Search Results (18)

Introduction: In minimally invasive, off-clamp partial nephrectomy (ocMIPN), the reconstructive strategy profoundly influences functional outcomes. Traditional nephrometry scores aid preoperative planning but do not directly inform the choice of closure technique. This dual-institutional study aimed primarily to identify preoperative CT-derived parameters predictive of renorrhaphy versus a sutureless approach, and secondarily to compare perioperative and functional outcomes between these techniques. Methods: We retrospectively analyzed 201 consecutive ocMIPN cases performed using a standardized off-clamp technique by two experienced surgical teams across robotic platforms and conventional laparoscopy. Preoperative CT scans were centrally reviewed to quantify morphometric features, including contact surface area (CSA), tumor radius, and Gerota’s fascia thickness. Univariable and multivariable logistic regression models—one restricted to radiologic variables and one expanded with RENAL score terms—were generated to identify independent predictors. Perioperative outcomes, renal functional metrics, and Trifecta rates were compared between cohorts. Results: Among the 201 patients, 101 (50.2%) underwent sutureless reconstruction and 100 (49.8%) renorrhaphy. Cohorts were comparable at baseline except for tumor size (3.1 vs. 3.6 cm; p = 0.04). In multivariable analysis, CSA > 15 cm² (OR 3.93; 95% CI 1.26–12.26; p = 0.02) and tumor radius (OR 1.14 per mm; 95% CI 1.01–1.29; p = 0.04) consistently predicted renorrhaphy, while Gerota’s fascia < 10 mm emerged as significant only in the expanded specification (OR 0.08; 95% CI 0.01–0.70; p = 0.02). Integration with RENAL improved predictive performance (ΔAUC 0.06; NRI 0.14; IDI 0.07), and the final model demonstrated strong discrimination (AUC 0.81) with satisfactory calibration. Perioperative outcomes, postoperative renal function, and Trifecta achievement were similar between groups (all p ≥ 0.21). Conclusions: A concise set of CT-derived morphologic markers—CSA, tumor radius, and perinephric fascia thickness—anticipated reconstructive strategy in ocMIPN and augmented the discriminatory power of RENAL nephrometry. When anatomy was favorable, sutureless repair was not associated with statistically significant differences in perioperative safety or renal function, although the study was not powered for formal equivalence testing. These findings support the integration of radiologic markers into preoperative planning frameworks for nephron-sparing surgery. Full article

Background/Objectives: The optimal surgical approach for stage I renal cell carcinoma (RCC) in ultra-octogenarians remains debated, especially when balancing oncologic control, renal preservation, and procedural safety. While ablative techniques and active surveillance are often favored in frail patients, robust comparative evidence supporting nephron-sparing surgery in this age group is limited. Methods: We retrospectively reviewed consecutive patients aged ≥80 years who underwent minimally invasive surgery for cT1 clear cell RCC at a high-volume tertiary-care center between July 2001 and August 2025. Patients were stratified into two cohorts: minimally invasive partial nephrectomy (MIPN, n = 51) and radical nephrectomy (MIRN, n = 26). All MIPNs were performed using an off-clamp approach. Baseline, perioperative, functional, and oncologic outcomes were compared. Kaplan–Meier analysis estimated overall survival (OS), cancer-specific survival (CSS), and progression to significant chronic kidney disease (sCKD, defined as CKD stage ≥ 3b). Results: Groups were comparable in age, comorbidities, and ASA score. MIRN patients exhibited higher tumor complexity (RENAL score: 9 vs. 7, p = 0.01) and a greater proportion of pT1b lesions (77% vs. 37.3%, p = 0.01). Perioperative transfusions occurred exclusively in the MIRN group (p = 0.01), whereas complication rates were low and similar between groups. MIPN was associated with significantly higher eGFR at follow-up (48 vs. 30.9 mL/min/1.73 m², p = 0.01) and a delayed progression to sCKD (p = 0.01), with no differences in OS or CSS at a median follow-up of 30.5 months. Conclusions: In this real-world series of ultra-octogenarians with cT1 clear cell RCC, off-clamp minimally invasive partial nephrectomy ensured superior renal function preservation and delayed progression to sCKD, without compromising oncologic control at mid-term follow-up. Beyond statistical outcomes, these results underscore the importance of tailoring surgical strategies to protect long-term functional autonomy and preserve physiological resilience in elderly patients. Full article

