Objectives: Radical nephrectomy (RN) is the mainstay surgical treatment for localized kidney tumors not amenable to partial resection. A huge development in the surgical approach has been recorded with the first laparoscopic assisted radical nephrectomy (LARN) reported in 1991 and a little more than a decade later, the utilization of robotic assisted radical nephrectomy (RARN) has become popular worldwide. We aimed to compare the outcome of RARN vs. LARN regarding safety, feasibility and efficiency.
Methods: A systematic review was conducted using PubMed, Cochrane, PMC PubMed central and Google Scholar using relevant search terms including nephrectomy, radical, robotic and laparoscopic. All papers published and available till January 2025 were included in our study.
Results: Across the included studies, operative time varied significantly between RARN and LARN. While early studies reported longer durations for RARN, more recent analyses have demonstrated narrowing differences, with some reporting comparable operative times. Variability was attributed to factors such as robotic docking time, higher BMI, and more complex cases in RARN cohorts. Estimated blood loss (EBL) was consistently lower in the RARN group, with studies reporting significantly reduced mean EBL. Length of hospital stay (LHS) was comparable or shorter with RARN in most studies, with some reports of successful same-day discharges. Postoperative pain management showed a trend toward reduced analgesia requirements in RARN, suggesting improved patient comfort. Complication rates were low and comparable in both groups, with some studies indicating a slight advantage for RARN in intraoperative and postoperative outcomes. Warm ischemia time (WIT), relevant in donor nephrectomy, was marginally longer with RARN but not clinically significant. Additionally, RARN demonstrated significant ergonomic benefits for the surgeon, reducing musculoskeletal strain and fatigue. However, the overall procedural cost for RARN remained higher, driven primarily by equipment and maintenance expenses.
Conclusion: Robotic Assisted Radical Nephrectomy has multiple advantages and can be even safer than the laparoscopic approach on comparing the perioperative outcomes. With wider usage and availability around the world, the cost-effectiveness of RARN will also improve.

Keywords

Nephrectomy, radical nephrectomy, robotic assisted nephrectomy, minimally invasive nephrectomy, renal cancer

Renal cancer is the fourteenth most common cancer worldwide affecting around 434,840 in 2022 [1], wherein Clear Cell Renal Cell Carcinoma (ccRCC) represents 70% of the adult renal cancer. Renal Cell Carcinoma (RCC) is the sixteenth most common cause of cancer death [1]. The risk factors include male gender (1.7:1, M: F), older age, high blood pressure and most importantly tobacco smoking. Depending on the physical, physiological and clinical presentation, management approaches to RCC greatly vary. It can range from conservative options such as watchful waiting (WW) and active surveillance (AS), to surgical and radiological options such as, partial and radical nephrectomy as well as thermal ablation [2]. While WW is mainly applied to elderly/unfit/frail patients with adverse perioperative outcomes with poor oncological outcomes, AS with serial imaging is another method used mainly for small suspected RCC < 4 cm in comparatively fitter patients.
Radical Nephrectomy (RN) is the gold standard surgical option for treatment of > T2 tumors, where tumor is surgically amenable. Depending on surgeon, hospital, patient choice and tumor factors, RN can also be offered to T1 patients [2].
The pace of uptake of robotic radical nephrectomy has been relatively slower compared to other procedures such as robotic radical prostatectomy, robotic partial nephrectomy or robotic pyeloplasty. This is likely due to the less overt advantages that the robotic approach offers compared to pure laparoscopy, for radical nephrectomy. The first reported case of robotic assisted laparoscopic nephrectomy was in 2001 by Guillonneau et al. [3] performed on a non-functioning kidney. Since then, robotic nephrectomy has gained more popularity and demonstrated positive results, both in patient and surgeon factors. This has been due to the technical advancements such as finer manipulations, three-dimensional (3D) views, greater range of movement and improving surgeon ergonomics. The use of RARN has increased from 1.5% in 2003 to 27% in 2015 [4]. In this comprehensive literature review, we aim to compare the outcomes of RARN versus LARN and attempt to evaluate its progress since the first reported case in 2001 to now in 2025.

