From Sutureless to Standard: A Comprehensive Analysis of Conversion Rates in Laparoscopic Partial Nephrectomy

From Sutureless to Standard: A Comprehensive Analysis of Conversion Rates in Laparoscopic Partial Nephrectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From Sutureless to Standard: A Comprehensive Analysis of Conversion Rates in Laparoscopic Partial Nephrectomy Wenfeng Li, Bao Hua, Sangqing Song, Weixin Pan, Qing Yang, Bin Xu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4207031/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Aug, 2024 Read the published version in BMC Urology → Version 1 posted 12 You are reading this latest preprint version Abstract Objective To assess the rate at which sutureless partial nephrectomy (SLPN) transitions to standard partial nephrectomy (SPN), focusing on preoperative factors that might prompt such conversions. Patients and methods In this retrospective study, we analyzed the efficacy of SLPN performed on adults at our institution from 2016 to 2023. The subjects were patients diagnosed with localized solid renal tumors. The primary technique employed was wedge resection, complemented by intraoperative ultrasound localization and argon beam coagulation for hemostasis, with suturing techniques used only when necessary. Predictive factors necessitating conversion to SPN were identified, and the associations among multiple variables were explored using various statistical analysis methods, including logistic regression, to identify key preoperative predictive factors. Results Our institution performed 353 SLPN, with 21 cases (5.9%) necessitating conversion to SPN. The conversion rates for the Laparoscopic Partial Nephrectomy (LPN) subgroup and the Robotic-assist Partial Nephrectomy (RPN) subgroup were 7.9% (17/215) and 2.9% (4/138), respectively, nearing statistical significance (P = .066). Significant differences were observed between the conversion group and the no conversion group in terms of preoperative estimated Glomerular Filtration Rate (eGFR), age at surgery, tumor size, and exophytic/endophytic characteristics. Multivariate analysis identified age at surgery, preoperative eGFR, radiological tumor size, and tumor exophytic/endophytic nature as significant predictors for conversion to SPN. Conclusion This investigation highlights the efficacy and feasibility of SLPN while identifying critical factors influencing the necessity for conversion to SPN. The identified predictors, including younger surgical age, superior preoperative eGFR, and specific tumor characteristics, provide valuable insights for refining surgical strategies. partial nephrectomy renal cell carcinoma suture sutureless Figures Figure 1 Introduction Renal Cell Carcinoma (RCC), primarily the clear cell subtype, represents 2%-3% of adult malignancies, with a 2% annual increase in incidence, posing a significant public health challenge[ 1 ]. Technological advances in ultrasound and CT scans have significantly boosted the detection of renal tumors, particularly smaller lesions, leading to a shift towards nephron-sparing strategies[ 2 ]. Partial Nephrectomy (PN) has become the preferred treatment for renal masses ≤ 7 cm, especially beneficial for patients with preexisting chronic kidney conditions, as it reduces the risk of chronic renal insufficiency and cardiovascular mortality[ 3 , 4 ]. Sutureless Partial Nephrectomy (SLPN) leverages cutting-edge surgical technologies, including hemostatic agents and sealants, to achieve optimal hemostasis and parenchymal reconstruction without traditional sutures[ 5 – 10 ]. This innovative approach aims to reduce warm ischemia time, minimize blood loss, and potentially hasten postoperative recovery, thereby lowering the risk of complications such as parenchymal damage and pseudoaneurysms[ 11 – 13 ]. Despite the advantages and potential of SLPN, the transition to Standard Partial Nephrectomy (SPN) remains infrequent. The scarcity of comprehensive data on the incidence of such conversions, their underlying reasons, and the patient and tumor characteristics that increase the risk highlights the need for further investigation. Understanding these factors is essential for improving surgical planning and patient counseling, ultimately enhancing the safety and efficacy of renal surgeries. Our research focuses on determining the frequency of conversions from SLPN to SPN in our institution and analyzing the preoperative factors associated with these conversions to better guide clinical decisions. Patients and Methods This study conducted a comprehensive investigation into the application of SLPN on patients aged 18 and above from 2016 to 2023. The patient cohort, selected based on the presence of clinically localized solid renal masses ≤ 4 cm in diameter, underwent a thorough pre-operative imaging review by a specialized uro-oncologist to assign RENAL nephrometry scores, considering factors such as tumor size, exophytic/endophytic properties, and location. The surgical approach predominantly entailed wedge resections, with intraoperative ultrasound facilitating precise tumor demarcation and renal parenchyma assessment. Excision was primarily executed using scissors, complemented by argon beam coagulation for effective hemostasis, resorting to suturing only when necessary. Participants were stratified into two categories to distinguish those requiring conversion to SPN. Comparative analyses of demographic and tumor-specific attributes were conducted to elucidate factors predisposing to surgical conversion. Statistical analyses employed median and Interquartile Range (IQR) for continuous variables, and frequencies with percentages for categorical ones, utilizing the Wilcoxon rank-sum and Chi-square/Fisher's exact tests accordingly. A logistic regression model with backward selection was adopted to explore multivariate associations, presenting results as odds ratios with 95% confidence intervals, ensuring