Objective: To evaluate the perioperative outcomes, functional impact, and oncologic efficacy of off-clamp robotic-assisted partial nephrectomy (RAPN) in patients with renal masses across multiple high-volume centers. Materials and Methods: We conducted a retrospective multicenter study including 563 patients (group 1) who underwent clampless RAPN between January 2018 and December 2024. Patients with solitary kidneys, tumors >7 cm, or prior renal surgery were excluded. The standardized surgical technique involved tumor resection without clamping of the renal artery, followed by the use of hemostatic agents and standard/selective suturing of the resection bed on demand. Patients in group 1 were compared to 244 consecutive patients treated in the same centres and treated with RAPN with an on-clamp procedure (group 2). Primary outcomes included operative time, blood loss, and complications, while secondary outcomes assessed renal function preservation and oncologic control at an at least 12-month follow-up. Results: The median operative time was 118 min (IQR: 100–140 min), and median estimated blood loss was 150 mL (range: 50–400 mL). The overall complication rate was 9.2%, with most classified as Clavien–Dindo Grade I–II. No intraoperative conversions to open surgery were recorded. Renal function was well preserved, with a median estimated glomerular filtration rate (eGFR) decline of 4.1% at three months (p > 0.05), and no cases of acute kidney injury. Oncologic outcomes were favorable, with a positive surgical margin rate (PSM) of 2.4% and two cases of tumor recurrences (0.36%) documented at a 12-month follow-up. Conclusions: The off-clamp RAPN is a safe and effective nephron-sparing approach, offering significant renal function preservation while maintaining oncologic efficacy. This technique minimizes ischemia–reperfusion injury and post-surgical fibrosis, providing a viable alternative to on-clamp RAPN. Further prospective trials are warranted to confirm long-term benefits and refine patient selection criteria. Full article

Introduction: Available guidelines recommend performing nephron-sparing surgery in selected renal cell carcinoma (RCC) patients. Many studies provided robot-assisted partial nephrectomy (RAPN) functional and oncological outcomes, with most of these including a wide timespan and a number of surgeons with different experiences, which might lead to the heterogeneity of the results. In this study, we aim to provide a contemporary report of RAPN patient outcomes performed at two referral centers by experienced surgeons. Materials and Methods: Overall, 333 RAPN patients treated at two European referral centers between 2019 and 2021 were identified. Continuous and categorical variables were reported using medians and proportions. Multi-variable logistic regression (MLR) models were fitted to test predictors of off-clamp technique use and trifecta achievement. Results: The median age was 65 (IQR: 57–73) years. The clinical stage distribution was as follows: 224 (67%) cT1a vs. 89 (26%) cT1b vs. 20 cT2 (7%). The median warm ischemia time was 14 (10–18) minutes, with trifecta being achieved in 74% (n = 240) of patients. In MLR models predicting off-clamp surgery, an increasing R.E.N.A.L. score was independently associated with a lower chance of attempting such a technique (OR: 0.69, p-value < 0.001). In models predicting trifecta achievement, both a higher R.E.N.A.L. score (OR: 0.78, p-value = 0.007) and the presence of multiple lesions (OR: 0.29, p-value = 0.007) were independently associated with lower chances of reaching the outcome. Significant upstaging of chronic kidney disease (CKD) stage was recorded in 9.4% of patients after one year of follow-up. Conclusions: We reported the contemporary outcomes of patients treated with RAPN by highly experienced surgeons from two referral centers. This report represents a valid benchmark that could be used for individual patient counseling in the decision-making process. Full article