Search strategy

Our review database included PubMed, PMC PubMed Central, Cochrane, and Google Scholar. The search terms included: “Nephrectomy”, “Radical Nephrectomy”, “Robotic Assisted Nephrectomy”, “Laparoscopic Nephrectomy”, “Renal Cell Carcinoma”, “Renal Cancer”.

Inclusion and exclusion criteria

The following inclusion criteria were used: 1) Studies published in English Language only; 2) Studies performed in adults; 3) Evaluation of at least one perioperative outcome such as Operating time (OT), estimated blood loss (EBL), length of hospital stay (LHS), warm ischemic time (WIT) and complications; 4) Robotic donor nephrectomies (RDN) vs laparoscopic donor nephrectomy (LDN).
The exclusion criteria were as follows: 1) Reviews; 2) Pediatrics studies; 3) Studies on partial nephrectomy only; 4) Studies in languages other than English.
We have included all studies since 2006 - January 2025.

Data collection

We performed an extensive web search of studies using the above-mentioned terms. The initial result includes 639 papers. Abstract and manuscripts were screened, and a total 23 reviews were selected based on the inclusion criteria using the PRISMA chart (Figure 1). Data analysis was done using the Microsoft Excel sheet. The summary of all the studies included are in (Table 1). A summary of findings between robotic and laparoscopic as per the studies included is found in (Table 2).

Operation time

Patient safety and length of hospital stay are two important aspects considered when developing any new technique/ intervention. Operative time is defined as the total duration of a surgical procedure, encompassing the period from the initial incision to the final closure [27]. Nazemi et al. [5] in their early study in 2006 found that RARN required longer operative time (345 min in RARN arm vs 237.5 min in LARN arm). This study was in the nascent phases of RARN as robotic nephrectomy had only been introduced at their institute in 2001 and the study was concluded in 2004. All the 57 recorded surgeries were performed by the same surgeon. RARN showed comparable outcomes to LARN and these have been discussed in more details in relevant sections in this article.
Helmers et al. [6] and Yang et al. [7] found comparable operative times in both cohorts with no statistically significant difference in the two groups. Both these studies, reported more than 10 years after Nazemi et al. [5], demonstrate an improvement in operative times from ~300 min to ~150 min in the RARN arm.
Similarly, Anele et al. [8] in 2019 demonstrated an average operating time of 185 min in RARN arm vs 126 min in the LARN arm, which was statistically significant, however they also noted that the RARN arm involved more lymph node dissection (LND) and was used in patients with a higher body mass index, which might have contributed to the increased time. It was also of note in this study that the post-operative histopathology in RARN study showed a higher incidence of advanced disease (T3-4) (52.5% vs 24.2%) thereby indicating that the RARN cohort might have been more surgically complicated.
Takagi et al. [9] in their retrospective study on the learning curves for RARN vs LARN found that the surgeons needed 26 RARN procedures to achieve proficiency vs 23 LARN procedures for the laparoscopic surgery, and both these improvements in proficiency were statistically significant. They also noted, that more experienced surgeons had a smaller number of cases needed to achieve proficiency (Table 2).

Estimated blood loss (EBL)

Multiple studies and analyses have evaluated the intraoperative estimated blood loss (EBL) between RARN and LARN. The estimation of intra-operative blood loss as well as post-operative blood transfusion have a huge impact on morbidity and mortality related to any surgical intervention while also being a key indicator of perioperative safety.
In a retrospective study in 2015 in Taiwan, Hu et al. [10] found significantly smaller blood loss in the RARN arm (mean = 68.89 mL) vs the Laparoscopic hand assisted arm (mean = 358.33 mL).
Overall, the EBL with RARN was either equivalent [5, 7] or more commonly, reported as reduced compared to LARN [6, 9]. This was likely related to the superior 3D visualization and finer manipulation available when using the robot which offers superiority in performing vascular dissection and hemostasis. The third ‘retraction’ arm afforded by the robotic technique allows for improved traction that enables better visualization of vascular structures and focused coagulation prior to dissection. It also allows for better exposure and visualization of bleeders for quick and focused control.

