Comparison of Perioperative Outcomes Between Retroperitoneal Single-Port and Multiport Robot-Assisted Partial Nephrectomies

Abstract

Objective:

To report early institutional experience with the single-port robotic platform and compare perioperative outcomes between single-port robot-assisted partial nephrectomies (SP-RAPN) and multiport robot-assisted partial nephrectomies (MP-RAPN) when utilizing a retroperitoneal approach.

Methods:

A retrospective chart review of patients who underwent SP-RAPN or MP-RAPN at our institution between November 1, 2013 and May 30, 2021 was performed. Surgical platforms were compared through univariate analysis using the Kruskal–Wallis test for continuous variables and χ² test for categorical variables.

Results:

A total of 20 SP-RAPN and 42 MP-RAPN were performed utilizing a retroperitoneal approach. Patients who underwent SP-RAPN were more likely to have a lower radius, endophytic/exophytic, nearness, anterior/posterior, location score (4 vs 6; p = 0.0084) and their masses tended to be more exophytic, although this was not statistically significant (p = 0.0535). Patients undergoing SP-RAPN had a shorter postoperative length of hospital stay (1 vs 2 days; p < 0.0001). There were no significant differences in operative time, estimated blood loss, ischemia time, positive margin rate, malignant histology, postoperative complication rate, or Clavien–Dindo complication grade.

Conclusion:

Retroperitoneal SP-RAPN appear to be safe without compromising perioperative outcomes when compared with MP-RAPN for low-complexity renal masses. Further studies are recommended to assess the role of the SP for higher-complexity renal masses and to characterize variables that influence the observed difference in length of hospital stay.

Introduction

Advances in robot-assisted surgery within the past decade have motivated the investigation of a retroperitoneal approach to partial nephrectomies (PN) for the treatment of localized renal masses. This approach facilitates surgical access to posterior and lateral renal masses and avoids exposure of intraperitoneal organs, thereby decreasing the rate of gastrointestinal complications.^1
–3 The four-arm approach to retroperitoneal robot-assisted partial nephrectomies (RAPN) was first described by Feliciano and Stifelman.⁴ Since the adoption of this surgical technique, multiport (MP) retroperitoneal RAPN have been associated with lower operative times, blood loss, and hospital length of stay (LOS) without compromising oncologic outcomes when compared with the transperitoneal approach.¹

The role of the da Vinci single-port (SP) robotic surgical system for the treatment of localized renal masses has been evaluated since its introduction to the market in 2018.⁵ The system features instrument and camera upgrades that facilitate intracorporeal articulation.^5,6 The development of single-port surgical procedures and technology has been motivated by the potential to minimize the morbidities associated with multiple incisions.⁷ The da Vinci SP was developed to overcome limitations associated with these procedures like restricted maneuverability from working in small spaces such as the retroperitoneum and poor ergonomics.^5,6,8

Although the feasibility, safety, and oncologic efficacy between the MP and SP technologies have been demonstrated for radical prostatectomies, there is paucity of evidence comparing the two technologies for RAPN.^9

–15 To our knowledge, no study has directly compared both technologies for retroperitoneal RAPN for these measures.

The goal of this study is to present our early institutional experience with the SP and compare perioperative outcomes between the SP and MP for retroperitoneal RAPN.

Materials and Methods

All patients who underwent RAPN for a localized renal mass from November 2013 to May 2021 at the University of Illinois at Chicago Medical Center were retrospectively analyzed. Patient demographics, perioperative outcomes, clinical information, mass characteristics, and postoperative complications were collected through chart review under Institutional Review Board approval. Only patients who underwent a retroperitoneal RAPN were included in the analysis.

R.E.N.A.L. (radius, endophytic/exophytic, nearness, anterior/posterior, location) nephrometry scores were calculated from preoperative imaging when available.¹⁶ All MP (da Vinci Xi, Intuitive Surgical, Sunnyvale, CA)-RAPN and SP (da Vinci SP, Intuitive Surgical, Sunnyvale, CA)-RAPN procedures were performed by two fellowship-trained and experienced robotic surgeons.