Incidences of kidney cancers are steadily increasing. The surgical resection of renal tumors remains the treatment of choice, and different techniques provide similar oncological outcomes. Minimally invasive methods, especially partial nephrectomy (PN), have emerged as the preferred method of tumor resection, both in traditional and robot-assisted laparoscopy. PN may be performed as an open or laparoscopic operation. On-clamp PN is a variant of PN that includes the clamping of renal vessels; off-clamp PN is performed without any ischemia. Objectives: To assess the short-term loss of eGFR after on-clamp and off-clamp PN. Methods: Data from 2021 to 2024 were retrospectively collected from a hospital database. The patients included in the study had a diagnosed kidney tumor that was confirmed by MRI or CT imaging. The patients were divided into two groups depending on the type of treatment they received: on-clamp PN or off-clamp PN. Hematocrit (HCT), hemoglobin (Hb) and eGFR were measured and compared. Results: Both groups had comparable preoperative HTC, Hb, and eGFR. eGFR loss 24 h after the procedure was 35.4% lower in the off-clamp group compared to the on-clamp group (p = 0.027). Conclusions: Off-clamp PN is a safe and viable method for kidney tumor resection, both in traditional and robot-assisted laparoscopy. This technique results in a smaller perioperative loss of eGFR, which relates to better short-term functional outcomes than on-clamp PN. Full article

The aim of our study is to evaluate the effectiveness and safety of a sutureless off-clamp robot-assisted partial nephrectomy (sl-oc RAPN), particularly its impact on renal function. A multicenter study was conducted from April 2021 to June 2022. Patients diagnosed with a renal mass of >2 cm and a PADUA score of ≤6 consecutively underwent an sl-oc RAPN procedure. Tumor features, patients characteristics, and intraoperative outcomes were assessed. An evaluation of renal function was performed preoperatively, and again at 1 and 3 months after surgery by measuring the creatinine and blood urea nitrogen levels. The renal function of the two separate kidneys was assessed by a sequential renal scintigraphy performed before and at least 30 days after surgery. A total of 21 patients underwent an sl-oc RAPN. The median age was 64 years (IQR 52/70), the median tumor diameter was 40 mm (IQR 29/45), and the median PADUA score was 4 (3.5/5). The intraoperative outcomes included operative time (OT), 90 (IQR 74/100) min; estimated blood loss (EBL), 150 (IQR 50/300) mL; and perioperative complications, CD > 3 1(5%); only two patients presented positive surgical margins in their final histology (2/21, 10%). Compared to the preoperative value, a decrease in renal function was highlighted with a statistically significant median decrease of 10 mL/min (p < 0.01). The renal scintigraphy showed an overall decrease in renal function compared to the preoperative value, with a range in the operated kidney that varied from 0 to 15 mL/s and from 0% to 40%, with a median value of 4 mL/s and 12%. sl-oc RAPN is a safe procedure, with a minimal impact on kidney function alteration. This technique has proven effective in preserving renal function and maintaining optimal oncological outcomes with limited complications. Full article

Background: To compare perioperative outcomes and trifecta rates between laparoscopic and robotic partial nephrectomies (PN) using the Hugo™ RAS System, a study was conducted between October 2022 and September 2023. Methods: Twenty-two patients underwent minimally invasive PN for cystic renal tumors at our institution (group A: RAPN = 6; group B: Laparoscopic PN = 16). The trifecta was defined as the coexistence of negative surgical margin status, no Clavien–Dindo grade ≥ 3 complications, and eGFR decline ≤ 30%. Continuous variables were presented as median and IQR and compared using the Mann–Whitney U test, while categorical variables were presented as frequencies (%) and compared using the χ² test. For all statistical analysis, a two-sided p-value < 0.05 was considered statistically significant. Results: All patients successfully underwent off-clamp minimally invasive PN without the need for conversion or additional port placement. Group A showed a lower preoperative eGFR rate and a higher clinical tumor size, while group B displayed a higher number of male patients and bilateral lesions. However, these differences were not statistically significant (all p > 0.1). Regarding perioperative data, group A showed a lower operative time (79.5 vs. 134.5 min, p = 0.01), while group B showed a higher trend of benign histology (62.5% vs. 33.3%). All the other perioperative data were comparable between the two groups (all p > 0.2). The rate of trifecta achievement was 83.3% and 87.5% (p = 0.80) for group A and B, respectively. Conclusion: This study emphasizes the advantages of RAPN over laparoscopic procedures in terms of operative time. Extensive experience in Laparoscopic PN could be a key factor when approaching RAPN learning curve. Full article