rigorous variable selection criteria to mitigate overfitting. Statistical analyses were performed using version 26.0 of the SPSS software package (SPSS Inc., Chicago, IL, USA). Results From 2016 to 2023, our institution documented a total of 353 SLPN procedures, with 21 instances (5.9%) necessitating a transition to SPN. Delving into specifics, within the Laparoscopic Partial Nephrectomy (LPN) subgroup, there were 17 conversions out of 215 cases (7.9%, 95% Confidence Interval [CI] 4.3–11.5) to SPN, while the Robotic-assisted Partial Nephrectomy (RPN) subgroup saw 4 conversions out of 138 cases (2.9%, 95% CI 0.1–5.7), P = .066. Intriguingly, the overall conversion rate exhibited a marginal decline throughout the study, descending from an initial 8.0–6.0%, but this change did not reach statistical significance (P = .726) (Fig. 1 ). Table 1 encapsulates the demographic profiles and tumor characteristics of both the no conversion and conversion groups. The conversion group demonstrated a notably younger median age at the time of surgery (58.0 years [IQR: 55.0–72.0] as opposed to 64.0 years [IQR: 59.0–72.0] in the no conversion group, P = .007) and a superior preoperative Estimated Glomerular Filtration Rate (eGFR) with a median of 66.4 [IQR: 62.6-88.19] compared to 57.5 [IQR: 49.4–73.3] mL/min/1.73 m² in the conversion group, (P = .001). No significant disparities were observed in terms of gender, Body Mass Index (BMI), Charlson Comorbidity Index (CCI), American Society of Anesthesiologists (ASA) score, and histopathological findings. The tumor characteristics such as the proximity to the collecting system, anterior versus posterior location, and the RENAL nephrometry score were comparable. However, notable distinctions were made in the radiological dimensions of the tumors (26.0 cm [IQR: 22.0–30.0] in conversion group versus 31.0 cm [IQR: 29.0–35.0] in no conversion group, P = .001) and the exophytic/endophytic properties of the tumors (P = .036), highlighting significant differences. Table 1 Patient and tumor characteristics No Conversion N = 332 Conversion N = 21 P Age at surgery (y), Median (IQR) 64.0 (59.0–72.0) 58.0 (55.0–72.0) 0.007 Number of males, n (%) 208 (62.7) 11 (52.4) 0.347 Body mass index (kg/m2), Median (IQR) 28.0 (25.9–31.5) 29.1 (26.0-32.9) 0.363 Preoperative eGFR (mL/min/1.73 m2), Median (IQR) 57.5 (49.4–73.3) 66.4 (62.6–88.1) 0.001 CCI, Median (IQR) 1.0 (1.0–3.0) 1.0 (1.0–3.0 0.941 ASA score, Median (IQR) 2.0 (1.0–3.0) 2.0 (1.0–2.0) 0.461 Radiographic tumor size(cm), Median (IQR) 26.0 (22.0–30.0) 31.0 (29.0–35.0) 0.001 RENAL-NS, n (%) Low: 4–6 203 (61.1) 12 (57.1) 0.716 Medium: 7–9 129 (38.9) 9 (42.9) RENAL-NS components, n (%) Exophytic/endophytic properties (E) >50% exophytic 173 (52.1) 6 (28.6) 0.036 =7 96 (28.9) 1 (4.8) 0.056 >4 but < 7 47 (14.2) 4 (19.0) <=4 189 (56.9) 16 (76.2) Anterior/posterior (A) Anterior 146 (44.0) 5 (23.8) 0.148 Posterior 97 (29.2) 7 (33.3) Middle (X) 89 (26.8) 9 (42.9) Location relative to polar lines (L) Entirely polar 126 (38.0) 5 (23.8) 0.215 Crosses polar line 100 (30.1) 10 (47.6) Entirely between polar lines 106 (31.9) 6 (28.6) Histopathology, n (%) Clear cell 252 (75.9) 15 (71.4) 0.918 Papillary 40 (12.0) 3 (14.3) Chromophobe 4 (1.2) 0 (0) Other malignant 3 (0.9) 0 (0) Benign 33 (9.9) 3 (14.3) Intraoperative features are contrasted in Table 2 . The group undergoing conversion to SPN exhibited a heightened median estimated blood loss (EBL) (91 mL [IQR: 57–195] versus 77 mL [IQR: 48–100] in the no conversion group, P = 0.039) alongside an elongated duration of surgery (125 minutes [IQR: 102–182] compared to 109 minutes [IQR: 97–123], P = 0.021). The WTI remained consistent across groups (17 minutes [IQR: 13–19] for the conversion group versus 16 minutes [IQR: 14–19] for the no conversion group, P = .725), with no significant correlation between the surgical approach (LPN or RPN) and the likelihood of conversion (P = .284). Table 2 Intraoperative characteristics No Conversion N = 332 Conversion N = 21 P Procedure type, n (%) LPN 198 (59.6) 15 (71.4) 0.284 RPN 134 (40.4) 6 (28.6) Estimated blood loss (mL), Median (IQR) 77 (48–100) 91 (57–195) 0.039 Operative time (min), Median (IQR) 109 (97–123) 125 (102–182) 0.021 Warm ischemia time (min), Median (IQR) 17 (13–19) 16 (14–19) 0.725 Multivariate analysis pinpointed pivotal predictors for conversion, encompassing the patient's age at the time of surgery (Odds Ratio [OR]: 0.087 [95% CI: 0.018–0.420], P = .002); preoperative eGFR (OR: 86.118 [95% CI: 14.192-522.561], P < .001); radiological tumor size (OR: 92.608 [95% CI: 12.397-691.779], P < .001); and the tumor's exophytic/endophytic nature (OR: 32.525 [95% CI: 5.719-184.987], P < .001). Discussion A major challenge in LPN is suturing renal parenchyma, which can prolong WTI and operative time, potentially leading to postoperative renal atrophy and impaired function recovery. The introduction of sutureless technologies like bipolar and monopolar coagulation, thulium laser, and argon beam coagulation has simplified these surgeries. These methods are beneficial for novice surgeons, offering ease of use and effective hemostasis. For instance, bipolar and monopolar coagulation minimize intraoperative bleeding by coagulating tissue and sealing blood vessels. The thulium laser, precise and minimally damaging, is ideal for delicate kidney resections, while argon beam coagulation effectively coagulates larger bleeding areas[ 5 – 10 ]. These technologies reduce WIT, crucial for protecting renal function, especially in small T1a tumors, and can shorten surgical time and reduce blood loss, improving safety and effectiveness[ 11 – 13 ]. During the period from 2016 to 2023, our study showed a conversion rate of 5.9% in SLPN procedures, with 21 out of 353 surgeries transitioning to SPN. Notably, the LPN subgroup exhibited a higher conversion rate of 7.9% (17/215), compared to a lower rate of 2.9% (4/138) in