Complications were recorded using the Clavien–Dindo classification system.¹⁷ Final pathology analysis was reported according to the modified 2016 World Health Organization classification of renal neoplasms and staged according to the American Joint Commission On Cancer Tumor, Nodes, Metastasis (AJCC TNM) Staging System for Kidney Cancer.^18,19 Outcomes measured include surgical margin positivity, estimated blood loss (EBL), operating room (OR) time, ischemia time, and hospital LOS.

Surgical technique

All patients were positioned in the lateral decubitus position on a flexed table. A 1 to 5 cm horizontal incision was made above the iliac crest in the midaxillary line. A balloon dilator was utilized to develop the retroperitoneal space. For patients who underwent MP-RAPN, a modified four-arm approach was utilized for trocar positioning; only three arms were positioned in the retroperitoneum and the fourth arm was not included to avoid excessive mobilization of the peritoneum. A GelPoint with a robotic trocar was placed at the incision site. An additional trocar was placed at the 12th rib costovertebral angle.

After placement, a laparoscopic approach was used to mobilize the peritoneum to allow placement for the medial trocar and assistant trocar. The medial trocar was placed in parallel with the two previous trocars. A 12 mm assistant trocar was placed lateral to the umbilicus, in the retroperitoneum. For SP-RAPN, a Mini GelPoint was placed at the incision site. An additional 12 mm assistant port was placed in one of two locations: below the GelPoint in sidecar manner or at the paraspinal muscle border. For both surgeries, after hilar exposure, a bulldog clamp was utilized at the discretion of the surgeon to clamp the renal artery before tumor excision for warm ischemia. Renorrhaphy was then performed based on the surgeon's preference.

Statistical analysis

Quantitative data were described in medians and interquartile ranges. Qualitative data were described as numbers and percentages. Statistical analysis was performed using the SAS on Demand software (Cary, NC). Surgical platforms were compared through univariate analysis using the Kruskal–Wallis test for continuous variables and χ² for categorical variables. A p-value <0.05 was considered statistically significant.

Results

A total of 62 patients underwent a retroperitoneal RAPN from November 2013 to May 2021. Of these patients, 20 (35%) underwent SP-RAPN and 42 patients underwent MP-RAPN. MP cases were performed from 2013 to 2020 and SP cases were performed from 2019 to 2021. No significant differences in median age, body mass index, sex, race, or Charlson Comorbidity Index scores were observed between the two groups. Additional preoperative baseline characteristics are listed in Table 1.

Table 1.

Baseline Patient Demographics and Characteristics for Single-Port Robot-Assisted Partial Nephrectomies vs Multiport Robot-Assisted Partial Nephrectomies

	SP-RAPN (n = 20)	MP-RAPN (n = 42)	p
Median age, years (IQR)	56.5 (48.5–65)	60 (54–64)	0.4463
Median BMI, kg-m² (IQR)	30.75 (25.2–38.8)	29.88 (25.1–33.1)	0.3991
Sex (female), n (%)	4 (20)	17 (41)	0.1113
Race, n (%)			0.6005
White	6 (30)	9 (21)
AA	4 (20)	13 (31)
Other	10 (50)	20 (48)
Smoking, n (%)	11 (55)	15 (38)	0.1503
Diabetes, n (%)	5 (25)	11 (26)	0.9202
Median CCI score, n (IQR)	4.5 (2.5–6)	3.5 (2–5)	0.3814

AA = African American; CCI = Charlson Comorbidity Index; IQR = interquartile range; MP-RAPN = multiport robot-assisted partial nephrectomies; SP-RAPN = single-port robot-assisted partial nephrectomies.