Objectives: To compare perioperative outcomes of patients treated with sutureless off-clamp robotic partial nephrectomy (sl-oc RAPN) by either a novice or an expert robotic surgeon at two different institutions. Methods: Data concerning two continuous series of patients with cT1-2N0M0 renal tumors treated with sl-oc RAPN either by a novice or an expert surgeon were extracted from prospectively populated institutional databases over the last 4 years. Perioperative outcomes as well as the baseline characteristics of patients and tumors were compared by using χ² and Mann–Whitney tests for categorical and continuous variables, respectively. A 1:1 propensity match score analysis (PMSa) generated two homogeneous cohorts. Logistic regression analysis was performed to assess predictors of trifecta outcomes, defined as negative surgical margins, no Clavien–Dindo ≧ 3 grade complications, and no ≧ 30% postoperative eGFR reduction. Results: Overall, 328 patients were treated by an expert surgeon, while 40 were treated by a novice surgeon. After PMSa analysis, two cohorts of 23 patients each were generated, homogeneous for all baseline variables (p ≥ 0.07). Hospital stay was the only significantly different outcome observed between the two groups (5 days vs. 2 days; p < 0.001). No statistically significant differences were recorded when comparing trifecta outcomes (expert: 100% vs. novice: 87%; p = 0.07). In the logistic regression analysis, no statistically significant predictors of trifecta outcomes were recorded. Conclusions: sl-oc RAPN is a feasible and safe nephron sparing technique, even when performed by a novice robotic surgeon. Full article

Few data are available on survival outcomes of partial nephrectomy performed for cystic renal tumors. We present the first long-term oncological outcomes of cystic (cystRCC) versus pure clear cell renal cell carcinoma (ccRCC) in a propensity score-matched (PSM) analysis. Our “renal cancer” prospectively maintained database was queried for “cystRCC” or “ccRCC” and “off-clamp robotic partial nephrectomy” (off-C RPN). The two groups were compared for age, gender, tumor size, pT stage, and Fuhrman grade. A 1:3 PSM analysis was applied to reduce covariate imbalance to <10% and two homogeneous populations were generated. Student t- and Chi-square tests were used for continuous and categorical variables, respectively. Ten-year oncological outcomes were compared between the two cohorts using log-rank test. Univariable Cox regression analysis was used to identify predictors of disease progression after RPN. Out of 859 off-C RPNs included, 85 cases were cystRCC and 774 were ccRCC at histologic evaluation. After applying the PSM analysis, two cohorts were selected, including 64 cystRCC and 170 ccRCC. Comparable 10-year cancer-specific survival probability (95.3% versus 100%, p = 0.146) was found between the two cohorts. Conversely, 10-year disease-free survival probability (DFS) was less favorable for pure ccRCC than cystRCC (66.69% versus 90.1%, p = 0.035). At univariable regression analysis, ccRCC histology was the only independent predictor of DFS probability (HR 2.96 95% CI 1.03–8.47, p = 0.044). At the 10-year evaluation, cystRCC showed favorable oncological outcomes after off-C RPN. Pure clear cell variant histology displayed a higher rate of disease recurrence than cystic lesions. Full article

Off-clamp partial nephrectomy represents one of the latest developments in nephron-sparing surgery, with the goal of preserving renal function and reducing ischemia time. The aim of this study was to evaluate and compare the functional, oncologic, and perioperative outcomes between off-clamp robot-assisted partial nephrectomy (off-C RAPN) and off-clamp open partial nephrectomy (off-C OPN) through a propensity score-matched (PSM) analysis. A 1:1 PSM analysis was used to balance variables potentially affecting postoperative outcomes. To report surgical quality, 1 year trifecta was used. Univariable Cox regression analysis was performed to identify predictors of trifecta achievement. The Kaplan–Meier method was used to compare cancer-specific survival (CSS), overall survival (OS), disease-free survival (DFS), and metastasis-free survival (MFS) probabilities between groups. Overall, 542 patients were included. After PSM analysis, two homogeneous cohorts of 147 patients were obtained. The off-C RAPN cohort experienced shorter length of stay (LoS) (3.4 days vs. 5.4 days; p < 0.001), increased likelihoods of achieving 1 year trifecta (89.8% vs. 80.3%; p = 0.03), lower postoperative Clavien–Dindo ≤ 2 complications (1.3% vs. 18.3%, p < 0.001), and lower postoperative transfusion rates (3.4% vs. 12.2%, p = 0.008). At univariable analysis, the surgical approach (off-C RAPN vs. off-C OPN, OR 2.22, 95% CI 1.09–4.46, p = 0.02) was the only predictor of 1 year trifecta achievement. At Kaplan–Meier analysis, no differences were observed between the two groups in terms of OS (log-rank p = 0.451), CSS (log-rank p = 0.476), DFS (log-rank p = 0.678), and MFS (log-rank p = 0.226). Comparing RAPN and OPN in a purely off-clamp scenario, the minimally invasive approach proved to be a feasible and safe surgical approach, with a significantly lower LoS and minor rate of postoperative complications and transfusions as a result of improved surgical quality expressed by higher 1 year trifecta achievement. Full article

