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Page 2 of 7 Carilli et al. Mini-invasive Surg 2024;8:9 https://dx.doi.org/10.20517/2574-1225.2023.132

as Clavien-Dindo grade 2. Positive surgical margins were reported in one case (4.5%). No local recurrence or
metastasis were diagnosed within a median follow-up of six months.

Conclusion: Our case series showed the feasibility of off-clamp RAPN in patients with multiple ipsilateral renal
tumours in experienced hands. Further studies with larger sample size and longer follow-up are warranted to better
define the optimal management strategy in such an uncommon scenario.

Keywords: Off-clamp, robot-assisted partial nephrectomy (RAPN), multiple ipsilateral renal tumours

INTRODUCTION
In recent years, off-clamp robot-assisted partial nephrectomy (RAPN) has known broader diffusion and
[1-3]
emerged as a promising technique in the management of complex renal masses . Several studies have
investigated the feasibility and the outcomes of off-clamp RAPN for single renal tumours and found no
[4,5]
benefit in terms of renal function , while there remains a paucity of data regarding its application and
outcomes in patients with multiple ipsilateral renal tumours.

The present study analysed a cohort of patients who underwent off-clamp RAPN for multiple ipsilateral
renal tumours at our Institution and aimed to report the perioperative outcomes.

METHODS
Patients
Data of consecutive patients affected by multiple ipsilateral renal tumours managed by RAPN between
September 2018 and June 2023 were retrospectively analysed.

Surgical technique
All patients underwent Da Vinci Xi RAPN with a transperitoneal approach. A four-arm da Vinci robot was
set up with a 30° lens. All the 8-mm robot ports were aligned along the pararectal line. The following robotic
instruments were used: ProGrasp forceps, monopolar curved scissors, fenestrated bipolar forceps, and a
large needle driver. An assistant 12-mm AirSeal port (Conmed, Largo, FL, USA) was placed in the
periumbilical position. In the case of the right-sided procedure, an additional 5-mm port was placed at the
level of the xiphoid for managing the liver.

Once a renal tumour was identified, the renal cortex surrounding the lesion was contoured with monopolar
energy. The lesion was excised by a combination of sharp and blunt dissection, while pursuing an
[6]
anatomical enucleation technique whenever feasible as previously described . Eventual vessels encountered
during the dissection emerging from the resection bed were controlled by either bipolar coagulation or
application of re-absorbable clips (i.e., Absolok, Ethicon EndoSurgery, Cincinnati, OH, USA). After
resection was completed, renorrhaphy was modulated according to active bleeding (sutureless vs. single-
[7]
layer vs. double-layer), as previously described by our group . Hemostatic agents were eventually employed
on the basis of the surgeon’s preference.

Data collection and outcomes measurements
Preoperative variables, including age, sex, body mass index (BMI), Charlson Comorbidity index (CCI),
haemoglobin (Hb), estimated glomerular filtration rate (eGFR), number of renal tumours, each lesion
tumour size and R.E.N.A.L. [(R)adius (tumour size as maximal diameter), (E)xophytic/endophytic
properties of the tumour, (N)earness of tumour deepest portion to the collecting system or sinus, (A)nterior
[8]
(a)/posterior (p) descriptor and the (L)ocation relative to the polar line] nephrometry score , were collected
at baseline. eGFR was calculated using the Modification of Diet in Renal Disease equation .
[9]