR) over 60 mL/min and those below. Patients with worse kidney disease had increased post-operative complications but had reduced kidney function deterioration and CKD upstaging at 3 months (56). The authors noted no oncologic differences and concluded that RAPN was a viable option to treat kidney cancer in patients with CKD. Interestingly, lower CKD stages were found to be associated with reduced kidney function loss in a more recent study, though the authors hypothesized that the data was confounded by smaller tumor diameter in the lower stage CKD patients (57). Regardless, rapid kidney function loss was not seen in the study for severe CKD patients. The increased risk of complications was demonstrated in a recent multicenter propensity matched study, including a higher risk of severe complications (58). For a solitary kidney, RAPN has been found to have significant improvement in hospital stay with comparable oncologic and functional outcomes versus OPN and LPN (59,60). RAPN was also found to have similar functional outcomes in patients with a solitary kidney and those without in a propensity matched study, though patients with a solitary kidney had higher rates of acute kidney injury (61).

Outcomes of robotic partial nephrectomy compared to other approaches at a population level

The proliferation of RAPN across multiple clinical settings is in part due to its improved outcomes compared to OPN and LPN. The most widely used assessment of perioperative outcomes for partial nephrectomy is known as the trifecta, which was first described by Hung et al. to include negative cancer margin, minimal renal function decrease measured by warm ischemia time under 25 minutes, and no perioperative complications (62). This framework was expanded by Krane et al. to include outcome measurements beyond the perioperative period. They proposed the pentafecta, which included the trifecta outcomes plus long-term maintenance of kidney function and absence of tumor recurrence (63). Numerous studies have found that RAPN correlates with improved trifecta achievement compared to OPN and LAPN (64-66). A meta-analysis by Cacciamani et al. compared RAPN outcomes to OPN and LPN, finding that RAPN was superior to OPN and LPN with respect to complications, loss of kidney function, and mortality (67). RAPN was superior to OPN with respect to recurrence rate, hospital stay and readmissions and was superior to LPN with respect to conversion rate and positive margins. In an aggregate, RAPN appears to be the most effective approach to achieve the pentafecta.

With respect to trending clinical outcomes against the gradual adoption of RAPN, most studies in our review emphasize complications, readmissions, and length of stay. Ghani et al. found that RAPN was associated with reduced intra-operative and post-operative complications compared to OPN and LPN, as well as reduced transfusion rates (13). Pak et al. specifically found that RAPN had reduced inpatient complications and readmissions at 3 months, while both RAPN and LPN had shorter length of stay compared to OPN (38). Liu et al. provided the most compelling connection between the gradual adoption of robotic technology and improved outcomes, although they did not differentiate between RAPN and LAPN when comparing to OPN. They found that minimally invasive partial nephrectomy had reduced length of stay, transfusions, complications (including kidney damage), and mortality compared to OPN between 2005 and 2011 (32). Notably, surgery before 2008 was associated with increased complications for partial nephrectomy on multivariable analysis, which corresponds roughly to the time frame robotic surgery began to become more widely adopted. Most recently, Porreca et al. performed a retrospective examination of surgical outcomes for several procedures before and after implementation of a robotic program, including for partial nephrectomy. There was a significant reduction in median length of stay from 6.5 to 4.1 days, without a concomitant rise in readmissions, operative time, or complications (68). Surgeon experience is a key mediating factor in the improved outcomes of RAPN as it becomes more widespread. Krane et al. showed that increasing experience correlated with treating more complex masses by nephrometry score, without increased complications or positive margins (69).

Intraoperative imaging in robotic partial nephrectomy

The improved outcomes of RAPN are driven by surgical innovation enabled by the robotic platform. One such improvement is the use of intracorporeal intraoperative ultrasound to delineate complex renal masses prior to resection. Sun et al. noted the utility of intraoperative ultrasound during RAPN for endophytic tumors, as it independently predicted improved ischemia time and resulted in better pentafecta achievement (70). In a meta-analysis, the proportion of negative surgical margins with use of intra-operative ultrasound was an impressive 97.6%, which is linked to reduced recurrence and distant metastasis (71). Contrast may be used to enhance microvasculature for real time visualization, which may improve ischemia time by enabling selective clamping of renal vessels supplying a mass (72,73). Ultrasound can also be used to determine whether a tumor is near a main or segmental blood vessel, allowing a surgeon to avoid additional bleeding (73,74).