Background/Objectives: The absence of validated tools to assess the skill transfer from laparoscopy to robotic surgery remains an unsolved issue in the context of robot-assisted partial nephrectomy (RAPN). We aimed to describe and validate a novel proficiency score to critically evaluate the surgical quality of RAPN with the Hugo™ RAS System (Medtronic, Minneapolis, MN, USA). Methods: Between October 2022 and September 2023, 27 consecutive patients underwent off-clamp RAPN for localized renal tumors at our institution. To analyze the learning curve (LC), the cohort was chronologically divided into two phases of 6 months each. Proficiency was defined as the achievement of trifecta while maintaining a comparable intraoperative time in the interquartile range of laparoscopic partial nephrectomy performed by the same surgeon. A logistic binary regression model was built to identify predictors of proficiency achievement. Results: A proficiency score was achieved in 14 patients (74.1%). At univariable analysis, number of consecutive procedures > 12 (OR 13.7; 95%CI 2.05–21.1, p = 0.007), pathological tumor size (OR 0.92; 95%CI 0.89–0.99, p = 0.04) and essential blood hypertension (OR 0.16; 95%CI 0.03–0.82, p = 0.02) were found to be predictors of proficiency score. At multivariable analysis, after adjusting for potential confounding factors, number of consecutive procedures > 12 (OR 8.1; 95%CI 1.44–14.6, p = 0.03) was the only independent predictor of proficiency score achievement. Conclusions: Our results showed that the skills of an experienced laparoscopic surgeon are transferrable to the novel Hugo™ RAS System in the context of nephron-sparing surgery. Improved surgical quality may be expected after completing the first 12 consecutive procedures. Full article

Partial nephrectomy (PN) is the primary surgical method for renal tumor treatment, typically involving clamping the renal artery during tumor removal, leading to warm ischemia and potential renal function impairment. Off-clamp approaches have been explored to mitigate organ damage, yet few results have emerged about the possible effects on hemoglobin loss. Most evidence comes from retrospective studies using propensity score matching, known to be sensitive to PS model misspecification. The energy balancing weights (EBW) method offers an alternative method to address bias by focusing on balancing all the characteristics of covariate distribution. We aimed to compare on- vs. off-clamp techniques in PN using EB-weighted retrospective patient data. Out of 333 consecutive PNs (275/58 on/off-clamp ratio), the EBW method achieved balanced variables, notably tumor anatomy and staging. No significant differences were observed in the operative endpoints between on- and off-clamp techniques, although off-clamp PNs showed slight reductions in hemoglobin loss and renal function decline, albeit with slightly higher perioperative blood loss. Our findings support previous evidence, indicating comparable surgical outcomes between standard and off-clamp procedures, with the EBW method proving effective in balancing baseline variables in observational studies comparing interventions. Full article

The current literature relating to the novel Hugo^TM RAS System lacks consistent data concerning the bedside features of robot-assisted partial nephrectomy (RAPN). To describe the trocar placement and docking settings for RAPN with a three-arm configuration to streamline the procedure with Hugo^TM RAS, between October 2022 and April 2023, twenty-five consecutive off-clamp RAPNs for renal tumors with the Hugo^TM RAS System were performed. We conceived a trouble-free three-arm setting to ease and standardize RAPN trocar placement and docking settings with Hugo^TM RAS. Perioperative data were collected. Post-operative complications were reported according to the Clavien–Dindo classification. The eGFR was calculated according to the CKD–EPI formula. Continuous variables were presented as the median and IQR, while frequencies were reported as categorical variables. Off-clamp RAPNs were successfully performed in all cases without the need for conversion or additional port placement. The median age and BMI were 69 years (IQR, 60–73) and 27.3 kg/m² (IQR, 25.7–28.1), respectively. The median tumor size and R.E.N.A.L. score were 32.5 mm (IQR, 26–43.7) and 6 (IQR, 5–7), respectively. Two patients were affected by cT2 renal tumors. The median docking and console time were 5 (IQR, 5–6) and 90 min (IQR, 68–135.75 min), respectively, with slightly progressive improvements in the docking time achieved. No intraoperative complications occurred alongside clashes between instruments or with the bed assistant. In experienced hands, this simplified three-instrument configuration of the Hugo^TM RAS System for off-clamp RAPN resulted in feasible and safe practice, providing patient-tailored trocar placement and docking with non-inferior peri-perioperative outcomes to other robotic platforms. Full article