Length of hospital stay (LHS)

Length of hospital stay forms an important factor in the economic landscape of elective surgeries in healthcare. Therefore, a reduction in LHS with stable or improving patient safety profile is important in acceptance and diffusion of new surgical techniques.
When looking at the trend of peri-operative outcomes with evolution of robotic nephrectomy, LHS has shown significant reduction. All the reported studies have shown comparable outcomes [7, 9-12] or a significantly shorter length of stay in RARN arm when compared to LARN [13]. Studies such as Hu et al. [10] in 2015, Crocerossa et al. [14] and Grimaud et al. [15] in 2021 and Windisch et al. [16] in 2022 all demonstrate a significantly shorter LHS in RARN arm as compared to LARN arm.
In 2021 Ragavan et al. [17] reported the first day-case robotic nephrectomies. They included simple nephrectomies (n = 7), radical nephrectomies (n = 15) along with radical nephrectomy with para-aortic lymphadenectomy (n = 5), and adrenalectomy (n = 5)] in the upper-tract surgery. Their results with 0% readmission rates and no major post-operative complications (Clavien-Dindo grade > I) demonstrate a very positive trend in the direction of robotic surgery.

Pain Management

Post-operative pain management after RARN and LARN can have significant impact on LHS and patient morbidity. Most published papers showed minimal use of analgesia post-surgery in both approaches. Boger et al. [18] in 2010 showed the average use of opioids in form of oral morphine solution was 30 mg in RARN as compared to 33 mg in LARN. This compared to the earlier study conducted by Nazemi et al. [5] in 2006 found a larger difference in morphine usage; with 19 mg post RARN vs 30 mg post LARN, when they initially transitioned from open to robotic surgery.
The lesser use of analgesia between the two approaches was again attributed to finer movement and manipulation offered by robotic instrument stability which caused less tissue damage. The lesser use of analgesia could also be attributed to the advanced training and increased experience of the robotic surgeons.

Complication rate

Complication rates are a central consideration in evaluating the safety of minimally invasive techniques for any surgical intervention. It is reported using the Clavien–Dindo scale [31]. Multiple studies have assessed whether RARN confers a higher or lower risk of intraoperative and postoperative complications compared to LARN.
In his study, Nazemi et al. [5], the complication rates were 1% for RARN and 2% for LARN, demonstrating more superior perioperative outcome when using the robotic approach. The authors concluded that both approaches were equally safe, and the choice of surgical modality should be based on surgeon experience and institutional resources rather than concerns over safety.
In their systematic review Hinojosa-Gonzalez et al. [19] for donor nephrectomies, found a lower overall complication rate in robotic group (n = 397) vs laparoscopic group(n = 542), even though not significantly significant ( p= 0.95). Both approaches were associated with low rates of intraoperative complications and conversions to open surgery, with minor complications such as ileus, wound issues, and urinary tract infections comprising the majority of adverse events.
In the meta- analysis conducted by Li J et al. [20], the authors concluded that intraoperative complications were lower in RARN, but postoperative ones were higher in comparison to LARN, intraoperative complications (OR, 1.13; 95% Cl, 0.61, 2.12; p= 0.62), postoperative complications (OR, 1.07; 95% Cl, 0.68, 1.67; p= 0.62).
In a retrospective single-center study by Windisch et al. [16], RDN had a smaller complication rate at 1.4% as compared to LDN at 1.9%. Similarly, a prospective analysis by Palese et al. [21] reported a difference in complication rates between the two techniques, reinforcing the notion that RDN is a safer alternative to LDN when performed in high volume centers by experienced surgeons.

