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

Larger tumors have a greater risk of local invasion and complex vascular anatomy, increasing the difficulty
of partial nephrectomy. However, RAPN, for large tumors, is feasible, but outcomes are highly dependent
[34]
[31]
on surgeon experience . A recent review showed that, with careful planning and expertise, RAPN can
achieve negative margins, maintain renal function, and manage complications effectively. In the attempt to
provide the best surgical planning, 3DVMs could be a helpful tool for these patients .
[7]
Finally, for solitary kidneys, preserving renal function is of paramount importance, as the risk of post-
surgical renal insufficiency is high. RAPN in solitary kidneys is associated with positive oncologic outcomes
while prioritizing nephron-sparing techniques [35,36] .

In the case of completely endophytic renal masses, the lack of visual clues and a large contact surface area
make RAPN particularly difficult.

In this case, AR can overlay 3DVMs onto the actual anatomy during surgery, helping the surgeon visualize
the hidden tumor in real time .
[37]

However, the complexity of these cases requires careful perioperative management to minimize ischemia
time and preserve maximum renal function. Also in this case, 3DVMs could help give a comprehensive
[38]
preoperative planning to optimize both functional and oncologic outcomes . Specifically, Pecoraro et al.
reported that 3DVM can be a valuable tool for managing highly complex renal masses with unusual
[11]
anatomy and imperative indications for NSS .
They presented three clinical cases with similar renal anatomy and tumor characteristics on 3DVMs, and
with potentially independent vascularization and drainage for the lower pole.

In the first case presented in the study, the infundibulum of the upper calyceal group was dislocated by the
tumor, while an accessory artery fed the lower pole of the kidney. In this case, the treatment of choice was
enucleoresection. However, after three months, MRI was performed showing a functionally excluded
hydrocalyx. This was due to the damage of the infundibular connection to the upper calyceal system,
resulting in loss of almost all the upper pole renal tissue, as showed at renal scan. In light of this experience,
in the other two cases, an upper heminephrectomy was performed.

Indeed, the high risk of damage of the calyceal infundibulum pushed the surgeon to perform a hemi-
nephrectomy, instead of enucleoresection, following the plane of the tumor and sparing the lower pole of
the kidney with its arterial and venous pedicle of pertinence. This choice was made also considering the
potential loss of renal function after surgery.

In this case, it is noteworthy that 3DVM defined a precise anatomical cluster that influenced and modulated
the final surgical approach of the surgeon based on the previous AR-guided surgery.

Similarly, Campi et al. reported the 3DVM application in a patient harboring two complex renal masses in a
horseshoe kidney .
[38]
Specifically, the 3D model allowed the identification of the presence of three renal arteries for the left
kidney. This influenced the surgeon to perform a selective clamping strategy (two out of three feeding
arteries) for the enucleation of the largest mass, after delineation of its contours via AR technology, and a
clampless strategy was used for the resection of the smallest mass, preserving all vascular branches