A modified strategy in robot-assisted laparoscopic partial nephrectomy for localized renal tuberculosis: the “unroofing and base excision” technique and clinical outcomes

Introduction

Tuberculosis remains one of the major infectious diseases threatening global health. According to the World Health Organization’s annual tuberculosis report, an estimated 10.8 million new cases and 1.25 million deaths from tuberculosis occurred worldwide in 2023 (1). Genitourinary tuberculosis is the second most common form of extrapulmonary tuberculosis, with over 90% of cases reported in developing countries (2,3). Renal tuberculosis is the most frequent clinical manifestation of genitourinary tuberculosis (2-4). Due to its insidious onset and lack of obvious early symptoms, renal tuberculosis is often misdiagnosed or overlooked. Consequently, most patients present at an advanced stage and miss the optimal window for treatment, particularly in developing countries (2,3,5). Renal tuberculosis may spread to other genitourinary organs. Moreover, Mycobacterium tuberculosis can persist in renal lesions even after adequate anti-tuberculosis therapy (4,6-8). As a result, patients with advanced renal tuberculosis often require nephrectomy (9-13). Nephrectomy can significantly impair patients’ quality of life and place a considerable burden on their families and society, especially in cases of bilateral renal tuberculosis or a solitary kidney. In developing countries, it is not uncommon for patients with renal tuberculosis to lose their ability to work and fall into poverty due to nephrectomy. Therefore, early diagnosis and timely treatment of renal tuberculosis are particularly important.

In patients with localized renal tuberculosis, the lesions are confined to a specific portion of the renal parenchyma, while the remaining parenchyma remains functional. For these lesions, ureteral stent placement and percutaneous drainage are commonly used for treatment (14-16); however, these approaches have limitations, including incomplete clearance of lesions and a high risk of recurrence. Partial nephrectomy offers a feasible option for removing tuberculous lesions while preserving residual functional renal tissue (11,12,17), especially in patients with bilateral renal tuberculosis or a solitary kidney. Although partial nephrectomy is widely used for renal tumors, its application in renal tuberculosis remains limited, likely due to challenges such as multifocal lesions, poorly defined lesion boundaries, and extensive perirenal adhesions. Robotic surgery, with its enhanced visualization and precise surgical manipulation, significantly improves the success rate of partial nephrectomy, making it a suitable option for patients with localized renal tuberculosis. Nonetheless, research on robot-assisted laparoscopic partial nephrectomy for renal tuberculosis remains limited. Herein, based on a detailed understanding of the pathological characteristics of renal tuberculosis, we propose a modification to the conventional robot-assisted laparoscopic partial nephrectomy that allows for the complete removal of tuberculous lesions while maximizing the preservation of normal renal tissues. We have provisionally termed this approach the ‘unroofing and base excision’ technique. We present this article in accordance with the SUPER reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-696/rc).

Preoperative preparations and requirements

From September 2021 to April 2024, four patients with localized renal tuberculosis underwent modified robot-assisted laparoscopic partial nephrectomy at the Department of Urology, Guizhou Provincial People’s Hospital. The criteria for selecting patients with renal tuberculosis for partial nephrectomy were as follows: (I) no evidence of active tuberculosis; (II) the patient received at least 3 months of anti-tuberculosis drug therapy prior to surgery; (III) the urine tests for acid-fast bacilli smear and Mycobacterium tuberculosis DNA transitioned from positive to negative; (IV) the preoperative glomerular filtration rate (GFR) of the affected kidneys was greater than 20 mL/min; (V) radiological imaging revealed that tuberculosis lesions were confined to a few adjacent renal calyces without renal pelvic involvement; (VI) radiological imaging revealed that the remaining renal tissue preserved normal morphology and structure; (VII) radiological imaging revealed no signs of ureteral stiffness, thickening, or stenosis. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional ethics committee of Guizhou Provincial People’s Hospital (No. QKHJC20182793) and informed consent was obtained from all individual participants.