the RPN subgroup, although not reaching statistical significance with P = .066. This variation aligns with the findings of Jeffrey J. Leow et al who reported a decreased likelihood of conversion in RPN procedures[ 14 ]. Studies by Choi JE et al and Pavan N et al further corroborate the perioperative advantages of robotic-assisted surgeries[ 15 , 16 ]. Contrary to expectations and trends reported in the literature, our study did not observe a significant decrease in conversion rates over the study period, with rates slightly declining from 8.0–6.0%, (P = .726). This finding may imply that factors other than technological advancements and surgical experience may play a crucial role in determining the likelihood of conversion, such as demographic and tumor characteristics. The stable conversion rates observed in our study also indirectly emphasize the low learning threshold of the sutureless technique, which seems to be unrelated to the surgeon's experience. This may be due to the intuitive operation process and fewer steps involved in the sutureless technique, thereby reducing the time and experience required to learn and master it[ 9 , 10 ]. Moreover, the simplification of the technique might also reduce the reliance on advanced skills of surgeons, allowing even less experienced surgeons to perform the surgery safely and effectively. Therefore, the ease of learning the sutureless technique could contribute to its rapid adoption and application, which is important for improving medical efficiency and patient outcomes. Although literature reports suggest that the likelihood of converting from partial nephrectomy to radical nephrectomy increases with age[ 17 ], our observations indicate a contrasting trend when employing sutureless techniques for managing the bleeding site post-renal partial nephrectomy. We noted that the age of patients in the conversion group was generally lower than that in the no conversion group. Younger patients typically have healthier kidneys with more robust blood flow. This enhanced vascularity may lead to increased bleeding during the excision of renal tumors[ 18 ]. When surgeons opt for sutureless techniques, which are less invasive and aim to preserve renal function, managing significant bleeding can pose a greater challenge. The higher the renal blood flow, the more difficult it may be to achieve effective hemostasis using these minimally invasive methods. Consequently, this might necessitate a shift to more traditional sutured techniques that offer better control of bleeding. EGFR is a critical indicator for assessing renal function in partial nephrectomy. Takagi et al highlighted the importance of selecting surgical methods for renal tumors in robot-assisted laparoscopic partial nephrectomy, particularly the guiding role of preoperative eGFR in the decision-making process[ 19 ]. This indicator is essential for evaluating a patient's ability to endure surgery and recover renal function postoperatively. In clinical practice, the decision to perform partial nephrectomy and the extent of resection are often directly influenced by preoperative eGFR. Ni and Yang demonstrated the significant role of preoperative eGFR in predicting postoperative renal function when comparing robot-assisted with open partial nephrectomy in patients with clinical T1 stage renal cell carcinoma[ 20 ]. However, in our study, the preoperative eGFR of patients in the conversion group was significantly higher than that in the no conversion group. Younger patients typically have higher eGFR, indicating better renal blood supply. However, this improved blood supply may increase the risk of intraoperative bleeding in partial nephrectomy using a sutureless technique. Although the sutureless technique offers the advantage of being minimally invasive, controlling bleeding and maintaining a clear surgical field can be more challenging in cases of significant bleeding. A higher eGFR may require surgeons to be more cautious in their surgical planning, considering the potential risks of uncontrollable bleeding associated with the sutureless technique. Similarly, our study found that the average size of tumors in patients who converted to traditional suturing during partial nephrectomy was significantly larger (31.0 vs 26.0 cm, P = .001) compared to those who did not require conversion, and the proportion of tumors with endophytic growth was also higher (P = .036). First, larger or endophytically growing renal tumors are often more closely intertwined with critical structures such as renal blood vessels, the ureter, and the renal pelvis[ 21 ]. This proximity makes it particularly important to repair these structures with traditional suturing techniques after damage during surgery, which is difficult to achieve with generally less invasive sutureless techniques. Studies have shown that partial nephrectomy for large or endophytic tumors involves longer operative times and a higher risk of surgical complications compared to radical nephrectomy[ 22 – 24 ]. Secondly, the complexity of blood supply to larger and deeper tumors increases the surgical challenge. These tumors typically have a more intricate vascular network, making intraoperative hemostasis more difficult and increasing the risk of accidental damage to surrounding vessels[ 25 ]. The literature further emphasizes the need for effective bleeding control in these scenarios, using more controllable suturing methods. The multivariate analysis identified key factors influencing the likelihood of surgical conversion during partial nephrectomy. These key factors include younger surgical age, higher preoperative eGFR, larger tumor size, and endophytic tumor characteristics. These findings suggest that younger patients, especially those with larger, complex tumors, particularly endophytic tumors, are more prone to surgical conversion. For larger renal tumors, especially those with complex anatomical features such as