It is essential to have full exposure of the lesion with an adequate normal parenchymal margin prior to reconstruction. We prefer to mobilize the kidney within Gerota’s fat so that we have complete access to normal parenchyma during renal reconstruction. After the hilum has been identified, we routinely open Gerota’s fascia anteriorly during transperitoneal cases with careful attention given to the location of the ureter. Gerota’s fat and fascia should be opened in manner that it can be reapproximated after reconstruction with hem-o-lock clips. On posterior tumors where a retroperitoneal approach is employed, it is feasible to open the Gerota’s only in the vicinity of the tumor.

Robotic NSS is most commonly performed with utilization of warm renal ischemia. Preoperative cross sectional imaging preferably with contrast enhancement is extremely helpful for surgical planning. Depending upon the complexity of the lesion, the renal artery and/or vein can be controlled. Many surgeons control the hilum using various techniques. In our experience, we prefer the bedside assistant placed bulldog clip appliers (Fig. 71.4a). Some surgeons use an additional port with placement of a laparoscopic satin sky clamp (Fig. 71.4b). Other commonly used methods include robotic controlled bulldog clips and the use of vessel loops (modified Rommel tourniquets). We recommend exposure of all renal hilar vessels prior to tumor excision in case of emergency situations. Clamping of only the renal arterial flow is ideal in smaller lesions in favorable locations where venous retrograde bleeding would not interfere with adequate tumor excision. This is also useful in situations where multiple arteries are present only the vessel responsible for supplying the vicinity of the tumor is clamped and the remainder of the renal blood flow drains through the open renal vein. This principle has been expanded to included superselective arterial clamping, that involves dissection through the renal parenchyma to the artery that is supplying only the tumor [4].

Cold ischemia has been well developed in open NSS where traditionally there has been access to the entire hilum and kidney for cooling. There have been few reports of combining minimally invasive approaches with cold ischemia techniques. In the laparoscopic era, Kaouk and colleagues placed ice slush intracorporeally using an endoscopic bag around the kidney [6]. Rogers and colleagues have placed ice robotically with the use of a Gelport [12]. Recently, our group developed an ice introduction system that can be used for robotic NSS transperitoneally or retroperitoneally [8].

We perform intraoperative intracorporeal renal ultrasound prior to excision of every lesion. This helps to assess the depth of the tumor and parenchymal margins (Fig. 71.5). We utilize the cold shears to excise the tumor as this will minimize electrocautery effect on margins. If there are large vessels encountered during excision, the assistant may place Hem-o-Lok clips or the console surgeon may place robotic Hem-o-Lok clips. Attention must be given to ensure negative margins and this can be achieved with an adequate parenchymal and/or renal sinus fat borders. Excessive suctioning can decrease pneumoperitoneum leading to pooling of blood on the tumor bed, therefore it should be used only when vision is impaired during excision (Fig. 71.6).