The renal masses did not show laterality predominance (p = 1.0000). There were no differences between SP-RAPN and MP-RAPN groups in tumor size (12.8 vs 9.7 g, respectively; p = 0.4751) or tumor diameter (3 cm vs 2.8 cm, respectively; p = 0.4357). Composite median R.E.N.A.L. scores differed between the SP-RAPN and MP-RAPN cohorts (4 vs 6, respectively; p = 0.0084) (Table 2). The primary difference between the SP-RAPN and MP-RAPN cohorts was in the anterior vs posterior tumor location, as SP cases were all equally distributed and MP cases were preferentially posterior or neither (p = 0.0246). SP-RAPN tumors tended to be preferentially exophytic (73% vs 50%), but this was not statistically significant (p = 0.0535). No additional significant differences were observed in the rest of the R.E.N.A.L. nephrometry parameters.

Table 2.

Tumor Characteristics

	SP-RAPN (n = 20)	MP-RAPN (n = 42)	p
Laterality (left), n (%)	10 (50)	21 (50)	1.0000
Median tumor mass, grams (IQR)	12.8 (7–22.6)	9.7 (5–16.6)	0.4751
Median tumor diameter, cm (IQR)	3 (2.4–4.2)	2.8 (2.4–3.6)	0.4357
Tumor location into the parenchyma, n (%)			0.0535
>50% exophytic	8 (73)	17 (50)
<50% exophytic	2 (18)	17 (50)
Endophytic	1 (9)	—
Anterior vs posterior, n (%)			0.0246
Anterior	4 (36)	2 (6)
Posterior	3 (27)	20 (59)
Neither	4 (36)	12 (35)
Nearness to collection system, n (%)			0.4099
>7 mm	8 (73)	17 (50)
Between 4 and 7 mm	2 (18)	10 (29)
<4 mm	1 (9)	7 (21)
Polarity, n (%)			0.2227
Entirely above or below	7 (64)	13 (38)
Crosses a polar line	1 (9)	5 (15)
>50% across polar line	—	8 (24)
Crosses axial renal midline	3 (27)	5 (15)
Entirely between polar lines	—	3 (9)
Hilar tumor	0 (0)	2 (6)	0.4033
Median R.E.N.A.L. score, n (IQR)	4 (4–6)	6 (5–7)	0.0084
4	10 (59)	4 (12)
5	1 (6)	5 (15)
6	2 (12)	9 (27)
7	2 (12)	9 (27)
8	1 (6)	4 (12)
9	1 (6)	3 (9)
Nephrometry risk class, n (%)			0.1047
Low	13 (77)	18 (53)
Moderate	4 (24)	16 (47)
High	—	—
Malignant histology, n (%)	19 (95)	36 (86)	0.2801
Benign	1 (5)	6 (14)
AML	—	3 (50)
Oncocytoma	—	3 (50)
MEST	1 (100)	—
Malignant
ccRCC	15 (79)	23 (64)
papRCC	3 (16)	11 (31)
Chromophobe	1 (5)	—
Clear cell tubulopapillary	—	1 (3)
Cystic	—	1 (3)
pT stage, n (%)			0.7581
pT1a	16 (84)	29 (81)
pT1b	2 (11)	6 (17)
pT2a	—	—
pT2b	—	—
pT3a	1 (5)	1 (3)
pN state, n (%)			0.2812
N1	—	—
Nx	19 (100)	32 (94)

AML = angiomyolipoma; ccRCC = clear cell RCC; MEST = mixed epithelial and stromal tumor; papRCC = papillary RCC; RCC = renal cell carcinoma; R.E.N.A.L. = radius, endophytic/exophytic, nearness, anterior/posterior, location.

There was no difference in malignant histology rate between groups (95% vs 85.7%, respectively; p = 0.2801). Renal cell carcinoma (RCC) comprised most malignant renal masses in both the SP-RAPN and MP-RAPN cohorts. The two major subtypes were clear cell RCC (79% vs 64%, respectively) and papillary RCC (16% vs 31%, respectively). Similarly, pT1a was the most common stage (84% vs 81%, respectively) observed. There were no significant differences in benign incidence, RCC subtypes, or pT stage between cohorts (Table 2).