endophytic growth, an increased incidence of surgical conversion during partial nephrectomy is supported by various studies in the field. These studies identified key factors leading to the decision to switch from less invasive, nephron-sparing surgical approaches to more traditional surgical techniques. Research from the Michigan Urological Surgery Improvement Collaborative (MUSIC) and another study highlighted factors influencing the conversion from robotic partial nephrectomy to robotic-assisted radical nephrectomy. MUSIC found tumor size and complexity as key determinants, while the latter study pointed to patient-specific factors like age, BMI, and comorbidity index, rather than tumor characteristics, as significant predictors of surgical conversion. These insights emphasize the need for comprehensive pre-surgical assessments considering both tumor and patient health status[ 26 , 27 ]. Together, these studies indicate that while tumor size and endophytic characteristics are important considerations, the overall demographic characteristics of the patient also play a significant role in surgical decision-making. This highlights the importance of comprehensive preoperative evaluation to predict surgical challenges and adjust approaches accordingly. During the evaluation of perioperative characteristics between the conversion group and the no conversion group, a significant difference in EBL was noted. The median EBL for the conversion group was 91 mL, while for the control group, it was 77 mL, showing a statistically significant difference (P = .039). Additionally, the conversion group faced significant prolongation in surgery time due to difficulties in achieving hemostasis, with a median time of 125 minutes compared to 109 minutes for the control group (P = .021). This increase in duration is not only due to the time required to manage bleeding but also reflects the inherently time-consuming nature of traditional suturing techniques compared to the originally planned procedures. Literature indicates that intraoperative blood loss and extended surgery times are independent risk factors for postoperative complications. Despite employing effective hemostasis techniques, the conversion group continued to encounter challenges with ongoing bleeding and the limitations inherent in the techniques used. Similarly, prolonged surgeries increase oxygen debt, risk of organ failure, sepsis, and death, particularly in high-risk patients. Laparoscopic surgeries, involving carbon dioxide insufflation, can alter hemodynamics and stress hormones, posing risks, especially for the elderly or those with comorbidities[ 13 ]. Shorter operations, like SLPN, are crucial for minimizing surgical impact and enhancing recovery. Additionally, extended surgery durations strain resources and staff, potentially worsening patient outcomes, underscoring the need for refined surgical methods and intraoperative efficiency. This study on SLPN offers crucial insights but has notable limitations, such as a small, institutionally-bound sample, potentially limiting broader applicability. Its retrospective design may introduce biases from incomplete or inconsistent records limits a full evaluation of SLPN's effectiveness. Additionally, variations in surgical techniques and surgeon expertise, which can significantly affect outcomes, were not thoroughly examined. Future research should focus on multicenter, diverse, and randomized controlled trials to enhance the reliability and generalizability of findings, alongside a detailed assessment of surgical methods and the refinement of surgeon skills to advance SLPN's safety and efficacy. Conclusion This study revealed that between 2016 and 2023, the conversion rate from SLPN to SPN was 5.9%, with LPN showing a higher conversion rate than RPN. Key factors influencing conversion included younger surgical age, higher preoperative eGFR, larger tumor size, and intrinsic tumor characteristics, underscoring the importance of individualized considerations in surgical planning and patient counseling. Furthermore, comprehensive preoperative assessment's role in anticipating surgical challenges and adjusting strategies was highlighted, offering valuable insights into enhancing the safety and efficacy of nephron-sparing surgeries. Abbreviations RCC Renal Cell Carcinoma PN Partial Nephrectomy SLPN Sutureless Partial Nephrectomy SPN Standard Partial Nephrectomy IQR Interquartile Range LPN Laparoscopic Partial Nephrectomy RPN Robotic-assisted Partial Nephrectomy EGFR Estimated Glomerular Filtration Rate BMI Body Mass Index CCI Charlson Comorbidity Index ASA American Society of Anesthesiologists EBL Stimated Blood Loss Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of Shanghai Ninth People’s Hospital (SH9H-2022-T359-1). All patients were given informed consent. All experiments were performed in accordance with relevant guidelines and regulations. Consent for publication Not applicable. Availability of data and materials The datasets generated and analysed during the current study are not publicly available but are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding No funding. Author's contribution WL: project development, manuscript writing and editing. BH: manuscript writing and editing. SS: data analysis. WP: data collection. QY: manuscript writing and data analysis. BX: project development, manuscript writing. Acknowledgements Thanks for patients helping this study. Many thanks for Dr. Bao Hua and Qing Yang. References Bukavina L, Bensalah K, Bray F, et al. Epidemiology of Renal Cell Carcinoma: 2022 Update. Eur Urol. 2022;82(5):529–42. Meyer AR, Carducci MA, Denmeade SR, et al. Improved identification of patients with oligometastatic clear cell renal cell carcinoma with PSMA-targeted (18)F-DCFPyL PET/CT. Ann Nucl Med. 2019;33(8):617–23. Wang S, Liu Z, Zhang D, Xiang F, et al. The incidence and risk factors of chronic kidney disease after radical nephrectomy in patients with renal cell carcinoma. BMC Cancer. 