Though intraoperative ultrasound may be used for LPN as well, it appears to have more benefits in RAPN, during which TilePro multi import display technology can be used to generate a real time image on the console during dissection. Kaczmarek et al. noted that usage of a robotic ultrasound probe enables greater surgeon autonomy compared to using laparoscopic ultrasound without sacrificing operative time, blood loss, or margin status (75). In a retrospective study comparing RAPN and LPN with holographic imaging and intraoperative ultrasound for endophytic tumors, RAPN had improved blood loss and ischemia time with comparable oncologic outcomes, renal function preservation, operative, hospital stay, and complication rate (76). These improvements were in part attributed to the ergonomic ease of manipulating multiple tools with the robotic platform, as well as the three-dimensional visualization facilitating the localization of the mass by ultrasound.

Subsequently, surgeons began to experiment with more sophisticated modalities of intraoperative imaging to manage more complex tumors. Three dimensional static and elastic augmented reality models have shown promise in guiding resection and reconstruction. Porpiglia et al. integrated such a model with the daVinci video interface, and used it to guide RAPN via TilePro, finding that it resulted in higher rates of enucleation alongside lower ischemia and collecting system violations compared to US guided RAPN (77). The advent of artificial intelligence has introduced exciting new advances in augmented reality. Shi et al. described an artificial intelligence auto matching technique to generate a real time overlay of a holographic model generated from anatomic imaging during RAPN, which reduced renal hilum exposure time (78). Porpiglia’s group implemented a convolutional neural network based software called “iKidney” to improve the accuracy of overlapping augmented reality models during RAPN, reducing the need for a dedicated assistant to superimpose said images (79). Sica et al. reported using iKidney to enucleate a very complex renal mass without major complication (80). Another 3D model software, IRIS, has been used to generate virtual anatomic kidney models that achieve better orientation and anatomical understanding than conventional computed tomography (81). IRIS models can be integrated intra-operatively with TilePro, and they were found to increase surgical precision of RAPN for complex kidney tumors in a propensity matched study (82). Furthermore, there was high overlap between preoperative plans generated by IRIS and intraoperative RAPN execution demonstrated in a prospective study (83). Surgeons in this study noted that the intra-operative models enhanced resident training, allowing trainees to identify critical vascular and tumor anatomy. These advances may allow RAPN to treat complex renal masses as routinely as small renal masses.

ICG in robotic partial nephrectomy

The robotic platform also allows the use of near-infrared fluorescent imaging via ICG to visualize tumors and their vascularity. ICG binds to plasma albumin and emits light in the near-infrared spectrum, notably having less affinity for tumors compared to normal renal parenchyma (84). ICG fluorescence patterns have been shown to correlate with some histologic findings but ultimately cannot adequately predict a lesions malignancy (85). Regardless, the relative hypointensity of most renal lesions enables clearer visualization of parenchymal margins during resection (86). Simone et al. was able to demonstrate the effectiveness of ICG transarterial tumor marking for endophytic tumors, allowing RAPN to be performed quickly with good margin control (87).

A key advantage of using ICG during RAPN is that it may minimize renal injury by allowing selective clamping of the tumor’s blood supply and reducing warm ischemia time through better visualization of the tumor. Krane et al. performed a prospective study of 47 RAPN patients with intraoperative ICG and compared them to 47 prior RAPN patients without ICG, finding that ICG significantly decreased warm ischemia time (25). However, there was no difference in ultimate complication rates with ICG administration, and the authors were unable to quantify any clinical benefit of ICG. A subsequent study by Borofsky et al. showed more promising results, with ICG visualization enabling a “zero ischemia” RAPN with super selective arterial clamping, which resulted in superior kidney function compared to standard RAPN at the cost of slightly longer operative times (26). Further prospective studies appeared to confirm the benefit of ICG for renal preservation in the immediate aftermath of RAPN (88,89). Long term data is somewhat more mixed. Lanchon et al. showed that super selective ICG based clamping was associated with improved GFR 6 months after the operation compared to standard RAPN, corresponding to reduced CKD (90). However, a randomized study performed by Long et al. showed no benefit in super selective ischemia at 6 months post-operative, even after adjusting for percentage of kidney volume preserved (91). On meta-analysis, ICG use appears to significantly improve both warm ischemia time and immediate post-operative GFR only (84,92).

