Minimally invasive nephron-sparing surgery.

Open partial nephrectomy, with its excellent 5- and 10-year oncologic follow-up data, is the gold standard against which all other nephron-sparing alternatives must be compared. The evolving minimally invasive nephron-sparing alternatives can essentially be divided into three categories: excision (laparoscopic partial nephrectomy), probe ablation (eg, cryotherapy, radiofrequency ablation), and noninvasive ablation (high-intensity focused ultrasound). A proposed algorithm for the evolving indications of minimally invasive nephron-sparing surgical options is presented in Fig. 23. Currently, by emulating the established techniques of open partial nephrectomy, laparoscopic partial nephrectomy has the most immediate clinical application and relevance. Emerging data support the efficacy and reproducibility of renal cryotherapy. Five-year follow-up data should be available in the near future. Although renal radiofrequency ablation has the potential to further minimize morbidity, serious concerns remain regarding the completeness of cancer cell kill and the reliability of intraoperative monitoring. Noninvasive technologic advancements such as high-intensity focused ultrasound have considerable potential for the future.