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Parra et al. Mini-invasive Surg 2024;8:16 https://dx.doi.org/10.20517/2574-1225.2024.01 Page 11 of 13

of renal function, without forgetting a higher likelihood of complications on those extremely challenging
[33]
cases .
Nowadays, 2D computed tomography (CT) images can be turned into three-dimensional (3D) models, and
[34]
3D virtual reconstructions have proven to be useful tools in the surgical planning of PN . Porpiglia et al.
demonstrated, first in 2017 and then in 2019, the downgrading in complexity in nephrometric scores
(RENAL and PADUA) using 3D reconstruction systems [35,36] . In 2020, they evaluated the role of 3D
virtual reconstructions in the surgical guidance during RAPNs, proving that 3D guidance was
associated with lower rates of ischemia, higher rate of complete enucleation and lower collecting
system damaging rate, compared to intraoperative ultrasound (US) guidance .
[37]

We know that the short follow-up period of our patients may be a limitation of the study and that
functional outcomes at one year would probably increase the impact. Therefore, future lines of research
should aim to validate new nomograms with the most important risk factors of the patients in order to
decide between one technique or another. This will require a longer follow-up time of our patients.

Another limitation of our study is the small sample size, with only 148 patients included. Despite the
advances in knowledge about the recovery of renal function and renal ischemia and the fact that
preservation of renal mass is the most important factor, we can confirm that controversies remain
unresolved, and the urology community would be enriched by additional investigation with respect to the
best approaches. This could include a contrast of conventional intraoperative ultrasonography with other
technologies such as indocyanine green dye, and the better use of preoperative imaging including 3D
reconstruction to increase surgeons’ knowledge of the patient’s anatomy and the relationships between the
vessels and the tumor. The different surgical techniques are relevant in this regard: polar nephrectomy,
enucleation, wedge resection and enucleoresection; their differences imply a greater or lesser preservation of
renal mass.

Upcoming studies should also provide information to help the urology community understand when
irreversible ischemic damage begins to occur with warm ischemia and which patients are at the greatest risk
of irreversible ischemic damage and impaired renal function.

In conclusion, even though renal tumors with a higher RENAL score imply the need to perform a longer
arterial ischemia time, its relationship with the deterioration of renal function is unclear as there are
probably other factors to blame, such as the patient’s previous comorbidities. Therefore, we believe more in
assuring oncologic results and promoting the absence of complications during PN. Greater knowledge of
the importance of the technique will be available in the future with the use of new technologies such as
robotics and 3D imaging.

DECLARATIONS
Authors’ contributions
Conceptualization, data curation, methodology, writing - original draft, writing - review and editing: de la
Parra I
Conceptualization, methodology, supervision, writing - review and editing: Gómez Rivas J
Data curation and supervision: Serrano Á
Data curation: Vives R, Gutiérrez Hidalgo B, Hermida JF, Ibañez L
Supervision: Fernández Montarroso L, Moreno-Sierra J