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Mari et al. Mini-invasive Surg 2024;8:7 https://dx.doi.org/10.20517/2574-1225.2023.103 Page 7 of 10
nephrometric aspects could be associated with a higher risk of PSMs, an additional multivariable analysis
was conducted, excluding the PADUA score and including tumor dimension and collecting system
compression, which showed significant associations with PSMs in univariate analysis. These factors were
consequently included in our multivariable analysis model, and it showed collecting system tumor
compression as a significant predictor (OR 1.34, 95%CI 1.12-1.84, P = 0.001).
Among intraoperative surgical factors, off-clamp tumor resection held notable significance with an OR of
3.00 in the PSM prediction, reinforcing its critical role in the outcome . The choice to opt for off-clamp
[21]
[22]
tumor resection in surgeries, while advantageous in some scenarios, presents its own set of challenges .
The off-clamp approach may compromise the surgeon’s visual field, obscuring the clear delineation of
structures and potentially decreasing the quality of the resection . Some experts advocate for optimal hilar
[23]
clamping specifically to circumvent this limitation. However, it is imperative to note that the literature
offers varying perspectives on the matter: in fact, some systematic reviews examining the potential impact of
renal pedicle management techniques on partial nephrectomies have found that the specific technique
employed - whether clamping or not - does not necessarily influence surgical or oncological outcomes .
[24]
This suggests that while visualization and surgical field clarity are undoubtedly crucial, other factors, skills,
and methodologies also play pivotal roles in determining the surgery’s success .
[25]
In discussing these results, achieving tumor-free margins during PN is an essential oncological goal, with
implications for surgical success. While literature suggests varying views, local recurrence appears more
[14]
probable in patients with PSMs, particularly in the context of high-risk tumor characteristics . In contrast,
low-grade primary tumors exhibit less aggressive PSM potential due to their slower cancer progression
rate . Some believe the possibility of tumor cell destruction during NSS might mitigate malignant cell
[15]
[16]
proliferation at resection sites .
Another aspect that warrants attention is the influence of surgeon expertise and, more in general, the
surgical caseload of the center on PSMs. The RECORD 2 study, in fact, underscored the significant
contribution of the annual PN volume in influencing PSM outcomes, stressing the importance of
centralization of this surgery in high-volume centers for this treatment . Notwithstanding our meticulous
[26]
approach, inherent limitations such as potential biases due to the absence of information about surgeon
expertise and variations in surgical techniques across surgeons must be acknowledged [27,28] .
Our study has inherent limitations. Firstly, although data collection was maintained prospectively in our
internet-based platform, the nature of our retrospective analysis could introduce biases. Secondly, certain
parameters such as clinical tumor size and deployment of intraoperative tools (e.g., ultrasound, near-
infrared fluorescence) were unavailable in this database. Therefore, their potential influence on PSMs
remains unexplored in this analysis. Novel technological advancements in robotic surgery and 3D modeling
might further enhance surgical precision [29,30] . Thirdly, the unicentric nature of this study could present
potential variation in practices and techniques. Fourthly, our research did not involve a centralized
pathological review, which could introduce variability in the reporting of PSMs based on individual
practices within the institution. Fifthly, we did not detail the specific experience or learning curve of each
surgeon involved in the procedures. Consequently, we did not consider the potential variance in outcomes
due to surgical experience, relying instead on the overall center caseload as an approximate metric of
experience.
It remains crucial for our model’s predictions concerning PSMs to be tested on other cohorts to ensure their
applicability and relevance to a broader population undergoing PN.