Open partial nephrectomy for complex tumours and >4 cm: Is it still the gold standard technique in the minimally invasive era?

The objective of this paper is to discuss the role of open partial nephrectomy (OPN) for complex renal tumours and large renal tumours > 4 cm in the minimally invasive era. The current status of OPN, laparoscopic partial nephrectomy (LPN) and robotic PN are reviewed. The literature search is done using the National Library of Medicine database (PubMed). The indication of OPN has been extended to T1b tumours (4-7 cm). PN and radical nephrectomy (RN) provide equivalent oncological outcomes for these tumours. In addition, there is a growing application of OPN for complex tumours (centrally located, hilar, multifocal). Despite the more challenging cohort of patients, there is no increase in the overall morbidity of OPN. In contemporary cohorts there is an increase in overweight patients and a higher incidence of central tumours treated with OPN. LPN has been extended to select patients with larger renal masses (4-7 cm) and centrally located tumours. LPN for tumours > 4 cm was in the early phase associated with increased complication rate and prolonged warm ischemia time (WIT). Complication rates decreased with improvement of surgical technique and expertise. Early experience with robotic PN is promising and perioperative outcomes are at least comparable to LPN. LPN and robotic PN have to compete with the functional and oncological results of OPN. In the era of nephron-sparing surgery (NSS), OPN remains the established standard for the management of T1 renal tumours in centres without advanced laparoscopic expertise. Complex scenarios with centrally located tumours, tumours in a solitary kidney, and multifocal lesions probably are best managed with OPN. LPN is feasible in numerous clinical scenarios in centres with advanced laparoscopic expertise but remains a challenging operation. Long-term studies are needed to further define the role of the robotic approach for PN.