Editorial Comment for Weizer et al.

W eizer and colleagues describe a technique for retroperitoneal robot-assisted partial nephrectomy. The technique, which is a derivation of the original technique demonstrated by Dr. James Porter (Swedish Medical Center, Seattle, WA) at numerous live surgeries in 2007 to 2010, is demonstrated with clearly reproducible results. The primary advantage of the retroperitoneal approach is in the approach to patients who have had multiple abdominal surgeries and posterior tumors. Posterior tumors can be more directly reached, but they can be easily reached transperitoneally as well with renal mobilization. Nevertheless, the retroperitoneal approach offers the advantage of a completely extraperitoneal procedure, which may have benefits for recovery but would require an adequately powered study to examine.

The authors rightfully comment on the benefit of experienced assistance. The need for experienced assistance is true for all robotic cases, and I am not sure it is unique to the retroperitoneal approach. The same could easily be stated for surgeons beginning their prostatectomy or cystectomy experiences.

Most importantly, the cases become more challenging as the amount of fat around the kidney is increased. Although this is true of the transperitoneal approach as well, there may be fewer landmarks visible in the retroperitoneal approach. It is important to recognize this limitation early in the learning curve.

Lastly, the approach is simply easier with the more recent iterations of the surgical robot. The older standard robot has much larger arms, thus resulting in significant clashing at the extremes of movement. The newer models have a reduced arm size, which simply makes all renal surgery easier to perform.

Overall, the retroperitoneal approach to robot-assisted partial nephrectomy is an addition to the renal surgeon's overall surgical armamentarium. The article by Weizer and associates represents an excellent resource for reproduction of the procedure.