Surgical Endoscopy

, Volume 29, Issue 5, pp 1241–1249 | Cite as

Endoscopic robot-assisted simple enucleation (ERASE) for clinical T1 renal masses: description of the technique and early postoperative results

  • Andrea MinerviniEmail author
  • Agostino Tuccio
  • Lorenzo Masieri
  • Domenico Veneziano
  • Gianni Vittori
  • Giampaolo Siena
  • Mauro Gacci
  • Graziano Vignolini
  • Andrea Mari
  • Arcangelo Sebastianelli
  • Matteo Salvi
  • Sergio Serni
  • Marco Carini
Dynamic Manuscript



Simple enucleation (SE) has proven to be oncologically safe. We describe the surgical steps and report the results of the Endoscopic Robotic-Assisted Simple Enucleation (ERASE) technique.


Data were gathered prospectively from 130 consecutive patients undergone ERASE for intracapsular kidney cancer, between 2010 and 2013. ERASE was performed using the 4S Da Vinci surgical system, (Intuitive Surgical, Sunnyvale, CA, USA) in a three-arm configuration. Patients’ characteristics and surgical outcomes of ERASE in cT1 were analyzed and the results in cT1a tumors were compared to those of pure laparoscopic SE performed in the same institution in the same time period.


The mean (range) preoperative tumor size was 3.2 cm (0.8–10.0 cm), and clinical stage was T1a for 101 patients, T1b for 28, and T2a for 1. Median PADUA score was 8 (IQR 7–9). In 33.9 % of patients, ERASE was done without pedicle clamping. Mean (±SD) warm ischemia time (WIT) was 18 ± 6 min. According to Clavien system, 1 grade 1 (0.8 %), 5 grade 2 (3.1 %), 4 grade 3 (3.8 %), and 1 grade 4 (0.8 %) surgical complications occurred. Positive surgical margin (PSM) rate was 2.8 %. ERASE in cT1a tumors was associated with a significantly lower need for pedicle clamping, shorter WIT, and lower estimated blood loss (EBL) along with similar operative time and intra and postoperative complication rates but with a significantly lower incidence of urinary fistulas requiring stent insertion compared to laparoscopic SE. Also mean time to drainage removal and length of hospital stay (LOS) were significantly lower in for ERASE. The two groups had comparable PSM rate.


ERASE has proven to be a feasible technique for the minimal invasive treatment of clinical stage T1 renal masses. The robotic approach can achieve surgical results superior to those of pure laparoscopy by reducing the need for clamping, WIT, EBL, and LOS.


Partial nephrectomy Peritumoral capsule Renal cell carcinoma RAPN Robotic partial nephrectomy Simple enucleation 



Drs Andrea Minervini, Agostino Tuccio, Lorenzo Masieri, Domenico Veneziano, Gianni Vittori, Giampaolo Siena, Mauro Gacci, Graziano Vignolini, Andrea Mari, Arcangelo Sebastianelli, Matteo Salvi, Professor Sergio Serni, and Professor Marco Carini have no conflicts of interest or financial ties to disclose.


No funding or other financial support was received.

Supplementary material

Supplementary material 1 (WMV 222239 kb)