Table 3 compares the perioperative parameters between SP-RAPN and MP-RAPN. There was no difference in median operative times (166.5 [135.5–201] minutes vs 158.5 [143–193] minutes, respectively; p = 0.9760). There were no differences in EBL, ischemia time, or rate of positive surgical margins between cohorts. Patients undergoing SP-RAPN had a shorter hospital LOS compared with MP-RAPN, which was statistically significant (1 vs 2 days, respectively; p < 0.0001). Major complication rate was not significantly different between groups (p = 0.9675). SP-RAPN cases were associated with a lower complication rate (10%) compared with MP-RAPN cases (24%), although this was not statistically significant (p = 0.1432).

Table 3.

Perioperative Outcomes for Single-Port Robot-Assisted Partial Nephrectomies vs Multiport Robot-Assisted Partial Nephrectomies

	SP-RAPN (n = 20)	MP-RAPN (n = 42)	p
Median OR time, minutes (IQR)	166.5 (135.5–201)	158.5 (143–193)	0.9760
Median EBL, mL (IQR)	50 (20–50)	50 (25–100)	0.1562
Off-clamp, n (%)	1 (2)	0 (0)	0.1440
Median ischemia time, minutes (IQR)	25 (17–27)	20 (16–25)	0.2471
Median LOS, days (IQR)	1 (1–1)	2 (1–3)	<0.0001
Malignant histology, n (%)	19 (95)	36 (86)	0.2801
Positive surgical margins, n (%)	0 (0)	4 (10)	0.1570
Postoperative complication, n (%)	2 (10)	11 (24)	0.1432
Postoperative major complication,^a n (%)	1 (5)	2 (5)	0.9675
Median CDG, n (IQR)	2 (1–3)	2 (1–2)	0.7503

Major complication = CDG >2.

CDG = Clavien–Dindo grade; EBL = estimated blood loss; OR = operating room.

Discussion

Our institution has previously reported on the feasibility of the SP technology in robot-assisted radical prostatectomies. It provides patients with earlier analgesia-free days and shorter hospital LOS without compromising outcomes when compared with multiport approaches. We have also described our initial experience using the SP technology for partial nephrectomies.¹³ In this study, we evaluated the perioperative outcomes between the SP and MP for retroperitoneal RAPN and found no significant differences in OR time, ischemia time, EBL, complication rate, and positive surgical margins (PSM), and observed a shorter hospital LOS for patients undergoing surgery with the SP. To the best of our knowledge, this the first study to directly compare RAPN outcomes between these two surgical platforms with a focus on retroperitoneal approach.

The perioperative outcomes observed in this study for MP-RAPN appear comparable with those reported in the literature. A meta-analysis performed by Zhou and colleagues in 2021 comparing outcomes between retroperitoneal and transperitoneal RAPN reports a mean tumor size range of 2.2 to 4.9 cm, mean R.E.N.A.L. score range of 5.2 to 8.4, mean OR time range of 80.5 to 244 minutes, mean EBL range of 13.5 to 203.4 mL, mean hospital stay range of 1.7 to 6 days, overall complication rate of 10.7%, and overall PSM rate of 2.9% for the retroperitoneal approach.²⁰

We observed a mean tumor size of 2.8 cm, mean R.E.N.A.L. score of 6.4, mean OR time of 171.7 minutes, mean ischemia time of 22.6 minutes, and mean LOS of 2.5 days, which are concordant with the ranges reported by Zhou and colleagues (Supplementary Table S1). Our overall complication rate and PSM rate of 24% and 10%, respectively, are higher than those reported in the literature. PSM rate can be influenced by many factors that include patient and tumor characteristics as well as surgical technique.²¹ Furthermore, the prognostic implication that PSM has on recurrence and survival is still controversial.^15,22 Ultimately, both PSM and complication rate depend on multiple factors and given the present study design, no inferences can be made to explain these differences.

