Robotic partial nephrectomy with cold ischemia and on-clamp tumor extraction: recapitulating the open approach

We describe a reproducible technique for achieving cold ischemia with intraoperative tumor assessment during robotic partial nephrectomy (RPN) that recapitulates the open approach: intracorporeal cooling and extraction (ICE). A total of seven patients underwent the ICE modification of RPN by transperitoneal (n=5) and retroperitoneal (n=2) approaches. A Gelpoint access port was used for the camera and assistant ports. Following hilar clamping, ice slush was introduced through the Gelpoint via syringes and applied over the kidney surface. The excised tumor was immediately extracted through the Gelpoint, allowing gross margin assessment by pathology during the renorrhaphy. RPN was achieved in all cases with successful introduction of ice slush and tumor extraction while on clamp. Median RENAL nephrometry score was 8 (range: 6-10), and there was one solitary kidney. Mean cold ischemia time was 19.6 min (range: 8-37) and mean estimated blood loss was 296.4 ml (range: 50-1000). Renal parenchymal temperatures <16°C were achieved within 7 min of cold ischemia and there was no drop in core body temperature >0.5°C during any procedures. Intraoperative assessment of the excised tumor showed adequate gross margins in all cases and final pathology confirmed negative surgical margins.