mally invasive nephron sparing surgery, and whether theuse of robotics for partial nephrectomy will become as com-monplace as its use for the treatment of prostate cancer.

Mark L. GonzalgoDepartment of Urology

The James Buchanan Brady Urological InstituteThe Johns Hopkins Hospital

Baltimore, Maryland

1. Caruso RP, Phillips CK, Kau E, Taneja SS and Stifelman MD:Robot assisted laparoscopic partial nephrectomy: initial ex-perience. J Urol 2006; 176: 36.

2. Rogers CG, Singh A, Blatt AM, Linehan WM and Pinto PA:Robotic partial nephrectomy for complex renal tumors: sur-gical technique. Eur Urol 2007; Epub ahead of print.

REPLY BY AUTHORS

LPN is now being performed for tumors with anatomicalcomplexity similar to tumors treated with open surgery. Weagree that emerging biological agents are likely to simplifyrenal hemostasis and repair. However, intraoperative ad-versity is never quite individually predictable. Therefore,

ready facility with laparoscopic skills will remain an inte-gral requirement.

Our recently developed early unclamping technique de-creases LPN ischemia time by more than 50% to a mean of13.9 minutes. Since the hilum is unclamped early, this tech-nique is associated with 100 ml greater intraoperative bloodloss compared to conventional LPN. However, unmaskingthese bleeders allows us to securely suture ligate them un-der vision. As a result, our postoperative hemorrhage ratehas decreased to 2%. As such, it is likely that operative EBLmay no longer be a predictor of postoperative hemorrhagewith this early unclamping technique (reference 4 in article).

Currently speculative advantages of robotic LPN are justthat.1 The renal terrain is considerably less forgiving thanthe prostate. Consequences of technical short cuts can becatastrophic and there is no reliable substitute for skilledsutured hemostasis of the partial nephrectomy bed.

1. Aron M, Koenig P, Kaouk JH, Nguyen MM, Desai MM and GillIS: Robotic and laparoscopic partial nephrectomy: matchedpair comparison from a high volume center. Unpublisheddata.

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