The da Vinci SP has been investigated for a retroperitoneal approach to RAPN since its inception. In 2014, Maurice and colleagues completed the first cadaveric retroperitoneal RAPN and radical nephrectomy utilizing a premarket model of the SP.⁸ With the commercial model, Kaouk and colleagues completed three RAPN with the SP utilizing a transperitoneal approach.¹² In 2020, Fang and colleagues published an article describing their institutional experience with the SP and were the first to report on the use of a retroperitoneal access for RAPN with the da Vinci SP.²³

In 2021, Glaser and colleagues published their results comparing outcomes between the SP- and MP-RAPN. A total of 78 patients were included in this study, of which 26 underwent RAPN with the SP. Most cases were associated with low-complexity R.E.N.A.L. scores and showed no differences in outcomes such as mean OR time, EBL, Clavien–Dindo complication grade, postoperative complication rates, and LOS. A retroperitoneal approach was utilized in 16 cases, 13 of which were done with the SP (p < 0.001); their perioperative outcomes were not stratified to account for retroperitoneal approach and no adequate conclusions can be made between SP and MP.¹⁵

In our study, we also observed similar perioperative outcomes between the SP and the MP for retroperitoneal RAPN and SP cases were associated with a shorter hospital LOS. This difference could be explained by the low-complexity nature of the SP cases, which were predominantly exophytic when compared with the MP cohort. Furthermore, LOS differences are often heterogeneous, and factors such as perioperative pathway changes and surgeon preference must be considered before attributing this observed difference directly to the SP technology. There has also been a migration toward lower length of hospital stay for robotic surgery and this paradigm change must be considered given that the MP cases were performed before the acquisition of the SP at our institution.²⁴

In 2021, Abaza and colleagues reported a single-surgeon series of 100 SP procedures assessing the rate of same-day discharge (SDD) at their institution when compared with the Xi. The study included 18 RAPN with an SDD rate of 83% with the SP compared with 17% of Xi cases (p < 0.001) with no difference in complication rate after adopting the SP technology.²⁵ It is unclear how many retroperitoneal cases were included in their cohort. Our study did not investigate SDD, but it is possible the SP technology can indirectly influence hospital LOS. Additional prospective studies evaluating length of hospital stay while adequately accounting for the various confounders are needed.

The da Vinci SP system offers a path to achieve true robotic-laparoendoscopic single-site surgery (LESS). Robotic LESS-PN have been associated with reduction in postoperative complications of any grade while preserving renal function and providing oncologic control.^26,27 Recently, Na and colleagues compared robotic LESS-PN outcomes between the SP and the Xi single-site platform (XiSSP). Their cohort consisted of 14 patients, of which 9 underwent PN with the SP.

They observed no differences in perioperative outcomes or postoperative complications between the two platforms, although SP cases were associated with increased OR and ischemia time. They made no comment on differences in LOS between platforms.¹⁴ Although not significant, SP-RAPN cases in our cohort were associated with a lower complication rate when compared with the MP-RAPN. However, this association could be explained by the lower-complexity nature of the masses in the SP cohort. Additional multi-institutional studies are needed to investigate whether this association persists when accounting for mass complexity.

Our study has several limitations. This was a retrospective single-institutional study. The cohort utilized was noncontemporaneous as several MP-RAPN cases were performed before the commercialization of the da Vinci SP. Given this timing, matching cases by surgical platform and year was not possible. Perioperative documents were used to determine OR time, ischemia time, and EBL, which are subject to error. Perioperative imaging was not available for several patients, which prevented R.E.N.A.L. score calculations.

SP-RAPN cases were associated with lower R.E.N.A.L. scores with a tendency to be more exophytic when compared with the MP-RAPN cohort, which implies a more straightforward case particularly when evaluating tendencies in complication rate, grade, and length of hospital stay. Although the results from this study were obtained from surgeons with vast experience in robot-assisted surgery, which may limit generalizable to all settings, these results still represent early experience with the SP that could be subject to a learning curve effect.²⁸ Finally, because of the modest sample size there is limited ability to detect statistical differences in many of the tested parameters.

Further studies should compare the SP and MP technologies utilizing the novel trifecta system to evaluate whether the SP technology truly offers a comparable functional outcomes and complication rates when accounting for mass complexity, and whether the observed difference in length of hospital stay can be explained by the adoption of the SP technology.²⁹

Conclusion

In this retrospective study, the da Vinci SP appears to demonstrate similar perioperative outcomes for retroperitoneal partial nephrectomies when compared with the da Vinci Xi for low-complexity renal masses. The observed difference in length of hospital stay cannot be attributed solely to the adoption of the SP technology given the limitations of the nonrandomized study design.