ICG has also been proposed as a potential mechanism to better enable the preservation of viable renal tissue during resection and renorrhaphy. This is particularly notable as several studies have called into question different methods of renoprotection through minimizing ischemia, and parenchymal preservation has been shown to play a greater role than ischemia in preserving renal function (27,28,93). Some urologists will give another dose of ICG at the time of renorrhaphy to assess the viability of the remaining tissue, as both resection and renorrhaphy are known to damage functional kidney (94). Omission of cortical renorrhaphy has been shown to be associated with reduced kidney damage after RAPN, owing to reduced volume loss (95,96). By visualizing non-viable parenchyma in real time, ICG could feasibly guide renal reconstruction in a way that maximizes preserved tissue.

Given that ICG enables visualization of renal arterial supply, some studies have suggested ICG use may help minimize blood loss. Yang et al. found that ICG enhanced RAPN reduced blood loss during surgery for malignant tumors but not for benign masses (97). Nonetheless, most of the literature has not shown significant differences in blood loss or transfusions with ICG (84,92). However, research leveraging ICG for hemorrhagic control during RAPN continues to move forward. Mazzoleni et al. demonstrated a super-selective embolization technique in combination with off clamp ICG guided RAPN that reduced blood loss and operative time compared to a standard ultrasound guided RAPN, though renal function change was comparable (98).

Alternative renorrhaphy and ischemia techniques in robotic partial nephrectomy

The balance between blood loss and renal preservation during partial nephrectomy continues to be an area of debate in urologic oncology. The robotic platform alongside the innovations in intra-operative renal imaging discussed in prior sections, have enabled more precise control of both the mass and renal hilum. Both the reduction of clamping and renorrhaphy have emerged as strategies to preserve renal function post-operatively.

Various strategies to control arterial ischemia have been employed in RAPN with success. A multicenter propensity matched study of selective clamping in RAPN found that selective clamping did not improve margin status, rates of kidney damage or progression to CKD (99). ICG may increase the effectiveness of selective clamping in preserving kidney function, as demonstrated by Lanchon et al. (90). Obrecht et al. compared zero ischemia, selective clamping and non-selective clamping, finding that zero ischemia was associated with reduced kidney damage while selective clamping increased the ischemia limit at which kidney injury became more likely (100). Antonelli et al. performed a randomized trial comparing off clamp and on clamp RAPN, finding no difference in surgical margins, blood loss, kidney damage or complications (101). Fong et al. performed a meta-analysis of off clamp and on clamp RAPN, finding that off clamp RAPN did appear to reduce post-operative kidney damage and margin positivity without significantly increasing complications (102). A later meta-analysis incorporated clinical trials and matched cohort studies for a more robust analysis of the effects of off clamp RAPN, finding reduced kidney damage and complication rate without clamping, albeit at the cost of higher blood loss (103). Oncologic outcomes were noted to be equivalent. Notably, when examining high complexity tumors, off clamp RAPN also reduced kidney damage without increasing complications (104). Finally intra-arterial hypothermia can be applied through arteriotomy or balloon catheter to prolong ischemia time without excess risk to the affected kidney (105). This approach has recently shown feasibility in complex masses in a small retrospective study, which may be relevant should such patients be limited by blood loss from receiving a zero ischemia RAPN (106).

