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Bianchi et al. Mini-invasive Surg 2021;5:37 https://dx.doi.org/10.20517/2574-1225.2021.64 Page 9 of 11

Figure 9. Surgical technique for retroperitoneal robot-assisted partial nephrectomy: (A) dissection of the pararenal fat to expose the
psoas muscle and the posterior layer of renal fascia; (B, C) incision in the posterior layer of renal fascia just above and parallel to the
psoas muscle, exposing the perirenal fat; (D) dissection of the perirenal fat from the kidney following the plane along the psoas muscle;
and (E, F) isolation of the renal artery from the perirenal fat.

caused by urinary fistulas .
[16]
The significance of tumor location on treatment choice is supported by the categorization of anterior and
posterior location by both the RENAL and PADUA scores [20,21] . rRAPN is ideally suited for posterior or
lateral renal masses, especially in the middle and upper pole of the kidney, because it allows direct access to
the posterior and lateral surface of the kidney and minimizes the extent of dissection inside renal fascia, but
it can be applied to anterior and medial masses in patients with a history of extensive previous abdominal
surgery and/or any pathological condition that may increase the risk of intra-abdominal scarring and
[16]
adhesions (e.g., previous peritoneal pathology or peritonitis and peritoneal dialysis) bearing in mind that,
as stated above, rRAPN represents only an alternative approach for posterior renal masses. Thus, the
surgeon’s experience and not the tumor location cover a primary role during selection of the optimal
surgical approach for posterior masses .
[7,8]

Previous history of retroperitoneal surgery or percutaneous procedures represents a relative
contraindication to rRAPN, as well as highly complex tumors and anatomical variations (e.g., horseshoe
kidney and pelvic kidney). Extremely obese patients are more difficult to treat retroperitoneally due to the
high volume of adherent perirenal fat and a transperitoneal approach should be preferred [15,16] .

Our retroperitoneal space creation technique, due to the extensive use of the surgeon index to guide the
procedure, implies fast access to the retroperitoneum. Moreover, the tactile feedback from the surgeon
index provides insight on the tissues’ characteristics, rendering the blunt dissection of the pararenal fat from
the trasversalis fascia almost atraumatic. The trocars’ placement with digital protection and feedback is safe
and protects the underlying anatomical structures from the trocars’ damage, while enabling fast placement.
In the literature, retroperitoneal space creation is almost always described using a balloon dissector. The
absence of a trocar balloon dilator further reduces the operative time and cost. Meanwhile, placing the