Editorial Comment on: Predictive Factors for Achieving Superorior Pentafecta Outcomes Following Robot-Assisted Partial Nephrectomy in Patients with Localized Renal Cell Carcinoma by Kang et al. (From: Kang M,Gong I-H,Park HJ,et al. J Endourol 2017;31:1231–1236)

Robot-assisted partial nephrectomy has become the preferred management strategy for surgeons looking to remove small renal masses in the United States and throughout the world. The endowristed instruments and magnification allow for a precise dissection and surgeon control while providing the benefit of a minimally invasive procedure. Currently published guidelines for the American Urologic Association and the European Urologic Association encourage the preservation of renal parenchyma when possible.

Kang et al. produced a very honest evaluation of their experience in performing this procedure. As they note, pentafecta outcomes are not easy, in fact, they occur less than half the time, something we are all hesitant to admit. Although many of their patients did not qualify for this outcome because of ischemic times, which may or may not be an important factor in long-term renal function, ¹ we applaud the authors for maintaining the high surgical standards published in the literature. ²

As they report, surgeon experience plays a substantial role in determining outcomes, particularly at the high standard of the pentafecta. We should continue to encourage the regionalization of this procedure in patients with complex renal masses. With the dissemination of daVinci robotic systems, more urologists are capable of performing this procedure. We can only hope that they all hold themselves to the highest surgical bar set, which in our eyes are pentafecta outcomes.

It is our role as surgeons to continue to assess the risk benefit ratio in all patients undergoing treatment for disease. We must provide our patients with the best cancer control and the fewest side effects. With the advent of surveillance, ablative technologies, and other techniques for oncologic control, we need to continue to reassess our own capabilities and strive to produce superior outcomes.