2022;22(1):1138. Mir MC, Derweesh I, Porpiglia F, et al. 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Cite Share Download PDF Status: Published Journal Publication published 28 Aug, 2024 Read the published version in BMC Urology → Version 1 posted Editorial decision: Revision requested 23 Jul, 2024 Reviews received at journal 22 Jul, 2024 Reviews received at journal 14 Jul, 2024 Reviewers agreed at journal 10 Jul, 2024 Reviewers agreed at journal 06 Jul, 2024 Reviewers agreed at journal 12 Apr, 2024 Reviewers agreed at journal 08 Apr, 2024 Reviewers invited by journal 07 Apr, 2024 Editor invited by journal 04 Apr, 2024 Submission checks completed at journal 04 Apr, 2024 Editor assigned by journal 04 Apr, 2024 First submitted to journal 02 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4207031","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":288919974,"identity":"f97c1990-a9f6-4ed8-9cdf-ca90137fffcf","order_by":0,"name":"Wenfeng Li","email":"","orcid":"","institution":"Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Wenfeng","middleName":"","lastName":"Li","suffix":""},{"id":288919976,"identity":"0942473e-3a7e-471c-adf6-9933d615145d","order_by":1,"name":"Bao Hua","email":"","orcid":"","institution":"Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Bao","middleName":"","lastName":"Hua","suffix":""},{"id":288919980,"identity":"95109abf-e7e8-4e52-9665-cef5e66ebbc5","order_by":2,"name":"Sangqing Song","email":"","orcid":"","institution":"Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sangqing","middleName":"","lastName":"Song","suffix":""},{"id":288919984,"identity":"56718886-4953-4441-b699-1caf4728fe83","order_by":3,"name":"Weixin Pan","email":"","orcid":"","institution":"Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Weixin","middleName":"","lastName":"Pan","suffix":""},{"id":288919987,"identity":"c047fe2d-f615-42bd-a3ff-90a80485ce57","order_by":4,"name":"Qing Yang","email":"","orcid":"","institution":"Shanghai Jiao Tong University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Qing","middleName":"","lastName":"Yang","suffix":""},{"id":288919990,"identity":"f8d4b390-9bc3-43e2-8afb-6235f9f138c2","order_by":5,"name":"Bin Xu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYBACCTBpA8TMzAcOfKiQkOMnTksaELO3JR6cccbCWLKBaC08Z5QP87ZVJG4gpEVyRvKzh18SbPLkI3IYDvDOk2DcwMD88NENPFqkJdLMjWUS0ooNb+QeOCC5TYLZnIHN2DgHjxY5iQQzackfhxM3zshLOGC4TYLNsoGHTRq/lvRv0hIJ/4FacgwOJM6R4DE4QECLtESOmeSHhAOJ83nOGBw42CAhQVCLZM+bMmmGhOTEDextCQcbjkkYSDYT8IvE8fRtkj8S7BLnNzMf/vynpq6+n7354WN8WkCAmQdIGByAcwkoBwHGH0BCvoEIlaNgFIyCUTAyAQC/6FCOklZiIgAAAABJRU5ErkJggg==","orcid":"","institution":"Shanghai Jiao Tong University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Bin","middleName":"","lastName":"Xu","suffix":""}],"badges":[],"createdAt":"2024-04-02 13:28:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4207031/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4207031/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12894-024-01578-6","type":"published","date":"2024-08-28T15:57:46+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":54864461,"identity":"5d818a42-4d72-468a-93e9-48d87575205b","added_by":"auto","created_at":"2024-04-17 20:35:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":21211,"visible":true,"origin":"","legend":"\u003cp\u003eRates of conversions from SLPN to SPN between 2016 and 2023.\u003c/p\u003e","description":"","filename":"fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-4207031/v1/f0c94dc66c211b6e11292fcd.png"},{"id":63821033,"identity":"23870c60-5702-412a-9008-9c36daf594f7","added_by":"auto","created_at":"2024-09-02 16:11:00","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":457055,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4207031/v1/25b80c35-7f14-4267-b13e-bce069ef7afd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"From Sutureless to Standard: A Comprehensive Analysis of Conversion Rates in Laparoscopic Partial Nephrectomy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRenal Cell Carcinoma (RCC), primarily the clear cell subtype, represents 2%-3% of adult malignancies, with a 2% annual increase in incidence, posing a significant public health challenge[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Technological advances in ultrasound and CT scans have significantly boosted the detection of renal tumors, particularly smaller lesions, leading to a shift towards nephron-sparing strategies[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Partial Nephrectomy (PN) has become the preferred treatment for renal masses\u0026thinsp;\u0026le;\u0026thinsp;7 cm, especially beneficial for patients with preexisting chronic kidney conditions, as it reduces the risk of chronic renal insufficiency and cardiovascular mortality[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSutureless Partial Nephrectomy (SLPN) leverages cutting-edge surgical technologies, including hemostatic agents and sealants, to achieve optimal hemostasis and parenchymal reconstruction without traditional sutures[\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This innovative approach aims to reduce warm ischemia time, minimize blood loss, and potentially hasten postoperative recovery, thereby lowering the risk of complications such as parenchymal damage and pseudoaneurysms[\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the advantages and potential of SLPN, the transition to Standard Partial Nephrectomy (SPN) remains infrequent. The scarcity of comprehensive data on the incidence of such conversions, their underlying reasons, and the patient and tumor characteristics that increase the risk highlights the need for further investigation. Understanding these factors is essential for improving surgical planning and patient counseling, ultimately enhancing the safety and efficacy of renal surgeries.