Step-by-step description

Here, we present a step-by-step description of the surgical technique developed by a surgeon who has performed over 700 robotic-assisted partial nephrectomies. The modified technique is designed to maximize the preservation of normal renal tissue. We also submit a video to help illustrate the process of “unroofing and base excision” technique (Video 1).

The surgery was performed using da Vinci Xi Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). The robotic instruments included a 30° downward-facing scope, ProGrasp forceps, monopolar curved scissors, and large needle drivers.

The surgery was performed using a transperitoneal approach. Patients were positioned laterally, with the affected side facing upward. An 8-mm camera port was placed at the intersection of the lateral border of the rectus abdominis and the level of the umbilicus. Two 8-mm robotic ports were inserted approximately 8 cm from each side of the camera port. Two 12-mm assistant ports were placed along the lateral border of the rectus abdominis in the lower abdomen. For right-sided procedures, an additional 8-mm robotic port was positioned below the xiphoid process for liver retraction.

The renal vein was identified by tracing the gonadal vein proximally into the renal vein on the left side, or into the inferior vena cava just below the hilum on the right side. The renal artery was located posterior to the renal vein and was circumferentially dissected to allow for the proper placement of bulldog clamps.

The approximate location of the lesions was determined based on preoperative imaging. Gerota’s fascia was incised, and dissection was performed along the renal capsule until the lesions were fully exposed. The surrounding fat was cleared circumferentially around the lesions, ensuring at least 2 cm of normal renal tissue was visible. The area around the lesions was covered with gauze. Exposure of the renal pelvis and ureter was essential to confirm the absence of lesion invasion and minimize the risk of intraoperative injury. A 1 cm incision was made in the weakened area at the top of the lesion cavity, and suction was quickly inserted to evacuate the lesion contents, minimizing the risk of intraperitoneal infection (Figure 1A). The incision was then enlarged to remove the lesion contents thoroughly. The lesion tops were maximally removed, resulting in a bowl-shaped structure of the remaining lesions, which enhanced the visibility of the surgical area and facilitated the identification of the lesion boundary (Figure 1B). This step was termed ‘unroofing’. Since the cavity wall lacks renal parenchyma and blood supply, the ‘unroofing’ process did not require clamping of the renal artery to minimize warm ischemia time. The cavity wall was then lifted to reveal the boundary between the lesions and the surrounding normal renal tissue, allowing for excision of the lesions about 0.2 cm from the cavity wall (Figure 1C). Proper tension was maintained to clearly identify the lesion boundary. Irrigation with sterile saline helped maintain a clear surgical field. For multilocular lesions, the septations were opened. To ensure complete removal of the tuberculosis lesions, the lesion base was opened from inside the cavity, and the lesions were gradually excised outward. Additionally, the lesion base can be opened at multiple locations to effectively remove complex and irregular lesions. Complete excision of the lesions created a U-shaped excision bed, which improved the efficiency of subsequent renorrhaphy and hemostasis (Figure 1D). This step was termed ‘base excision’. During the ‘base excision’ process, the renal artery was clamped if the bleeding disrupted the surgical field.

Figure 1 Modified ‘unroofing and base excision’ technique for localized renal tuberculosis. (A) A 1 cm incision was made in the weakened area at the top of the lesion cavity. (B) Maximal removal of the lesion tops created a bowl-shaped structure. (C) The cavity wall was lifted to reveal the boundary between the lesions and the surrounding normal renal tissue. (D) Complete excision of the lesions created a U-shaped excision bed. (E) The collecting system was closed using a 26-mm 3-0 V-Loc suture with five knots and a Hem-o-Lok clip at the free end. (F) The renal capsule was reapproximated using a 37-mm 2-0 V-Loc suture with five knots and a Hem-o-Lok clip at the free end.

Renorrhaphy was performed in two layers. The collecting system was closed using a 26-mm 3-0 V-Loc suture with five knots, and a Hem-o-Lok clip was applied at the free end (Figure 1E). The renal capsule was reapproximated using a 37-mm 2-0 V-Loc suture with five knots and a Hem-o-Lok clip at the free end (Figure 1F). After completing renorrhaphy, the renal artery was unclamped, and the excision bed was inspected for hemostasis.

