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Page 2 of 10 De Nunzio et al. Mini-invasive Surg 2024;8:22 https://dx.doi.org/10.20517/2574-1225.2023.138

Between 1992 and 2003, only one randomized controlled trial was carried out to compare partial and radical
nephrectomy. It concluded that partial nephrectomy yielded superior long-term renal function outcomes,
reducing the chances of developing advanced-stage chronic kidney disease (3a and 3b). Nevertheless, in the
case of renal cell carcinoma (RCC) patients, there were no notable distinctions in terms of local recurrence,
cancer-specific survival, or overall survival . Significantly, the partial nephrectomy group experienced
[4,5]
[6]
higher rates of severe hemorrhages and reoperations . Subsequently, there have been significant
advancements in surgical techniques, integrating minimally invasive methods such as laparoscopy and
robot-assisted surgery.

Nowadays, partial nephrectomy is the preferred surgical method for T1 renal tumors, especially for renal
masses smaller than 4 cm (T1a); additionally, it is becoming the preferred option for managing complex
[7,8]
tumors .
Likewise, the use of robotic-assisted partial nephrectomy (RPN) was proposed even for clinical T1 tumors,
[9]
even when dealing with intricate renal structures . While several surgical approaches can be employed in
RPN, the “trifecta” concept often encapsulates the overarching objective. This concept entails attaining
negative surgical margins, optimizing the retention of healthy renal tissue, and minimizing surgical
complications .
[10]

With the progression of surgical expertise and technology, there has been a changing emphasis on
safeguarding well-vascularized renal tissue by employing diverse methods such as enucleation, off-clamp
procedures, selective clamping with near-infrared fluorescence, and early unclamping. This approach seeks
to optimize renal function while reducing potential postoperative complications [11-13] . Presently, there are no
existing guidelines advocating for reconstructive techniques. Consequently, no agreement exists on the best
methods for performing renorrhaphy during robotic partial nephrectomy (RPN). Studies have indicated
that partial nephrectomy can reduce renal function, which can vary but may be as high as 20% for treated
kidneys [14-16] . It has been postulated that the primary factors contributing to this loss in renal function are the
extent of healthy tissue removed, the duration of ischemia, and the damage caused by the reconstructive
procedure during renorrhaphy [17-20] .

Indeed, many studies have explored how ischemia time and the amount of healthy renal tissue removed
affect renal function outcomes. Additionally, research has examined different reconstructive techniques and
their impact on postoperative outcomes, including complications such as bleeding and urinary leaks.
Nonetheless, limited data exists concerning the impact of renorrhaphy on renal function over an extended
period [21,22] . Several renorrhaphy techniques have been documented in the literature, primarily influenced
by a surgeon’s expertise and the complexity of the tumor, taking into account factors such as size, location,
or the presence of a solitary kidney. Furthermore, the choice of tumor removal technique, whether it
involves resecting a healthy margin or performing enucleation, can significantly influence the type of
reconstruction . Generally, enucleation is commonly viewed as a less invasive method of reconstruction in
[22]
comparison to resection with healthy margins. This is because enucleation typically involves fewer incisions
into the renal sinus, and hemostasis is usually managed by addressing blood vessels encountered during the
tumor removal process, rather than waiting until after the tumor has been excised . The suturing
[14]
technique should be tailored according to the tumor’s depth. The key to a successful laparoscopic partial
nephrectomy (LPN) primarily relies on effectively managing bleeding by coagulating smaller bleeding
points and mechanically controlling larger ones. When it comes to the renal parenchyma, suturing proves
[23]
to be the most efficient method for achieving hemostasis . Although there is a significant connection
between the suture technique and the functional results of partial nephrectomy, urological guidelines do not