Warm ischemic time (WIT)

WIT is a vital factor in donor nephrectomy; it is defined as the interval between arterial clamping and cold perfusion of the kidney. A shorter WIT is usually clinically associated with improved immediate graft function, although small variations are accepted (< 10 min) and may not significantly impact long-term outcomes [22]. Comparative analyses between RDN and LDN have shown a consistent, albeit small, increase in WIT associated with the robotic approach.
Hinojosa-Gonzalez et al. [19] performed a systematic review and meta-analysis including twelve studies and it showed that RDN was associated with a statistically significant increase in WIT compared to LDN, with a mean difference of 1.14 min(95% CI: 0.65–1.63 minutes, p < 0.0001). Despite this finding, the clinical effect on the graft function was negligible, and no significant differences in delayed graft function were observed.
A retrospective comparison between RDN and Laparoscopic Hand-Assisted DN (HADN) conducted by Windisch et al. [16], reporting no significant difference in WIT (RDN: 221 seconds vs LDN: 213 seconds; p= 0.446). Although operative times were longer in RDN, the approach was associated with a shorter LHS and reduced postoperative analgesia requirements.
Notably, a prospective study by Palese et al. [20] found no significant difference in WIT between RDN and LDN (mean WIT for both: 4.75 ± 1.54 min), underscoring that with optimized technique and experience, robotic approaches can match laparoscopic efficiency.

Oncological outcomes

The cancer specific survival (CSS) post-surgery for clear cell RCC is 80% as per EAU guidelines [2]. Hemal et al. [10] in their short term follow up of 8-9 months did not find any significant difference in the oncological outcome when comparing RARN with LARN. This was the only study we found that directly compared the robotic and laparoscopic nephrectomy arms in terms of the oncological survival.
Sands et al. [12] and Grimaud et al. [15], compared the surgical margin as part of their study, and found no difference in post-op surgical margin. However, more long-term data is currently needed to concretely conclude any advantage in oncological outcomes when comparing the two arms.

Surgeon ergonomics

Surgeon ergonomics is a critical yet often underappreciated aspect of surgical performance. RARN offers significant ergonomic advantages over LARN. In robotic surgery, the surgeon operates from a seated, console-based platform with ergonomic hand controls and high-definition 3D visualization, which reduces musculoskeletal strain and cognitive load. According to the International Ergonomic Association, ergonomics can be defined as the understanding of the interactions amongst human and other elements of a system, and the optimisation of the environment to best fit a human work’s requirements [23]. Major muscle groups used in laparoscopic surgery were identified and assessed including shoulder abductors and adductors, arm flexors and extensors, elbow flexors and extensors in addition to the wrist and hand fine movement, all these muscle groups were less activated in the robotic group when compared to the laparoscopic surgeons [24]. These ergonomic benefits are not only essential for surgeon comfort but also translate into improved surgical precision, reduced operative time in experienced hands, and improved and increased surgeon career longevity.
The existing literature directly comparing RARN vs LARN falls short of considering the surgeon ergonomics in their outcomes. This might be difficult to analyze for longer term benefit just yet, however in their 2024 study, Pérez-Salazar et al. [25] conducted simulator and experimental model surgical procedure and found robotic surgery to provide better ergonomic comfort to surgeons as compared to laparoscopic surgery.

Cost

Several studies have evaluated the economic implications of RARN compared to LARN, demonstrating increased overall cost with the robotic approach. Higher cost of maintenance and disposable instruments are the main two contributors to this. Gershmann et al. [26] has identified an average increase of about $1400 in the operation cost when using the robot. This was however associated with improved perioperative outcomes. More studies comparing the cost-effectiveness of RARN vs LARN can help global medicine in the future.

