Sutureless off-clamp robot-assisted partial nephrectomy: a single-surgeon case series with insights into technique and complications

Abstract

Aim: Previous literature has evaluated the feasibility and safety of robot-assisted partial nephrectomy (RAPN) performed entirely sutureless and off-clamp. The aim of the present study was to report a series of consecutive, unselected patients with renal masses of intermediate complexity who underwent sutureless off-clamp robot-assisted partial nephrectomy (sl-oc RAPN) by a single surgeon, focusing on surgical strategies, technique, and safety.

Methods: A retrospective analysis was conducted on 29 patients between January 2022 and September 2024. Preoperative clinical characteristics, intraoperative data, and postoperative outcomes were examined, with particular attention to adverse events classified according to the Clavien-Dindo system. Additionally, hemoglobin, serum creatinine, and estimated glomerular filtration rate (eGFR) were analyzed at discharge and at three months postoperatively.

Results: The median patient age was 60 years. All tumors were classified as T1a or T1b according to the tumor, node, metastasis (TNM) system. The median tumor diameter was 30 mm (range: 28-45), and the median PADUA score was 8 (range: 7-8). The median operative time (OT) was 135 min (range: 110/160), and the median estimated blood loss (EBL) was 100 mL (range: 50-100). Serum creatinine and eGFR at discharge and three months postoperatively showed no statistically significant changes (P > 0.05). Three patients (10%) experienced Clavien-Dindo ≥ 3 complications: two developed urine leakage requiring ureteral stent placement, and one experienced postoperative bleeding requiring blood transfusions.

Conclusion: Although limited by a small sample size and the absence of a control group, and with urinary fistula as a potential limitation of the technique, sl-oc RAPN appears effective for treating intermediate-complexity renal tumors. It maintains oncological outcomes, minimizes complications, and preserves renal function.

Keywords

Renal neoplasm / robotic partial nephrectomy / enucleation / off-clamp technique / sutureless

References

[1] EAU Guidelines on Renal Cell Carcinoma Cancer 2024; EAU Guidelines Office: Arnhem, The Netherlands, 2024. Available from: https://uroweb.org/guidelines/compilations-of-all-guidelines/ (accessed on 2025-8-25)

[2] AUA Guidelines on Renal Cancer 2024. Available from: https://www.auanet.org/guidelines-and-quality/guidelines/oncology-guidelines/renal-cancer (accessed on 2025-8-25)

[3] Kowalewski KF.Neuberger MSidoti Abate MAet alRandomized controlled feasibility trial of robot-assisted versus conventional open partial nephrectomy: the ROBOCOP II study.Eur Urol Oncol2024;7:91-7

[4] Masson-Lecomte A,Hupertan V.A prospective comparison of the pathologic and surgical outcomes obtained after elective treatment of renal cell carcinoma by open or robot-assisted partial nephrectomy.Urol Oncol2013;31:924

[5] Peyronnet B,Oger E.Comparison of 1800 robotic and open partial nephrectomies for renal tumors.Ann Surg Oncol2016;23:4277

[6] Antonelli A,Francavilla S.On-clamp versus off-clamp robotic partial nephrectomy: a systematic review and meta-analysis.Urologia2019;86:52-62

[7] Antonelli A,Sandri M.Is off-clamp robot-assisted partial nephrectomy beneficial for renal function?.BJU Int2022;129:217-24.

[8] Fong KY,Lim BJH.Off-clamp vs on-clamp robot-assisted partial nephrectomy: a systematic review and meta-analysis.BJU Int2024;133:375-86

[9] Ficarra V,Secco S.Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery.Eur Urol2009;56:786-93

[10] Kutikov A.The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth.J Urol2009;182:844-53

[11] Dindo D,Clavien PA.Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.Ann Surg2004;240:205-13 PMCID:PMC1360123

[12] Van Poppel H,Albrecht W.A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma.Eur Urol2011;59:543-52

[13] Choi JE,Kim DK,Lee SH.Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis.Eur Urol2015;67:891-901

[14] Thompson RH,Lohse CM.Every minute counts when the renal hilum is clamped during partial nephrectomy.Eur Urol2010;58:340-45

[15] Anceschi U,Bertolo R.On-clamp versus purely off-clamp robot-assisted partial nephrectomy in solitary kidneys: comparison of perioperative outcomes and chronic kidney disease progression at two high volume centers.Minerva Urol Nephrol2021;73:739-745

[16] Bertolo R,Carbonara U.European Association of Urology Young Academic Urologists Renal Cancer Working GroupResection techniques during robotic partial nephrectomy: a systematic review.Eur Urol Open Sci2023;52:7-21

[17] Sharma G,Ahluwalia P et al.Off-clamp versus on-clamp robot-assisted partial nephrectomy: a propensity-matched analysis.Eur Urol Oncol2023;6:525-30

[18] Antonelli A,Sandri M et al.Safety of on- vs off-clamp robotic partial nephrectomy: per-protocol analysis from the data of the CLOCK randomized trial.World J Urol2020;38:1101-8

[19] Bertolo R,Mir MC.Young Academic Urologists Kidney Cancer Working Group of the European Urological AssociationSystematic review and pooled analysis of the impact of renorrhaphy techniques on renal functional outcome after partial nephrectomy.Eur Urol Oncol2019;2:572-5

[20] Brassetti A,Anceschi U.Sutureless purely off-clamp robotassisted partial nephrectomy: avoiding renorrhaphy does not jeopardize surgical and functional outcomes.Cancers2023;15:698 PMCID:PMC9913582

[21] Bertolo R,Vittori M.Robotic off-clamp simple enucleation single-layer renorrhaphy partial nephrectomy (ROSS): surgical insights after an initial experience.J Clin Med2022;12:198 PMCID:PMC9821137

[22] Liu P,Shi B,Guo H.The outcome of sutureless in partial nephrectomy: a systematic review and meta-analysis.Biomed Res Int2022;2022:5260131 PMCID:PMC9526602

[23] Franco A,Tema G.Renal function preservation in purely off-clamp sutureless robotic partial nephrectomy: initial experience and technique.Diagnostics (Basel)2024;14:1579 PMCID:PMC11311424