Editorial Comment for Zargar et al.

The authors' ¹ have summarized a large, multi-institutional experience of nephron-sparing surgery in patients with a solitary kidney, whether anatomic or functional. This can be a difficult group of patients to treat, and the excellent outcomes achieved demonstrate that experience, good judgment, and meticulous technique are able to ensure adequate cancer control while preserving renal function. Indeed, in the entire series of 125 patients, there were no conversions to radical nephrectomy, and no patient needed long-term dialysis.

As one would expect, more complex tumors tended to be managed via the open approach, although the rates of complications were not significantly different between the robotic and open groups in those with both low and high R.E.N.A.L. scores. The rates and types of complications are reasonable and to be expected, and it is interesting to note that the blood loss and need for transfusion were comparable with both techniques. In addition, the type and duration of ischemia did not have an apparent effect on postoperative renal function, further suggesting that shorter is better, but minimizing parenchymal excision may be the most important factor.

At the end of the day, surgeons must select the best technique in their hands and experience to maximize renal function with adequate tumor excision. Over time, I suspect that the robotic approach will be used more commonly in this setting as we grow more comfortable with a wider range of complex procedures; nevertheless, we must not avoid an open technique when indicated and may need to consider a multidisciplinary approach. Alternatives to in situ partial nephrectomy include ablation, whether percutaneous or laparoscopic, and nephrectomy with ex vivo partial nephrectomy and autotransplantation.