Postoperative considerations and tasks

Clinical data were extracted from the medical record system, including age, sex, preoperative creatinine, preoperative GFR, preoperative urine acid-fast bacilli smear, preoperative urine Mycobacterium tuberculosis DNA, operative time, intraoperative blood loss, indwelling time of the abdominal drainage tube, length of postoperative hospital stay, perioperative complications, and pathological data. Lesion complexity was assessed using the RENAL nephrometry score system. Follow-up visits were conducted every 3 months during the first year and every 6 months thereafter, consisting of physical examination, serum creatinine measurement, renal dynamic imaging, and abdominal computed tomography. Descriptive analyses were used to summarize the perioperative data and clinical outcomes of the patients.

Patient demographics were summarized in Table 1. Four patients were included in this analysis, one of whom had a solitary kidney. All patients had unilateral disease and received quadruple anti-tuberculosis drug treatment prior to surgery. One patient had preoperative erythrocyte sedimentation rate (ESR) and serum creatinine level exceeding the upper limit of normal. The preoperative GFR of all affected kidneys was below 30 mL/min, indicating significantly compromised renal function on the affected side. The urine tests for acid-fast bacilli smear and Mycobacterium tuberculosis DNA were positive at initial diagnosis but turned negative after anti-tuberculosis drug treatment, suggesting a significant reduction in the activity and quantity of Mycobacterium tuberculosis. Imaging revealed that tuberculosis lesions were confined to several renal calyces at initial diagnosis, with no clear progression before surgery (Figure 2A). The RENAL scores of all patients were greater than or equal to 10.

Figure 2 Evaluation of renal tuberculosis lesions. (A) Preoperative imaging showing the localized renal tuberculosis lesions. (B) Positive PCR tests for Mycobacterium tuberculosis DNA in two surgical specimens. (C) Intraoperative image showing no signs of intraperitoneal tuberculosis dissemination. (D) Postoperative imaging showing the morphology and structure of the remaining renal tissue at the last follow-up visit. PCR, polymerase chain reaction.

Table 2 highlights the perioperative and follow-up outcomes. Although all patients received at least 3 months of preoperative anti-tuberculosis drug treatment, two surgical specimens tested positive for Mycobacterium tuberculosis DNA (Figure 2B). All surgeries were completed successfully, with no intraoperative complications or conversions to open surgery. In two cases, the warm ischemia time exceeded 30 minutes, partly due to severe adhesions between the tuberculosis lesions and surrounding tissues. None of the patients required blood transfusions. A small amount of lesion contents inevitably leaked into the abdominal cavity during the operation. However, none of the patients developed high fever, ascites, peritonitis, or intraperitoneal infection postoperatively. Moreover, one patient underwent augmentation cystoplasty 6 months later, with no signs of intraperitoneal tuberculosis dissemination observed during the procedure (Figure 2C). All postoperative complications were classified as Clavien-Dindo grade 1, and no patient required admission to the intensive care unit. All patients continued anti-tuberculosis drug treatment until completing a 1-year course. At the last follow-up visit, all patients maintained normal levels of ESR. The serum creatinine levels remained stable. The GFR of the affected side decreased by an average of 16.7%. The remaining renal tissue on the affected side maintained normal morphology and structure (Figure 2D).

Tips and pearls

Compared with the conventional approaches, the key steps of our technique include: (I) removing lesion tops maximally while preventing lesion contents from spilling into the abdominal cavity; (II) lifting the cavity wall to identify the boundary between the lesions and the surrounding normal tissue; (III) opening the lesion base from inside the cavity; (IV) opening the septations in multilocular lesions; (V) ensuring complete closure of the collecting system. The technique requires advanced laparoscopic and robotic skills, along with specific expertise in renal tuberculosis surgery. We recommend its initial application in carefully selected cases with single and peripheral lesions. Notably, conversion to radical nephrectomy should be considered if intraoperative exploration reveals more extensive lesions than anticipated from preoperative imaging or identifies involvement of the ureter or renal pelvis.