Minimizing renorrhaphy has also been explored to preserve renal function by reducing ischemia time and parenchymal damage from sutures. Initially, surgeons experimented with single layer suture techniques as opposed to the standard double layer. Bahler et al. assessed the feasibility of omitting cortical renorrhaphy in RAPN, finding that it reduced ischemia time and parenchymal volume loss without a significant difference in GFR (107). Ito et al. performed a multicenter study comparing single and double layer renorrhaphy, finding improved kidney function immediately after surgery for the single layer patients that did not persist at 1 year (108). Further studies attempted to extend this principle in investigating how foregoing suture entirely affects operative safety and renal function. Liu et al. performed a meta-analysis of several retrospective studies on sutureless partial nephrectomy, finding that it led to advantages in post-operative GFR, operative time and warm ischemia time without increasing blood loss or complications (109). However, no significant benefit regarding renal function was found. Combining sutureless and off clamp RAPN was theorized to maximize renal function to a more significant degree. Riolo et al. reviewed several studies measuring the outcomes of this novel approach, noting good preservation of renal function and low blood loss without worse oncological outcomes (110). The authors emphasized that patient selection was a key aspect in success, noting that all examined studies focused on patients with low nephrometry scores. Notably, a recent propensity matched analysis comparing sutureless to standard renorrhaphy in off clamp RAPN found improvements in trifecta achievement, operative time, blood loss, and complications with the sutureless approach (111).

The increasing role of enucleation in robotic partial nephrectomy

Tumor enucleation involves dissection of a renal mass away from normal parenchyma using the avascular tumor pseudocapsule, improving the amount of preserved parenchyma (112). Blackwell et al. performed the first comparative study between robotic enucleation and standard partial nephrectomy, showing that enucleation spared 96% of normal parenchyma compared with 89% for partial nephrectomy without any significant difference in positive margins (113). Culpan et al. compared robotic enucleation and partial nephrectomy with respect to trifecta outcomes in a retrospective multicenter study, finding a significantly improved trifecta outcome for enucleation, primarily with respect to GFR preservation (114). A recent study by Ellis et al. used 3D reconstruction to directly measure volumetric loss in enucleation versus standard RAPN, finding that the decrease in post-operative GFR for RAPN was proportional to volumetric loss (115).

Most renal enucleations are performed in low to intermediate complexity renal masses, and pair equivocal oncologic outcomes with improved functional outcomes compared to standard RAPN. Lu et al. performed a recent randomized control trial that found non-inferiority of oncologic margins in robotic enucleation compared to resection in tumors with nephrometry scores <10 (116). Enucleation was noted to have a lower operative and rate of tumor bed suturing than RAPN, albeit with higher blood loss. Patel et al. performed a retrospective study in a similar cohort with respect to tumor complexity, finding that enucleation was associated with improved blood loss, as well as improved length of stay, complication rate, and renal function (117). At 1 year follow-up, enucleation was associated with improved renal function and reduced CKD. Enucleation had significantly higher rate of positive margins, but this did not correlate to worse recurrence rates or survival. A large multicenter contemporary comparative study between enucleation and resection in RAPN found that enucleation had a significantly higher positive margin rate, albeit it was more protective with respect to ischemia time, intraoperative complications, postoperative kidney injury and worsening of CKD (118). A meta-analysis by Bertolo et al. found that enucleation had a favorable complication rate, length of stay, and GFR preservation, though there was significant heterogeneity in how studies defined enucleation and which outcomes were measured (119).

Though initially enucleation was thought to be most suited for simpler renal masses, enucleation has shown success with more complex tumors. Lu et al. performed a retrospective study of surgical outcomes of enucleation and RAPN for renal masses with PADUA >10, finding that enucleation had less blood loss, 30 day complications, and immediate post-operative renal function, albeit with thinner margins (120). Minoda et al. retrospectively analyzed outcomes for enucleation and RAPN for completely endophytic tumors, finding that enucleation was associated with better renal function up to 1 year post-op without differences in surgical margin, blood loss or complications (121).

