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Ditonno et al. Mini-invasive Surg 2023;7:36 https://dx.doi.org/10.20517/2574-1225.2023.62 Page 5 of 10

Figure 4. Intraoperative view during single port robot-assisted partial nephrectomy.

console time was observed between the two approaches. In the two groups, WIT, EBL, and length of
hospital stay (LoS) were similar, as were post-operative functional outcomes [serum creatinine and
[13]
estimated glomerular filtration rate (eGFR)] .
A simplified approach for retroperitoneal SP RAPN has been described by Pellegrino et al. in a recent case
series. The supine anterior retroperitoneal access (SARA) approach was aimed at providing a safer, more
effective, and consistent method for retroperitoneal surgery. The retroperitoneum is accessed through a
3 cm incision at approximately the McBurney point, 3 cm medial, and 3 cm caudal to the anterior superior
iliac spine. No dilating balloon is needed since a careful finger dissection is sufficient to move the parietal
peritoneum away from the incision site. The retroperitoneal adipose tissue is dissected in the direction of
the posterior region of the retroperitoneal cavity until exposure of quadratus lumborum muscle laterally
and iliopsoas muscle medially. At this point, ureter is identified and followed to the renal pelvis and renal
hilum. The rest of the surgical procedure replicates RAPN standard steps. Analysis of post-operative
outcome showed a mean (SD) WIT of 25 ± 7 min and a mean (SD) OT of 109 ± 18 min, with a mean (SD)
tumor size of 37 ± 12.5 mm. No patients required intraoperative or post-operative blood transfusion, and
[14]
the same-day discharge rate was 84% . The first three cases with the SARA approach were performed at
our institution, with promising results. No intra-operative and post-operative complications were observed,
and all the patients were discharged on post-operative day one, supporting the feasibility and safety of this
technique.

Surgical, functional, and oncological outcomes
The most consistent evidence on SP RAPN regards young patients with low complexity (R.E.N.A.L. score
≤ 6) small renal masses, defined as renal lesions ≤ 4 cm. Shukla et al. reported results of 12 patients with a
[15]
mean (SD) age of 57.8 years (±11) and a mean (SD) tumor size of 3.1 cm (±2.2), 83% of which with a
R.E.N.A.L. score ≤ 6. A mean (SD) OT for SP RAPN of 171.6 min (±40.5) was reported, with a mean (SD)
EBL of 68.3 mL (±74.6) and a WIT < 25 min. There were no intra-operative conversions or early post-
operative complications, with a median LoS of 1.2 days (range 1-3 days) and no readmission within the
90-day post-operative period. No significant changes between mean (SD) pre-operative and post-operative
hematocrit (41.9 ± 4.3 to 39.2 ± 3.4, P = 0.1) or mean (SD) eGFR (57.8 ± S4.9 to 58.6 ± 3.2, P = 0.1) was
registered. The most common histology was clear cell renal cell carcinoma (ccRCC), and only one patient