Footnotes

Authors' Contributions

All authors contributed to the conceptualization, methodology investigation, writing, and editing of this article. All authors approved the final article in its existing form.

Author Disclosure Statement

Simone Crivellaro is a consultant for Intuitive Surgical Inc.

Funding Information

No funding was received for this article.

Supplementary Material

Supplementary Table S1

Abbreviations Used

References

Pavan

, Derweesh

, Hampton

, et al. Retroperitoneal robotic partial nephrectomy: Systematic review and cumulative analysis of comparative outcomes. J Endourol, 2018; 32(7):591–596; doi: 10.1089/end.2018.0211.

Xia

, Zhang

, Wang

, et al. Transperitoneal versus retroperitoneal robot-assisted partial nephrectomy: A systematic review and meta-analysis. Int J Surg, 2016; 30:109–115; doi: 10.1016/j.ijsu.2016.04.023.

Mittakanti

, Heulitt

, Li

, et al. Transperitoneal vs. retroperitoneal robotic partial nephrectomy: A matched-paired analysis. World J Urol, 2020; 38(5):1093–1099; doi: 10.1007/s00345-019-02903-7.

Feliciano

, Stifelman

. Robotic retroperitoneal partial nephrectomy: A four-arm approach. JSLS, 2012; 16(2):208–211; doi: 10.4293/108680812x13427982376149.

Dobbs

, Halgrimson

, Talamini

, et al. Single-port robotic surgery: The next generation of minimally invasive urology. World J Urol, 2020; 38(4):897–905; doi: 10.1007/s00345-019-02898-1.

Kaouk

, Haber

, Autorino

, et al. A novel robotic system for single-port urologic surgery: First clinical investigation. Eur Urol, 2014; 66(6):1033–1043; doi: 10.1016/j.eururo.2014.06.039.

Kaouk

, Haber

, Goel

, et al. Single-port laparoscopic surgery in urology: Initial experience. Urology, 2008; 71(1):3–6; doi: 10.1016/j.urology.2007.11.034.

Maurice

, Ramirez

, Kaouk

. Robotic laparoendoscopic single-site retroperitioneal renal surgery: Initial investigation of a purpose-built single-port surgical system. Eur Urol, 2017; 71(4):643–647; doi: 10.1016/j.eururo.2016.06.005.

Dobbs

, Halgrimson

, Madueke

, et al. Single-port robot-assisted laparoscopic radical prostatectomy: Initial experience and technique with the da Vinci® SP platform. BJU Int, 2019; 124(6):1022–1027; doi: 10.1111/bju.14864.

10.

Vigneswaran

, Schwarzman

, Francavilla

, et al. A comparison of perioperative outcomes between single-port and multiport robot-assisted laparoscopic prostatectomy. Eur Urol, 2020; 77(6):671–674; doi: 10.1016/j.eururo.2020.03.031.

11.

Saidian

, Fang

, Hakim

, et al. Perioperative outcomes of single vs multi-port robotic assisted radical prostatectomy: A single institutional experience. J Urol, 2020; 204(3):490–495; doi: 10.1097/JU.0000000000000811.

12.

Kaouk

, Garisto

, Eltemamy

, et al. Pure single-site robot-assisted partial nephrectomy using the SP surgical system: initial clinical experience. Urology, 2019; 124:282–285; doi: 10.1016/j.urology.2018.11.024.

13.

Francavilla

, Abern

, Dobbs

, et al. Single-port robot assisted partial nephrectomy: Initial experience and technique with the da Vinci Single-Port platform (IDEAL Phase 1). Minerva Urol Nephrol, 2022; 74(2):216–224; doi: 10.23736/S2724-6051.21.03919-9.

14.