The first laparoscopic nephrectomy was successfully performed in 1990 by Ralph Clayman [28] after observing the general surgeons and laboratory experiments. The LHS for this patient was only 6 days with an operative time of 7 hours. Within 5 years of the first LARN, Winfield et al. [29] reported a short case series of partial nephrectomy.
The typical laparoscopic nephrectomies require that the surgeon and the assistant remain standing throughout the surgery. The assistant is required to hold the camera steady and occasionally assist with the instruments. The classical LARN are done via 3-4 port sites.
Around the same time the first robotic surgery was being performed, this was developed using the National Aeronautics and Space Administration (NASA) inspired technology [32]. At Stanford Research Institute they used the combination of three-dimensional (3-D) environment with robotic telemanipulation. In 1985, neurosurgical biopsies were taken using Programmable Universal Machine for Assembly 200 [32]. The first documented urological utilization of this technique was in 1991 by Davies et al. [33] for prostatectomies. Within a decade the first reported case series of RARN [3] reported increased operative times, but comparable outcomes.
The main advantages of RARN include the 3-dimensional visualization of intra-abdominal viscera along with magnification and increased instrument maneuverability, which in turn reduce the intra-operative and post-operative morbidity. It also gives the added advantage of ergonomic benefit for the surgeon as the head, foot and hand console can be adjusted to the surgeon’s physique and the assistant can also adjust the bed height, based on their physique.
We found that RARN has multiple advantages when compared to the well-established LARN approach. These advantages are mainly attributed to the advanced technology offered by the robotic system such as 3D visualization, the finer movement and less tissue trauma. Although it is thought to have longer operative time initially [5, 7] the increased experience of the surgeons performing this approach as well as its widespread usage allows to shorten this to almost equivalent time required for the LARN. Notably, the robotic approach involved more frequent lymph node dissection (LND) and greater median node count [25], compared to LARN in these studies that compared operation time.
In multivariable analyses Gershmann et al. [26] found RARN remained independently associated with a lower risk of intraoperative (odds ratio [OR] 0.50; p= 0.001) and postoperative complications (OR 0.72; p < 0.001). Klingler et al. [30] demonstrated a median tumor size of 66 cm3 (29-120) when using the Da Vinci system in RARN. Multiple different robots are available and currently being used across the world such as Da Vinci and Da Vinci Xi [34]; along with HugoTM [35] with ongoing progress in technology.
Some of the evolving changes in the new robots are the transition from a head console to a screen with hand and finger controls in HugoTM [35] and the introduction of joystick handler for control in VersiusTM [36].
Petros et al. [37] have concluded that RN allows for consistent outcomes regardless of procedure complexity. Which reinforces the advantage of the robotic approach in more challenging cases. We did not find a significant drop in blood loss using either RARN or LARN, although some studies suggested a reduction in EBL when using the robotic approach [9, 13].
Both approaches are considered minimally invasive with the RARN associated with fewer intra and post-operative complications on the Clavien–Dindo scale, shorter LHS and improved surgeon ergonomics. It has already demonstrated that it has long term advantages and potential for continued development with improving elements in the robot systems. Therefore, in our study we find robotic nephrectomy a suitable and promising progression from laparoscopic nephrectomy in terms of minimally invasive surgery. With wider usage of this technology, the cost effectiveness will also improve and this in turn can create more space for further patient and surgeon factor analysis in the field of robotic surgery.

Since its introduction, robotic surgery has shown immense promise and potential. This literature review, reflecting at the timeline of robotic surgery from 2006 till now helps highlight the safety profile and the ongoing improvement in patient safety with robotic surgery. With progress to day case robotic surgery and robotic nephrectomies, it would be helpful to see long-term outcomes for patients and surgeons. We recommend more research incorporating long term outcomes for both patients and surgeons, with greater emphasis on patient-centered measures such as postoperative pain, return to normal activities along with quality of life and surgeon outcomes and longevity.

Funding

None.

Competing interests

All authors declare that they have no competing interests.

Ethical statement

Not applicable.