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Pecoraro et al. Mini-invasive Surg 2024;8:29 https://dx.doi.org/10.20517/2574-1225.2023.90 Page 7 of 11

However, due to the lack of data on medium and long-term follow-up, it is not possible to presume that the
risk of AKI may overwhelm the benefits of single-stage surgery [37,39] .

The optimal time for surgery
The superiority of either the simultaneous or staged surgical procedure for these patients remains
controversial. However, the optimal time for surgery should depend on expertise and surgical complexity.
Tailored planning and appropriate patient counseling are important.

Procedure should be staged in patients where there is a high risk of AKI and long hospitalization. Moreover,
RENAL nephrometry score should be assessed for each patient [50,51] .

On the other hand, simultaneous procedures could decrease the cost in terms of single anesthesia time,
shorter overall hospitalization and faster overall recovery than two-step surgeries. Moreover, a single-step
strategy might have an impact on oncological outcomes, avoiding delay.

Nevertheless, these advantages could be balanced by the potential risks of AKI increased due to the
possibility of bilateral clamping approaches to renal pedicles.

The Mayo Clinic reported that 10.8% of patients undergoing simultaneous bilateral PN experienced AKI,
[28]
but none required dialysis . Staged procedures are recommended for patients with impaired renal
function. Lowrance et al. noted that sequential procedures could better preserve renal function and reduce
[52]
the likelihood of dialysis .
However, the only available study comparing simultaneous vs. two-step RAPN did not report any
[39]
significant difference in either functional or oncologic outcomes .

Complications
Similar intraoperative and postoperative complication rates were reported after RAPN for unilateral or
bilateral RAPN [53,54] ; furthermore, any conversion to open surgery was described in all the papers included in
the two most recent published reviews [48,49] .

Pandolfo et al. reported postoperative complication rates during simultaneous bilateral RAPN, including
renal hemorrhage, in 25.9% of cases, with major complications being rare (3.7%) and PSM rate of 3.7%,
comparable to unilateral procedures .
[45]

The authors concluded that simultaneous bilateral PN is feasible in expert hands with good functional and
[45]
oncologic outcomes .
Table 1 summarized the complications and the oncological outcomes in patients with synchronous bilateral
renal masses treated with surgery, AS, or AT.

Simultaneous bilateral PN offers high cancer control rates with no progression to metastasis, though there is
a risk of AKI. Long-term renal function is generally preserved, with only a minimal decline in eGFR.

AS is an effective approach for BSRMs, providing outcomes comparable to those seen in unilateral cases,
with no significant impact on renal function.