Can robotic partial nephrectomy replace the ablative techniques in the treatment of small renal masses?

With the advent of modern, improved abdominal imaging techniques, the ratio of incidentally discovered renal tumors increased 50-60% [1]. For small renal masses (SRM), the options are surgical removal, ablative treatment, or active surveillance, depending on the tumor characteristics as well as patient status and preference [2-5]. Minimaly invasive ablative techniques, such as cryo- or radio-frequency ablation of SRM, proved to have very good surgical and oncological results for patients unfit for surgery or for those who do not want surgical treatment. However, there are very strict criteria [2, 3, 4] for the ablative technique, significantly reducing the number of the appropriate candidates for this treatment.

The paper published by Harris and coworkers [6] aims to be a plea towards the shifting from ablative techniques to robotic partial nephrectomy. I congratulate the authors for their paper because it opens a new direction: they can do it, having an impressive experience with robotic urology in their center.

The results of the 26 cases – excellent, as of the whole group – can be good arguments for their purpose, but in fact, as the authors acknowledge, they are not strong enough due to many bias factors. The first and the most important is that in their retrospective study, all the patients were in a good health status and fit for surgery, while ablative surgery adresses mainly to patients in poor health condition with short life expectation. If we only look at the oncological results, it lacks a long postoperative follow-up (in this study it is only 12.5 months) although the group characteristics would have allowed for very good long-term follow-up (a weak paramenter on published studies regarding ablative techniques). Another bias factor is that almost all the procedures (87.5%) are performed by the same surgeon, so the results of a technical demanding procedure are those of a surgeon with a consistent experience in the field.

Thus, the answer to the title is ’not yet’, but we should not underestimate an expanding method (robotic partial nephrectomy - which had been looked at with skepticism but a few years ago) and I am convinced that by improving the technique, shortening the length of surgery, minimizing the risks and providing more consistent data, the procedure could be an alternative for many who nowadays are ‚unfit’ for surgery. It could also be a convincing method for those unwilling to be operated and whom prefer ablative techniques or active surveillance.