Diffusion of the single port robotic partial nephrectomy

The DaVinci Single Port platform was first used to perform a partial nephrectomy in 2007, and single port RAPN has become more widespread since the platform received FDA approval in 2018 (122). Key advantages of the single port robot include minimizing incisions, which theoretically improves post-operative pain and recovery. A recent meta-analysis examining perioperative functional and oncologic outcomes of single port and standard RAPN found that the single port RAPN had shorter length of stay, lower blood loss, and lower post-operative pain, without any difference in oncologic outcomes, complications or kidney function loss (123). Another meta-analysis emphasizing the trifecta outcome, finding that single port RAPN had lower positive margin rates and lower creatinine level at discharge but was paradoxically associated with worse trifecta achievement, which the authors theorized may be due to heterogeneity of included studies measuring oncologic and functional outcomes, as well as variation in the definition of trifecta (124). As such, the authors recommended caution regarding interpreting this data. Notably, the authors also found reduced blood loss and shorter length of stay. This data is generally congruent with findings on prior meta-analyses comparing single and multi-port RAPN, which tend to show increased in warm ischemia time, unchanged to reduced length of stay and blood loss, and equivocal change to kidney function with no significant difference in oncologic outcomes (125-127).

The single port robot has also had a significant impact on urologic practice and education. In an assessment of urology residents and fellows, 30% expressed concerns with a steeper learning curve with the robot and 40% felt that the single port robot negatively impacted their robotic surgery exposure mostly due to limited opportunities to train on the platform (128). Around 30–40% believed that the single port platform had significant clinical benefits for patients, especially for upper tract procedures. There is minimal formal study regarding the learning curve of multi or single port RAPN. Most of the literature uses console time, warm ischemia time and trifecta achievement to assess the learning curve. 15 cases for moderately complex tumors and 25 cases for high complexity tumors have been reported to achieve appropriate ischemia time for multi-port RAPN, though it may take as many as 150 cases to see ischemia time plateau. Seventy-seven cases have been reported as the number of cases to achieve plateau with respect to trifecta (129). The largest learning curve analysis for single port RAPN found that it took an experienced surgeon 33 cases to achieve competence with respect to ischemia time, operative time and trifecta (130). Though the learning curve appears to be steeper for single port RAPN, proficiency is certainly achievable within a reasonable case volume.

Progress of robotic access techniques

A key advantage of the robotic platform is the increased maneuverability of the robotic arms in tight compartments, particularly compared to standard surgical tools. RAPN can be performed via the transperitoneal or the retroperitoneal approach. While the transperitoneal approach has greater working space and recognition of anatomic landmarks, the retroperitoneal approach may avoid adhesions and may grant easier access to hilar structures and posterior masses (131). However, the retroperitoneal approach has been noted to be more technically difficult due to the lack of landmarks and comparably more difficult access and maneuverability. A meta-analysis by Carbonara et al. found that retroperitoneal RAPN offered equivalent outcomes to transperitoneal RAPN with respect to positive margins, pentafecta achievement and complications, though retroperitoneal RAPN had improved blood loss, operative time and length of stay (132). A contemporaneous meta-analysis by Bourgi et al. found essentially identical results (131).

To solve the problem of difficult access and maneuverability, several surgeons have proposed alternate access strategies. Silvestri et al. reported the multiport anterior retroperitoneal access technique, which involves placing trocars primarily along the pararectal line after expansion of the retroperitoneal space and medialization of the peritoneum, as opposed to the standard “arc” trocar configuration (133). The authors report that margin status, complications, and length of stay are similar to previously reported data on retroperitoneal RAPN, though they acknowledge the need for controlled studies in a cohort controlling for patient and tumor characteristics. Pellegrino et al. advanced this concept in single port RAPN with access at McBurney’s point, allowing supine positioning that avoids the injuries and respiratory difficulties the standard lateral decubitus approach presents (134). In a pilot study of 12 patients with a mean nephrometry score of 5, they achieved trifecta in all except 1 patient due to positive margins using this supine anterior approach, with acceptable operative and warm ischemia times. A subsequent single center study of ten patients by Passaro et al. found similar results, with all patients discharged the day after the operation and only one patient with positive margins (135). A larger single center study with a surgeon new to the single port robot showed gradual improvement in operative time and ischemia time over successive cases using anterior access, with no complications or positive margins reported (136). Though this initial data is promising, comparative studies will be needed in order to clearly verify the safety and efficacy of anterior retroperitoneal access with the single port robot.

