The Physiologic and Anesthetic Considerations in Elderly Patients Undergoing Robotic Renal Surgery

A number of patients are diagnosed with renal malignancies incidentally worldwide. Once a diagnosis of a renal malignancy is established, after a careful evaluation, patients can be offered a robotic nephrectomy or partial nephrectomy. We present a review of the physiologic and anesthetic considerations in elderly patients who are being considered for robotic renal surgery.Key words: Robotic partial nephrectomy, Robotic radical nephrectomy, Physiologic considerations, Anesthetic considerationsFrom the mid-1970s through the mid-1990s, the incidence of renal cell cancer (RCC) has risen by approximately 3% per annum in the United States¹ and 2.5% per annum in northern England.² The main reason for an increase in the incidence of RCC is the increased detection of early and pre-symptomatic tumors by routine radiologic imaging.² Urologists are now seeing more patients with RCC at early stages (T1) and offering these patients a robotic partial nephrectomy (RPN) or robotic radical nephrectomy (RRN) if the surgical expertise is available.³ A minimally invasive partial nephrectomy for small renal masses has been reported to show excellent functional and oncologic outcomes, with 5- to 10-year cancer-specific survival rates of 95% to 100%.⁴Many of the patients with newly diagnosed RCC are of advanced age and/or have some major comorbidity that often results in their poor performance status. It is envisaged that with an increase in life expectancy, urologists and urologic oncologists will see an increase in new referrals of RCC.⁵With the introduction of robotic renal surgery in the United Kingdom, it is likely that more patients will undergo an RRN/RPN over the next decade. Current literature supports the use of RPN in patients versus laparoscopic partial nephrectomy (LPN) due to a reduction in the warm ischemia time (WIT).⁶ This factor is of crucial importance in patients with a solitary kidney or patients with renal impairment undergoing a partial nephrectomy. The WIT reduces with RPN when compared with LPN.⁷We present a review of the important physiologic and anesthetic considerations in patients being considered for an RPN or RRN.