\u003c/p\u003e \u003cp\u003eOur research focuses on determining the frequency of conversions from SLPN to SPN in our institution and analyzing the preoperative factors associated with these conversions to better guide clinical decisions.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eThis study conducted a comprehensive investigation into the application of SLPN on patients aged 18 and above from 2016 to 2023. The patient cohort, selected based on the presence of clinically localized solid renal masses\u0026thinsp;\u0026le;\u0026thinsp;4 cm in diameter, underwent a thorough pre-operative imaging review by a specialized uro-oncologist to assign RENAL nephrometry scores, considering factors such as tumor size, exophytic/endophytic properties, and location.\u003c/p\u003e \u003cp\u003eThe surgical approach predominantly entailed wedge resections, with intraoperative ultrasound facilitating precise tumor demarcation and renal parenchyma assessment. Excision was primarily executed using scissors, complemented by argon beam coagulation for effective hemostasis, resorting to suturing only when necessary.\u003c/p\u003e \u003cp\u003eParticipants were stratified into two categories to distinguish those requiring conversion to SPN. Comparative analyses of demographic and tumor-specific attributes were conducted to elucidate factors predisposing to surgical conversion.\u003c/p\u003e \u003cp\u003eStatistical analyses employed median and Interquartile Range (IQR) for continuous variables, and frequencies with percentages for categorical ones, utilizing the Wilcoxon rank-sum and Chi-square/Fisher's exact tests accordingly. A logistic regression model with backward selection was adopted to explore multivariate associations, presenting results as odds ratios with 95% confidence intervals, ensuring rigorous variable selection criteria to mitigate overfitting. Statistical analyses were performed using version 26.0 of the SPSS software package (SPSS Inc., Chicago, IL, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFrom 2016 to 2023, our institution documented a total of 353 SLPN procedures, with 21 instances (5.9%) necessitating a transition to SPN. Delving into specifics, within the Laparoscopic Partial Nephrectomy (LPN) subgroup, there were 17 conversions out of 215 cases (7.9%, 95% Confidence Interval [CI] 4.3\u0026ndash;11.5) to SPN, while the Robotic-assisted Partial Nephrectomy (RPN) subgroup saw 4 conversions out of 138 cases (2.9%, 95% CI 0.1\u0026ndash;5.7), P\u0026thinsp;=\u0026thinsp;.066. Intriguingly, the overall conversion rate exhibited a marginal decline throughout the study, descending from an initial 8.0\u0026ndash;6.0%, but this change did not reach statistical significance (P\u0026thinsp;=\u0026thinsp;.726) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e encapsulates the demographic profiles and tumor characteristics of both the no conversion and conversion groups. The conversion group demonstrated a notably younger median age at the time of surgery (58.0 years [IQR: 55.0\u0026ndash;72.0] as opposed to 64.0 years [IQR: 59.0\u0026ndash;72.0] in the no conversion group, P\u0026thinsp;=\u0026thinsp;.007) and a superior preoperative Estimated Glomerular Filtration Rate (eGFR) with a median of 66.4 [IQR: 62.6-88.19] compared to 57.5 [IQR: 49.4\u0026ndash;73.3] mL/min/1.73 m\u0026sup2; in the conversion group, (P\u0026thinsp;=\u0026thinsp;.001). No significant disparities were observed in terms of gender, Body Mass Index (BMI), Charlson Comorbidity Index (CCI), American Society of Anesthesiologists (ASA) score, and histopathological findings. The tumor characteristics such as the proximity to the collecting system, anterior versus posterior location, and the RENAL nephrometry score were comparable. However, notable distinctions were made in the radiological dimensions of the tumors (26.0 cm [IQR: 22.0\u0026ndash;30.0] in conversion group versus 31.0 cm [IQR: 29.0\u0026ndash;35.0] in no conversion group, P\u0026thinsp;=\u0026thinsp;.001) and the exophytic/endophytic properties of the tumors (P\u0026thinsp;=\u0026thinsp;.036), highlighting significant differences.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient and tumor characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Conversion\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;332\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConversion\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;21\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at surgery (y), Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64.0 (59.0\u0026ndash;72.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.0 (55.0\u0026ndash;72.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of males, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e208 (62.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (52.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.347\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index (kg/m2), Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28.0 (25.9\u0026ndash;31.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.1 (26.0-32.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.363\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative eGFR (mL/min/1.73 m2), Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57.5 (49.4\u0026ndash;73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.4 (62.6\u0026ndash;88.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCCI, Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.0 (1.0\u0026ndash;3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.0 (1.0\u0026ndash;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA score, Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.0 (1.0\u0026ndash;3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0 (1.0\u0026ndash;2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.461\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiographic tumor size(cm), Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26.0 (22.0\u0026ndash;30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.0 (29.0\u0026ndash;35.