The growing cost effectiveness of RAPN

Cost effectiveness has become an important consideration in the adoption of RAPN, given the significant investment a robotic program takes to establish. Early data suggested that RAPN is more expensive than its open and laparoscopic counterparts. Kowalczyk et al. found that minimally invasive nephrectomy holds comparable costs to its open counterpart, though primarily LPN was assessed (31). Ghani et al. found that RAPN had a 35% increase in excess hospital charges vs. OPN, though the authors noted that the relationship between actual costs and charges could be complex and that the higher charges may be related to a higher proportion of RAPN patients being privately insured (13). Bahler et al. however found that RAPN had a higher median unadjusted total cost over 2009–2012 at $13,878 than LPN at $12,457 or OPN at $12,497 (41). However, the authors noted that by 2012 RAPN was less expensive than OPN at $15,879 compared to $16,954, though this difference was not statistically significant. In a later study focused on hospital charges using the same database, Mazzone et al. found that RAPN had only a $367 increase in mean total hospital costs compared to non-robotic assisted partial nephrectomies from 2009 to 2015, which was not statistically significant (42). The authors noted that though the costs of partial nephrectomy decreased throughout the study period, RAPN costs decreased at a more rapid rate.

The latest available data shows a clear shift in cost effectiveness towards RAPN. An early meta-analysis by Mir et al. in 2011 showed that RAPN had a mean cost of $11,962 compared to $11,427 for OPN and $10,311 for LPN (137). By the mid-2010s, RAPN had comparable costs to alternative approaches. Buse et al. found that although RAPN had higher mean in-hospital cost at $13,186 compared to $12,539 for OPN, the decreased rate of complications for RAPN offset its total cost by $5,005 per avoided complication, making it more cost effective (138). A subsequent model by the same group later found that RAPN had lower in-hospital costs and complications outright (139). Camp et al. analyzed hospital episode statistics data from 2008 to 2014 and found that RAPN had lower total 1 year medical costs at £2,089.37 compared to OPN at £2,996.55 and LPN at £2,225.05, though the difference was only significant compared to OPN (140). The authors noted that RAPN had lower average procedure cost at £4,444.35 compared to OPN at £5,024.19, but higher than LPN at £4,356.19. When medical cost and procedure cost was assessed in total, RAPN was comparable to LPN and more cost effective than OPN. The most recent cost effectiveness studies favor RAPN over both LPN and OPN. A 2023 study performed by the NHS found that RAPN was associated with a reduced cost of 1332 euros per patient compared to OPN, owing to reduced complications (141). Similarly, a 2026 study in Ireland found that mean cost was 9,988.47 euros for RAPN compared to 12,032.14 euros for OPN, owing to shorter length of stay and reduced complications (142). A 2026 Taiwanese study compared RAPN to LPN and found that RAPN saved $387,480 per quality adjusted life years due to reduced dialysis risk and readmissions (143). Though RAPN is associated with higher initial expenditure due to acquisition and maintenance of the robot, improved outcomes resulting from the more advanced technology may reduce long term expenditures.

Conclusions

Partial nephrectomy is the widely acknowledged clinical standard for treating small, localized renal masses. Though partial nephrectomy has been historically performed with an open approach, the 21^st century has heralded a gradual transition to laparoscopic, and finally robotic, surgery. Robotic partial nephrectomy offers key advantages, including improved ergonomics and visualization, reduction of perioperative morbidity, seamless integration of ultrasound, and delineation of masses with ICG. These advantages have allowed robotic partial nephrectomy to offer improved outcomes as measured by both trifecta and pentafecta compared to its open and laparoscopic counterparts. Furthermore, robotic technology continues to progress, driving further surgical innovation. As such, the robotic approach has become the predominant modality for performing partial nephrectomy in the United States, with the rest of the world following a similar trajectory. There is a strong argument that robotic partial nephrectomy is inching toward or has already become “gold standard” for the management of small renal masses.

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