Discussion

Renal tuberculosis is a significant cause of renal dysfunction. In patients with renal tuberculosis who show negative urinalysis results after anti-tuberculosis drug treatment, 10–50% of renal specimens still test positive for Mycobacterium tuberculosis (4,6-8). In the present study, two out of four surgical specimens tested positive for Mycobacterium tuberculosis after at least 3 months of anti-tuberculosis drug treatment. This suggests that patients who receive only drug treatment may be at high risk of recurrence following drug discontinuation. Therefore, patients with renal tuberculosis may require surgical intervention to effectively eradicate lesions and prevent recurrence after drug discontinuation. Moreover, long-term use of anti-tuberculosis drugs often leads to various adverse effects such as hepatotoxicity and optic nerve damage, while surgical intervention can help shorten the treatment course. One of the primary therapeutic goals for localized renal tuberculosis is to avoid nephrectomy while preserving residual renal function. Ureteral stent placement and percutaneous drainage of renal tuberculosis lesions have several limitations, including incomplete clearance of lesions and a high risk of recurrence. Growing evidence suggests that partial nephrectomy can improve the prognosis and quality of life for patients with localized renal tuberculosis (11,12,17). Nevertheless, not all patients are suitable candidates for partial nephrectomy. Currently, there are no standard criteria for selecting patients with renal tuberculosis for partial nephrectomy. The key inclusion criterion in our study included: (I) the affected kidney must have a GFR of ≥20 mL/min. Otherwise, the affected kidney is considered to have limited functional preservation value; (II) lesions must be confined to adjacent calyces without renal pelvic or ureteral involvement. Involvement of renal pelvis or ureter risks retrograde infection of other calyces through contaminated urine; (III) patients must complete at least 3 months of anti-tuberculosis therapy and achieve negative results for urine analysis to minimize dissemination risk. Future studies are necessary to establish standard criteria to identify the most suitable patients with renal tuberculosis for partial nephrectomy.

Partial nephrectomy is commonly used in patients with renal tumors, as these tumors typically have an intact capsule, allowing for their complete removal along the capsule (18). In contrast, renal tuberculosis often presents as multiple irregular lesions without distinct boundaries and with severe adhesions to surrounding tissues. Conventional partial nephrectomy may lead to the removal of excessive healthy renal tissue in patients with renal tuberculosis. Therefore, the main surgical challenge is to fully excise the tuberculous lesions while preserving as much functional renal tissue as possible. Notably, there is currently limited evidence regarding the optimal surgical approach for treating renal tuberculosis, but minimally invasive options appear to be safe and comparable to open surgery (19). Our modified ‘unroofing and base excision’ technology provides the following advantages: (I) the ‘unroofing’ process generally does not require clamping of the renal artery to minimize the warm ischemia time; (II) the bowl-shaped structure formed after the ‘unroofing’ process enlarges the surgical field and facilitates the identification of the lesion boundary and the excision of lesions; (III) the bowl-shaped structure avoids accidental damage to the renal pelvis during lesion excision; (IV) the U-shaped excision bed formed after the ‘base excision’ process increases the efficiency of renorrhaphy and hemostasis; (V) the U-shaped excision bed prevents excessive needle insertion and unnecessary nephron damage. In our study, two patients had warm ischemia times exceeding 30 minutes, predominantly due to large lesion volumes, multifocal lesions, and dense adhesion to surrounding tissues. Notably, their decline in GFR was less than that of the other two patients. Three patients had a GFR decrease greater than 15%. Potential reasons include residual function of lesion tissues, excision of adjacent normal renal tissues, and nephron loss attributed to warm ischemia. Notably, the absolute decreases in GFR for the three patients were 7.8, 3.6, and 4.7 mL/min, respectively, which remained within an acceptable range. The relatively high percentage decrease in GFR may be attributed to the low baseline preoperative GFR values. To preliminarily compare the warm ischemia time and GFR decrease between the conventional strategy and our modified technique, we conducted a literature review. A relevant study on partial nephrectomy for renal tuberculosis involving five patients reported a median warm ischemia time of 25.0 (24.0–29.0) minutes and an average decrease in GFR of 9.6±9.0 mL/min (20). Our warm ischemia times (27, 25, 35, and 45 minutes) were slightly higher, potentially reflecting the complexity of our cases; however, our absolute GFR decreases (7.8, 3.6, 1.5, and 4.7 mL/min) remained comparable to the reported values. No major intraoperative complications occurred in our series. Both estimated blood loss and postoperative hospital stay fell within the reported ranges for conventional approaches (17,20-22).