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRENAL-NS, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow: 4\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e203 (61.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.716\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium: 7\u0026ndash;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e129 (38.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRENAL-NS components, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExophytic/endophytic properties (E)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;50% exophytic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e173 (52.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;50% exophytic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e159 (47.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNearness to collecting system in mm (N)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;=7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e96 (28.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;4 but \u0026lt;\u0026thinsp;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47 (14.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;=4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e189 (56.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (76.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior/posterior (A)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e146 (44.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e97 (29.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle (X)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e89 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation relative to polar lines (L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEntirely polar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e126 (38.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.215\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCrosses polar line\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100 (30.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (47.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEntirely between polar lines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e106 (31.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistopathology, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClear cell\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e252 (75.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.918\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePapillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChromophobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther malignant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIntraoperative features are contrasted in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The group undergoing conversion to SPN exhibited a heightened median estimated blood loss (EBL) (91 mL [IQR: 57\u0026ndash;195] versus 77 mL [IQR: 48\u0026ndash;100] in the no conversion group, P\u0026thinsp;=\u0026thinsp;0.039) alongside an elongated duration of surgery (125 minutes [IQR: 102\u0026ndash;182] compared to 109 minutes [IQR: 97\u0026ndash;123], P\u0026thinsp;=\u0026thinsp;0.021). The WTI remained consistent across groups (17 minutes [IQR: 13\u0026ndash;19] for the conversion group versus 16 minutes [IQR: 14\u0026ndash;19] for the no conversion group, P\u0026thinsp;=\u0026thinsp;.725), with no significant correlation between the surgical approach (LPN or RPN) and the likelihood of conversion (P\u0026thinsp;=\u0026thinsp;.284).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Conversion\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;332\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConversion\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;21\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedure type, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLPN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e198 (59.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (71.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.284\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRPN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e134 (40.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEstimated blood loss (mL), Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77 (48\u0026ndash;100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (57\u0026ndash;195)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time (min), Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e109 (97\u0026ndash;123)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e125 (102\u0026ndash;182)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWarm ischemia time (min), Median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (13\u0026ndash;19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (14\u0026ndash;19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.725\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMultivariate analysis pinpointed pivotal predictors for conversion, encompassing the patient's age at the time of surgery (Odds Ratio [OR]: 0.087 [95% CI: 0.018\u0026ndash;0.420], P\u0026thinsp;=\u0026thinsp;.002); preoperative eGFR (OR: 86.118 [95% CI: 14.192-522.561], P\u0026thinsp;\u0026lt;\u0026thinsp;.001); radiological tumor size (OR: 92.608 [95% CI: 12.397-691.779], P\u0026thinsp;\u0026lt;\u0026thinsp;.001); and the tumor's exophytic/endophytic nature (OR: 32.525 [95% CI: 5.719-184.987], P\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eA major challenge in LPN is suturing renal parenchyma, which can prolong WTI and operative time, potentially leading to postoperative renal atrophy and impaired function recovery. The introduction of sutureless technologies like bipolar and monopolar