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De Nunzio et al. Mini-invasive Surg 2024;8:22 https://dx.doi.org/10.20517/2574-1225.2023.138 Page 5 of 10

was secured using a Surgicel (Ethicon, Johnson & Johnson, Summerville, NJ) pledget to reduce the risk of
the knot tearing through the renal capsule. Renorrhaphy was conducted in two layers, regardless of the type
of suture used. The deep-layer closure was carried out in a continuous baseball stitch, which involved tying
off blood vessels and mending the collecting system if it had been inadvertently breached. The spaces in the
renorrhaphy were sealed by employing these identical sutures in a continuous mattress or baseball stitch
pattern.

Sutureless technique
A selective suturing, as well as the no suturing of the tumor bed, was initially proposed by Farinha et al. in
2021 . Their study indicated that the introduction of this new technique did not lead to a higher incidence
[30]
of complications, while concurrently reducing both the duration of operation and hospitalization. Brassetti
et al., in a recent study, conducted an evaluation of safety, oncologic outcomes, and functional results of
[31]
complete sutureless, off-clamp RPN at a single, high-volume medical center . The first step of this
technique involves visualized bleeding vessels and the forced monopolar mode is used for high-precision
coagulation. After the tumor excision, the entire tumor bed undergoes repeated monopolar coagulation to
achieve a “caramelization” of the surgical field. The unintentional opening of the calyces is closed with a
continuous running suture using a 4/0 absorbable monofilament thread. A hemostatic agent (Floseel) is
applied to the tumor bed. A different range of hemostatic agents has been created to minimize bleeding
during partial nephrectomy. These agents are typically classified into four kinds: mechanical, active or
flowable agents and fibrin sealants. Mechanical agent categories include substances such as porcine gelatin,
cellulose, bovine collagen, and polysaccharide spheres, which form a matrix at the site of bleeding and
activate the extrinsic coagulation cascade. Active agents, which contain thrombin, directly influence the
intrinsic coagulation pathway by converting fibrinogen into fibrin. Flowable hemostats, composed of gelatin
or mixtures of gelatin and thrombin, have a fluid consistency that allows them to be delivered directly to the
bleeding site via syringe. The gelatin granules expand by absorbing blood and serve as a tamponade. Fibrin
sealants are formed from a combination of fibrinogen and thrombin, mimicking a fibrin clot in the final
[32]
stage of the coagulation cascade . The outcomes are quite remarkable concerning surgical duration, both
intra- and postoperative complications, and the preservation of renal function. These findings signify
notable progress in the surgical treatment of small kidney tumors. In relation to perioperative results,
performing a sutureless, off-clamp partial nephrectomy significantly reduces both operative time and warm
ischemia time. This reduction could be a key factor in preserving renal function. Additionally, the results
suggest that sutureless partial nephrectomy is technically safe, providing promising perioperative results and
preserving renal function. In a recent study by Franco et al., the efficacy and safety of sutureless off-clamp
robot-assisted partial nephrectomy (sl-oc RAPN) were assessed, focusing on its effects on renal function .
[33]
Researchers evaluated renal function preoperatively and at one- and three-month post-surgery through
creatinine and blood urea nitrogen levels. They also conducted sequential renal scintigraphy before and at
least one month after the operation to assess the renal function of both kidneys. It was observed that there
was a statistically significant median decrease in renal function of 10 mL/min (P < 0.01). The scintigraphy
results indicated an overall decline in renal function compared to preoperative values, with the operated
kidney experiencing a range of changes from 0 to 15 mL/s and 0% to 40%, resulting in a median reduction
of 4 mL/s and 12%. This finding underscores that sl-oc RAPN is a safe procedure with low impact on kidney
function. In a separate study, De Nunzio et al. compared the perioperative outcomes of patients undergoing
sl-oc RAPN performed by both novice and expert robotic surgeons, finding no statistically significant
differences in trifecta outcomes (100% for experts vs. 87% for novices; P = 0.07) . This highlights that the
[34]
technique is not only feasible but also safe, even when conducted by less experienced surgeons.
Furthermore, performing a totally sutureless technique could reduce the costs of robotic equipment,
reducing the reliance on expensive robotic arms. However, only few studies demonstrated the possible
impact of cost-effective measures, including the use of only one needle carrier or even none, and more
efforts are needed to prove this hypothesis.