During the procedure, the exposure of tuberculous lesions and the leakage of lesion contents are inevitable. Given that the primary challenge of our modified technique is preventing tuberculosis dissemination and intraperitoneal infection, it is critical to administer adequate preoperative anti-tuberculosis drug treatment. In our study, all patients received at least 3 months of anti-tuberculosis drug treatment prior to surgery, and preoperative urine tests for acid-fast bacilli smear and Mycobacterium tuberculosis DNA were negative. There is currently no standard consensus regarding the optimal timing of drug discontinuation. We required patients to complete a 1-year course of medication and be symptom-free before discontinuing drugs. In addition to medication, gauze placement around the tuberculosis lesions helped prevent dissemination and intraperitoneal infection. Rapid and thorough aspiration of lesion contents following the opening of the lesion cavity further minimized the risk. Here, none of the patients experienced local recurrence or distant dissemination during the follow-up period. Moreover, all patients maintained normal ESR levels, and none required reinitiation of drug therapy. Adjunctive local measures such as povidone-iodine and chemotherapy agent irrigation may help reduce the risk of local recurrence and distant metastasis. In our ongoing work, we plan to expand the cohort to 20 patients and investigate the clinical utility of intraoperative povidone-iodine and chemotherapy agent irrigation.

It is important to emphasize that our current study is a selected series aimed at proposing a modified surgical technique and testing its feasibility, and several limitations should be acknowledged. First, this study was a retrospective study involving a relatively small sample size. The reproducibility of ‘unroofing and base excision’ technique requires further confirmation with a larger sample size from multiple centers. Moreover, this study did not directly compare the efficacy of our modified approach with that of the conventional technique. We are actively establishing a multi-center collaboration with three medical centers. The subsequent study is designed to enroll 20 patients to validate the reproducibility and feasibility of our modified technique and to compare its perioperative and functional outcomes with conventional surgical approaches. Finally, the long-term prognosis associated with our modified approach should be further investigated in future studies. To obtain long-term and reliable clinical outcome data, we have established a 5-year follow-up plan for the patients. Follow up visits include chest and abdominal computed tomography (CT) scans, renal dynamic imaging, serum creatinine measurement, ESR test, and urine analysis every 3 to 6 months for the first 2 years, followed by every 6 to 12 months thereafter.

Conclusions

Our modified technique allows for the radical removal of tuberculosis lesions while maximizing the preservation of functional renal tissues. Therefore, we recommend implementing this approach to other centers seeking to develop robotic surgery for localized renal tuberculosis in the future.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-696/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-696/prf

Funding: The work was supported by National Natural Science Foundation of China (No. 82403994), Guizhou Provincial Basic Research Program (Natural Science) (No. QKHJCMS[2025]509), and Science and Technology Fund Project of Guizhou Provincial Health Commission (No. gzwkj2025-062).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-696/coif). All authors report that the work was supported by National Natural Science Foundation of China (No. 82403994), Guizhou Provincial Basic Research Program (Natural Science) (No. QKHJCMS[2025]509), and Science and Technology Fund Project of Guizhou Provincial Health Commission (No. gzwkj2025-062). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional ethics committee of Guizhou Provincial People’s Hospital (No. QKHJC20182793) and informed consent was obtained from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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