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Carilli et al. Mini-invasive Surg 2024;8:9 https://dx.doi.org/10.20517/2574-1225.2023.132 Page 3 of 7

Perioperative and post-operative data were collected, including console time, estimated blood loss (EBL),
resection and suture technique for each lesion, eventual use of hemostatic agents, length of hospital stay, Hb
at discharge, and eGFR at discharge and after 30 days. Eventual intra- and post-operative complications
with or without readmissions (occurred within 30 days) were recorded and classified according to the
[10]
Clavien-Dindo system . Final pathology examination of excised tumours was performed to have histology,
grading, staging and surgical margin status assigned.

Data analysis
Continuous variables were summarised using medians and interquartile ranges (IQR); frequencies and
proportions were used to report categorical variables. Data analysis was conducted using the SPSS 21.0
software (IBM, Armonk, NY, USA).

RESULTS
Twelve patients were included in the analysis. Table 1 shows the distribution of baseline patient
characteristics. Based on preoperative CT scan, median tumour size was 34 mm and the median R.E.N.A.L.
score was 6. Two patients (16.7% of cases) had a history of partial nephrectomy performed on the
contralateral kidney (open approach in one case, pure laparoscopic in the other case). One patient had
undergone percutaneous renal mass biopsy and enrolled for a period of active surveillance before partial
nephrectomy.

Table 2 summarises the perioperative and post-operative outcomes. Median console time was 134 min. An
off-clamp approach with pure enucleation was possible in 20 out of 28 lesions (71.4%). Median EBL was
200 mL. Median Hb showed a 21.5% reduction between baseline and discharge (14.4 vs. 11.3 g/dL), while
median eGFR showed an 8.1% reduction during the same time span considered (86 vs. 79 mL/min). No
differences were observed in renal function both at discharge and after 30 days (79 and 80 mL/min,
respectively), compared to baseline.

No intraoperative complications were recorded. Post-operative complications occurred in two patients
(16.7%), both classified as Clavien-Dindo grade 2. Namely, one patient required a blood transfusion on the
2nd post-operative day. The other patient was readmitted two weeks after surgery due to flank pain: CT
scan revealed a 7-cm perirenal hematoma without arterial enhancement, which was managed
conservatively.

No local recurrence or metastasis was diagnosed within a median follow-up of six months.

DISCUSSION
[11]
Multiple ipsilateral renal tumours are relatively rare, with an incidence ranging from 4.5% to 8% . In this
specific setting, a nephron-sparing approach is paramount, taking into account the high risk of ipsilateral
and/or contralateral recurrence (described in about 5% of cases) [12,13] .

RAPN is our preferred approach for managing multiple ipsilateral renal tumours. While most surgeons will
agree on the robotic approach in this setting, the management of renal hilum remains open for debate. In
2008, a non-ischemic technique of RAPN for hereditary multiple or small exophytic tumours was first
described: in this case series, one patient harboured four ipsilateral renal tumours and was managed by off-
[14]
clamp RAPN without complications . Another retrospective analysis of 12 patients with multiple