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Pecoraro et al. Mini-invasive Surg 2024;8:25 https://dx.doi.org/10.20517/2574-1225.2023.134 Page 7 of 12

[23]
However, the only metanalysis available failed to show any difference in the change of renal function,
despite the higher rate of enucleation in the 3DVMs group. However, using the estimated renal plasmatic
flow (ERPF) derived renal scan as a functional renal parameter, Amparore et al. found a worrisome ERPF
[29]
drop in the 2D group relative to the 3D group (-10% vs. -19.6%; P = 0.002) . Additionally, in multivariate
analysis, the use of 3DVMs was the only protective factor against ERPF drop (ERPF drop > 20%: OR: 0.3,
95%CI: 0.1-0.6; P = 0.002).

Moreover, a large institutional study found that, regardless of the definition of Trifecta, the 3D model
[11]
group consistently exhibited two-fold higher success rates (OR: 2.7, P < 0.001; OR: 2.0, P = 0.0008; OR: 2.8,
P = 0.02; OR: 2.0, P = 0.003).

A Multinstitutional study identified preoperative estimated glomerular filtration rate (eGFR), the type of
[30]
ischemia technique used, and early postoperative renal function as key predictors of renal function one year
after partial nephrectomy. This emphasizes the importance of precise surgical techniques and optimal
intraoperative decision-making in ensuring favorable long-term outcomes for patients undergoing complex
renal surgeries.

The role of 3DVMs and AR in this context is significant, as these technologies facilitate enhanced
visualization of tumor margins and critical structures. This allows surgeons to perform precise resections
while minimizing unnecessary damage to healthy renal parenchyma, which is crucial in reducing ischemia
time and preserving kidney function. By minimizing surgical trauma, AR can positively influence these
predictive factors - preoperative eGFR, ischemia technique, and early postoperative renal function -
ultimately improving functional and oncologic outcomes in complex renal tumor cases.

Incorporating AR-guided RAPN could, therefore, be a game-changer in managing complex renal masses,
ensuring better functional preservation and enhanced patient recovery.

VIRTUAL SURGERY AND ANATOMIC SURGICAL INSIGHTS
Another significant advantage of using 3DVMs is the ability to conduct “virtual” surgery before performing
the actual procedure in the operating room. This approach not only provides valuable insights into the
previously mentioned steps, such as renal pedicle management and resection-reconstruction techniques, but
also helps predict potential intraoperative scenarios that may require intervention. For example, it aids in
identifying aberrant renal vessels, planning selective clamping of renal artery branches, and improving
control of the renal hilum in case of bleeding. This allows the surgeon to evaluate the potential for
postoperative renal function more effectively, rather than focusing solely on tumor excision.

RAPN AND 3DVMS IN COMPLEX RENAL MASSES
RAPN has demonstrated its effectiveness as a treatment option for a range of complex renal tumors,
including completely endophytic, large, and hilar masses, and recurrent tumors and cases involving a
solitary kidney .
[31]

In this context, advances in robotic technology, AR, and 3D modeling have significantly improved
outcomes, allowing for better preservation of renal function, reduced complications, and strong oncologic
control [32,33] .