  1. 1.
    Ljungberg B, Cowan NC, Hanbury DC et al (2010) EAU guidelines on renal cell carcinoma: the 2010 update. Eur Urol 58:398–406CrossRefPubMedGoogle Scholar
  2. 2.
    Antonelli A, Cozzoli A, Nicolai M et al (2008) Nephron-sparing surgery versus radical nephrectomy in the treatment of intracapsular renal cell carcinoma up to 7 cm. Eur Urol 53:803–809CrossRefPubMedGoogle Scholar
  3. 3.
    Minervini A, Di Cristofano C, Lapini A et al (2009) Histopathological analysis of peritumoral pseudocapsule and surgical margins status after tumor enucleation for renal cell carcinoma. Eur Urol 55:1410–1418CrossRefPubMedGoogle Scholar
  4. 4.
    Kutikov A, Vanarsdalen KN, Gershman B et al (2008) Enucleation of renal cell carcinoma with ablation of the tumour base. BJU Int 102:688CrossRefPubMedGoogle Scholar
  5. 5.
    Carini M, Minervini A, Lapini A et al (2006) Simple enucleation for the treatment of renal cell carcinoma between 4 and 7 cm in greatest dimension: progression and long-term survival. J Urol 175:2022CrossRefPubMedGoogle Scholar
  6. 6.
    Carini M, Minervini A, Masieri L et al (2006) Simple enucleation for the treatment of pT1a renal cell carcinoma: our 20-year experience. Eur Urol 50:1263CrossRefPubMedGoogle Scholar
  7. 7.
    Gill IS, Kavoussi LR, Lane BR et al (2007) Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol 178:41–46CrossRefPubMedGoogle Scholar
  8. 8.
    Lane BR, Gill IS (2010) 7-year oncological outcomes after laparoscopic and open partial nephrectomy. J Urol 183:473–479CrossRefPubMedGoogle Scholar
  9. 9.
    Shikanov S, Lifshitz DA, Deklaj T et al (2010) Laparoscopic partial nephrectomy for technically challenging tumours. BJU Int 106:91–94CrossRefPubMedGoogle Scholar
  10. 10.
    Gettman MT, Blute ML, Chow GK, Neururer R, Bartsch G, Peschel R (2004) Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system. Urology 64:914–918CrossRefPubMedGoogle Scholar
  11. 11.
    Benway BM, Bhayani SB, Rogers CG et al (2009) Robotic partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional comparison of over 200 procedures. J Urol 182:866–873CrossRefPubMedGoogle Scholar
  12. 12.
    White MA, Haber GP, Autorino R et al (2011) Outcomes of robotic partial nephrectomy for renal masses with nephrometry score of ≥7. Urology 77:809–813CrossRefPubMedGoogle Scholar
  13. 13.
    Dulabon LM, Kaouk JH, Haber GP et al (2011) Multi-institutional analysis of robotic partial nephrectomy for hilar versus nonhilar lesions in 446 consecutive cases. Eur Urol 59:325–330CrossRefPubMedGoogle Scholar
  14. 14.
    Patel MN, Krane LS, Bhandari A et al (2010) Robotic partial nephrectomy for renal tumors larger than 4 cm. Eur Urol 57:310–316CrossRefPubMedGoogle Scholar
  15. 15.
    Laydner H, Autorino R, Spana G et al (2012) Robot-assisted partial nephrectomy for sporadic ipsilateral multifocal renal tumours. BJU Int 109:274–280CrossRefPubMedGoogle Scholar
  16. 16.
    Minervini A, Serni S, Tuccio A et al (2012) Simple enucleation versus radical nephrectomy in the treatment of pT1a and pT1b renal cell carcinoma. Ann Surg Oncol 19:694–700CrossRefPubMedGoogle Scholar
  17. 17.
    Minervini A, Serni S, Tuccio A et al (2011) Local recurrence after tumour enucleation for renal cell carcinoma with no ablation of the tumour bed: results of a prospective single-centre study. BJU Int 107:1394–1399CrossRefPubMedGoogle Scholar
  18. 18.
    Minervini A, Vittori G, Lapini A et al (2012) Morbidity of tumour enucleation for renal cell carcinoma (RCC): results of a singlecentre prospective study. BJU Int 109:372–377CrossRefPubMedGoogle Scholar
  19. 19.
    Ficarra V, Novara G, Secco S et al (2009) Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery. Eur Urol 56:786–793CrossRefPubMedGoogle Scholar
  20. 20.
    Khalifeh A, Autorino R, Eyraud R, et al. Three-year oncologic and renal functional outcomes after robot-assisted partial nephrectomy. Eur Urol 64(5):744–50.
  21. 21.
    Ficarra V, Galfano A, Cavalleri S (2009) Is simple enucleation a minimal partial nephrectomy responding to the EAU Guidelines’ recommendations? Eur Urol 55:1315–1318CrossRefPubMedGoogle Scholar
  22. 22.
    Cambio AJ, Evans CP (2006) Management approaches to small renal tumors. BJU Int 97:456–460CrossRefPubMedGoogle Scholar
  23. 23.
    Van Poppel H, Da Pozzo L, Albrecht W et al (2007) A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 51:1606–1615CrossRefPubMedGoogle Scholar
  24. 24.
    Benway BM, Bhayani SB, Rogers CG et al (2010) Robot-assisted partial nephrectomy: an international experience. Eur Urol 57:815–820CrossRefPubMedGoogle Scholar
  25. 25.
    Rosenthal CL, Kraft R, Zingg EJ (1984) Organ-preserving surgery in renal cell carcinoma: tumor enucleation versus partial kidney resection. Eur Urol 10:222–228PubMedGoogle Scholar
  26. 26.
    Blackley SK, Ladaga L, Woolfitt RA, Schellhammer PF (1988) Ex situ study of the effectiveness of enucleation in patients with renal cell carcinoma. J Urol 140:6–10PubMedGoogle Scholar
  27. 27.
    Touijer K, Jacqmin D, Kavoussi LR et al (2010) The expanding role of partial nephrectomy: a critical analysis of indications, results, and complications. Eur Urol 57:214–222CrossRefPubMedGoogle Scholar
  28. 28.
    Minervini A, Ficarra V, Rocco F et al (2011) Simple enucleation is equivalent to traditional partial nephrectomy for renal cell carcinoma: results of a nonrandomized, retrospective, comparative study. J Urol 185:1604–1610CrossRefPubMedGoogle Scholar
  29. 29.
    Minervini A, Serni S, Di Cristofano C, Carini M (2009) Rebuttal from authors re: Vincenzo Ficarra, Antonio Galfano and Stefano Cavalleri. Is simple enucleation a minimal partial nephrectomy responding to the EAU guidelines’ recommendations? Eur Urol 55:1319–1320CrossRefPubMedGoogle Scholar
  30. 30.
    Minervini A, Raspollini MR, Tuccio A, et al. (2013) Pathological characteristics and prognostic effect of peritumoral capsule penetration in renal cell carcinoma after tumor enucleation. Urol Oncol. doi: 10.1016/j.urolonc.2013.07.018

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Andrea Minervini
    • 1
    • 3
    Email author
  • Agostino Tuccio
    • 1
  • Lorenzo Masieri
    • 1
  • Domenico Veneziano
    • 2
  • Gianni Vittori
    • 1
  • Giampaolo Siena
    • 1
  • Mauro Gacci
    • 1
  • Graziano Vignolini
    • 1
  • Andrea Mari
    • 1
  • Arcangelo Sebastianelli
    • 1
  • Matteo Salvi
    • 1
  • Sergio Serni
    • 1
  • Marco Carini
    • 1
  1. 1.Department of Oncology, Urologic Clinic IUniversity of Florence, Careggi HospitalFlorenceItaly
  2. 2.Ospedali Riuniti BMMReggio CalabriaItaly
  3. 3.Clinica Urologica I, Azienda Ospedaliera CareggiUniversità di Firenze, San Luca NuovoFlorenceItaly

Personalised recommendations