To compare outcomes of sutureless (SL) vs. renorrhaphy (RR) off-clamp robotic partial nephrectomy (ocRPN), we retrospectively analyzed procedures performed at our center, from January 2017 to April 2021, for cT1-2N0M0 renal masses. All the patients with a minimum follow-up < 1 month were excluded from the analysis. The trifecta rate defined surgical quality. Any worsening from chronic kidney disease (CKD) I-II to ≧ IIIa (from IIIa to ≧ IIIb, and from IIIb to ≧ IV) was considered as significant stage migration (sCKDsm). A 1:1 propensity score-matched (PSM) analysis minimized baseline imbalances between SL and RR cohorts in terms of age, gender, ASA score, baseline estimated glomerular filtration rate (eGFR), tumor size, and RENAL score. Logistic regression analyses identified predictors of trifecta achievement. Kaplan–Meier (KM) analysis assessed the impact of RR on significant chronic kidney disease sCKDsm-free survival (SMFS), while Cox regression analyses identified its predictors. Overall, 531 patients were included, with a median tumor size of 3.5 cm (IQR: 2.7–5); 70 (13%) presented with a cT2 mass. An SL approach was pursued in 180 cases, but 10 needed conversion to RR. After PSM analysis, patients receiving SL showed a higher trifecta rate (94% vs. 84%; p = 0.007). SMFS probabilities were comparable at KM analysis (log-rank = 0.69). Age (OR: 0.97; 95%CI: 0.95–0.99; p = 0.01), a RENAL score ≧ 10 (OR: 0.29; 95%CI: 0.15–0.57; p < 0.001), and RR (OR: 0.34; 95%CI: 0.17–0.67; p = 0.002) were independent predictors of trifecta achievement. Age (OR: 1.04; 95%CI: 1.003–1.07; p = 0.03) and baseline eGFR (OR: 0.99; 95%CI: 0.97–0.99; p = 0.05) independently predicted sCKDsm. Compared to RR, our experience seems to show that the SL approach significantly increased the probabilities of achieving the trifecta in the observed group of cases. Full article

Background: Nephron-sparing surgery represents the gold standard treatment for organ-confined renal tumors. We present 15-years of outcomes after off-clamp laparoscopic partial nephrectomy (ocLPN). Methods: a retrospective analysis was performed on patients who underwent ocLPN between May 2001 and December 2005. Baseline demographic, clinical, pathologic, surgical, functional and survival data were collected. The Kaplan–Meier method evaluated group-specific oncologic outcomes at 5, 10 and 15 years and the log rank test assessed differences between groups. The same analysis investigated the probabilities of developing a significant renal function impairment (sRFI) and achieving ROMeS. Cox analyses identified predictors of this latter tricomposite outcome. Results: We included 63 patients whose median tumor size was 3 cm (IQR:2–4). At 15 years, the chances of developing local recurrence, metachronous renal cancers or distant metastases were 2 ± 2%, 23 ± 6% and 17 ± 5%, respectively. Consequently, disease-free, cancer-specific and overall-survival probabilities were 68 ± 6%, 90 ± 4% and 72 ± 6%. MCRSS and UCISS well predicted oncologic outcomes. Overall, nine (14%) patients experienced an sRFI and 33 (52%) achieved ROMeS. Age (HR: 1.046; p = 0.033) and malignant histology (low-risk cancers HR: 3.233, p = 0.048) (intermediate/high risk cancers HR: 5.721, p = 0.023) were independent predictors of ROMeS non-achievement. Conclusions: At 15 years from ocLPN, most of patients will experience both excellent functional and oncologic outcomes. Full article