, Lee

, Yoon

, et al. True single-site partial nephrectomy using the SP surgical system: Feasibility, comparison with the Xi Single-Site Platform, and Step-By-Step Procedure Guide. J Endourol, 2020; 34(2):169–174; doi: 10.1089/end.2019.0528.

15.

Glaser

, Burns

, Fang

, et al. Single- versus multi-port robotic partial nephrectomy: A comparative analysis of perioperative outcomes and analgesic requirements. J Robot Surg, 2022; 16(3):695–703; doi: 10.1007/s11701-021-01271-y.

16.

Kutikov

, Uzzo

. The R.E.N.A.L. nephrometry score: A comprehensive standardized system for quantitating renal tumor size, location and depth. J Urol, 2009; 182(3):844–853; doi: 10.1016/j.juro.2009.05.035.

17.

Dindo

, Demartines

, Clavien

. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg, 2004; 240(2):205–213; doi: 10.1097/01.sla.0000133083.54934.ae.

18.

Moch

, Cubilla

, Humphrey

, et al. The 2016 WHO classification of tumours of the urinary system and male genital organs-part A: Renal, penile, and testicular tumours. Eur Urol, 2016; 70(1):93–105; doi: 10.1016/j.eururo.2016.02.029.

19.

Amin

, Greene

, Edge

, et al. The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more “personalized” approach to cancer staging. CA Cancer J Clin, 2017; 67(2):93–99; doi: 10.3322/caac.21388.

20.

Zhou

, Liu

, Cao

, et al. Retroperitoneal or transperitoneal approach in robot-assisted partial nephrectomy, which one is better?. Cancer Med, 2021; 10(10):3299–3308; doi: 10.1002/cam4.3888.

21.

Malkoç

, Maurice

, Kara Ö, et al. Predictors of positive surgical margins in patients undergoing partial nephrectomy: A large single-center experience. Turk J Urol, 2019; 45(1):17–21; doi: 10.5152/tud.2018.57767.

22.

Laganosky

, Filson

, Master

. Surgical margins in nephron-sparing surgery for renal cell carcinoma. Curr Urol Rep, 2017; 18(1):8; doi: 10.1007/s11934-017-0651-5.

23.

Fang

, Saidian

, Magi-Galluzzi

, et al. Single-port robotic partial and radical nephrectomies for renal cortical tumors: Initial clinical experience. J Robot Surg, 2020; 14(5):773–780; doi: 10.1007/s11701-020-01053-y.

24.

Johnson

, Lane

, Weizer

, et al. Partial nephrectomy should be classified as an inpatient procedure: Results from a statewide quality improvement collaborative. Urol Oncol, 2021; 39(4):239.e9–239.e16; doi: 10.1016/j.urolonc.2021.01.001.

25.

Abaza

, Murphy

, Bsatee

, et al. Single-port robotic surgery allows same-day discharge in majority of cases. Urology, 2021; 148:159–165; doi: 10.1016/j.urology.2020.08.092.

26.

Greco

, Autorino

, Rha

, et al. Laparoendoscopic single-site partial nephrectomy: A multi-institutional outcome analysis. Eur Urol, 2013; 64(2):314–322; doi: 10.1016/j.eururo.2013.01.025.

27.

Springer

, Greco

, Autorino

, et al. Analysis of oncological outcomes and renal function after laparoendoscopic single-site (LESS) partial nephrectomy: A multi-institutional outcome analysis. BJU Int, 2014; 113(2):266–274; doi: 10.1111/bju.12376.

28.

Ferriero

, Bove

, Tuderti

, et al. Impact of learning curve on perioperative outcomes of off-clamp minimally invasive partial nephrectomy: Propensity score matched comparison of outcomes between training versus expert series. Minerva Urol Nephrol, 2021; 73(5):564–571; doi: 10.23736/S2724-6051.20.03673-5.

29.

Anceschi

, Flammia

, Mattevi

, et al. External validation of a novel comprehensive trifecta system in predicting oncologic and functional outcomes of partial nephrectomy: Results of a multicentric series. J Clin Med Res, 2022; 11(3):796; doi: 10.3390/jcm11030796.

Supplementary Material

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