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Page 6 of 11 Pecoraro et al. Mini-invasive Surg 2024;8:29 https://dx.doi.org/10.20517/2574-1225.2023.90

that prioritize PN over RN in managing bilateral renal masses to reduce the likelihood of dialysis and
maintain long-term renal health, without compromising oncological safety.

Minimally invasive surgery is the method of choice for treating bilateral sporadic SRM, as it has a
comparable prognosis to that for unilateral sporadic SRM [10-12] . However, surgical management of bilateral
synchronous SRM is a surgical challenge, because of two different goals: the minimal postoperative renal
function loss and the complete eradication of the renal tumor. For this reason, if technically feasible, the
preservation of both kidneys through a bilateral NSS would be preferred.

Specifically, robotic approach, thanks to the wide maneuverability and three-dimensional vision, allows a
blunt dissection of the tumor pseudocapsule from the healthy parenchyma and an easier suture of the renal
parenchyma [43,44] in unilateral SRM.

Additionally, and especially in the case of BSRM, robotic approach could enable simultaneous bilateral
procedures maintaining the same position of the robot beside the surgical bed. This results in shorter
operative time and cosmetic benefits as the minimal incisions for the trocar ports can be partially used for
both sides [30,40] .

[45]
A recent review addressed the management of complex renal tumors, such as those that are large (cT2-
T3), endophytic, hilar, or occur in a solitary kidney. These conditions often pose significant challenges in
traditional surgical settings. The findings support RAPN as a viable option in the case of bilateral renal
masses, since it maintains oncological control while preserving renal function.

Managing synchronous bilateral renal masses, especially in complex regions such as the renal hilum, could
be challenging. RAPN allows surgeons to access difficult-to-reach tumors with greater dexterity and
precision, offering better outcomes in complex surgeries compared to traditional laparoscopic or open
[46]
surgeries, in terms of lower blood loss, shorter hospital stays, and quicker recovery times .
In summary, this systematic review underscores the importance of RAPN as a safe and effective surgical
option for managing bilateral renal masses, particularly in complex cases where traditional approaches may
pose higher risks or complications.

Nevertheless, a lot of questions are still open, mainly regarding the approach of the renal pedicle
(unclamping, selective, or main clamping), the optimal timing for surgery (one vs. two-step surgeries) and
the complication rate.

Management of the vascular pedicle
Preoperative planning to avoid clamping of the main renal artery is crucial in minimizing renal damage. In
a series by Gallo et al., artery clamping was avoided or minimized in many cases, leading to a low warm
ischemia time (WIT) and improved renal function over time .
[47]
Two recently published reviews showed that the data reported in literature regarding renal pedicle
management are still not homogenous [48,49] .

For example, two studies demonstrated that selective clamping is preferred over total bilateral renal artery
clamping, as it could prevent the onset of postoperative acute kidney injury (AKI) in patients [40,47] . On the
contrary, two other studies focusing on main clamping RAPN observed postoperative AKI [37,39] .