coagulation, thulium laser, and argon beam coagulation has simplified these surgeries. These methods are beneficial for novice surgeons, offering ease of use and effective hemostasis. For instance, bipolar and monopolar coagulation minimize intraoperative bleeding by coagulating tissue and sealing blood vessels. The thulium laser, precise and minimally damaging, is ideal for delicate kidney resections, while argon beam coagulation effectively coagulates larger bleeding areas[\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These technologies reduce WIT, crucial for protecting renal function, especially in small T1a tumors, and can shorten surgical time and reduce blood loss, improving safety and effectiveness[\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDuring the period from 2016 to 2023, our study showed a conversion rate of 5.9% in SLPN procedures, with 21 out of 353 surgeries transitioning to SPN. Notably, the LPN subgroup exhibited a higher conversion rate of 7.9% (17/215), compared to a lower rate of 2.9% (4/138) in the RPN subgroup, although not reaching statistical significance with P\u0026thinsp;=\u0026thinsp;.066. This variation aligns with the findings of Jeffrey J. Leow et al who reported a decreased likelihood of conversion in RPN procedures[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Studies by Choi JE et al and Pavan N et al further corroborate the perioperative advantages of robotic-assisted surgeries[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eContrary to expectations and trends reported in the literature, our study did not observe a significant decrease in conversion rates over the study period, with rates slightly declining from 8.0\u0026ndash;6.0%, (P\u0026thinsp;=\u0026thinsp;.726). This finding may imply that factors other than technological advancements and surgical experience may play a crucial role in determining the likelihood of conversion, such as demographic and tumor characteristics. The stable conversion rates observed in our study also indirectly emphasize the low learning threshold of the sutureless technique, which seems to be unrelated to the surgeon's experience. This may be due to the intuitive operation process and fewer steps involved in the sutureless technique, thereby reducing the time and experience required to learn and master it[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Moreover, the simplification of the technique might also reduce the reliance on advanced skills of surgeons, allowing even less experienced surgeons to perform the surgery safely and effectively. Therefore, the ease of learning the sutureless technique could contribute to its rapid adoption and application, which is important for improving medical efficiency and patient outcomes.\u003c/p\u003e \u003cp\u003eAlthough literature reports suggest that the likelihood of converting from partial nephrectomy to radical nephrectomy increases with age[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], our observations indicate a contrasting trend when employing sutureless techniques for managing the bleeding site post-renal partial nephrectomy. We noted that the age of patients in the conversion group was generally lower than that in the no conversion group. Younger patients typically have healthier kidneys with more robust blood flow. This enhanced vascularity may lead to increased bleeding during the excision of renal tumors[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhen surgeons opt for sutureless techniques, which are less invasive and aim to preserve renal function, managing significant bleeding can pose a greater challenge. The higher the renal blood flow, the more difficult it may be to achieve effective hemostasis using these minimally invasive methods. Consequently, this might necessitate a shift to more traditional sutured techniques that offer better control of bleeding.\u003c/p\u003e \u003cp\u003eEGFR is a critical indicator for assessing renal function in partial nephrectomy. Takagi et al highlighted the importance of selecting surgical methods for renal tumors in robot-assisted laparoscopic partial nephrectomy, particularly the guiding role of preoperative eGFR in the decision-making process[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This indicator is essential for evaluating a patient's ability to endure surgery and recover renal function postoperatively. In clinical practice, the decision to perform partial nephrectomy and the extent of resection are often directly influenced by preoperative eGFR. Ni and Yang demonstrated the significant role of preoperative eGFR in predicting postoperative renal function when comparing robot-assisted with open partial nephrectomy in patients with clinical T1 stage renal cell carcinoma[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, in our study, the preoperative eGFR of patients in the conversion group was significantly higher than that in the no conversion group. Younger patients typically have higher eGFR, indicating better renal blood supply. However, this improved blood supply may increase the risk of intraoperative bleeding in partial nephrectomy using a sutureless technique. Although the sutureless technique offers the advantage of being minimally invasive, controlling bleeding and maintaining a clear surgical field can be more challenging in cases of significant bleeding. A higher eGFR may require surgeons to be more cautious in their surgical planning, considering the potential risks of uncontrollable bleeding associated with the sutureless technique.\u003c/p\u003e \u003cp\u003eSimilarly, our study found that the average size of tumors in patients who converted to traditional suturing during partial nephrectomy was significantly larger (31.0 vs 26.0 cm, P\u0026thinsp;=\u0026thinsp;.001) compared to those who did not require conversion, and the proportion of tumors with endophytic growth was also higher (P\u0026thinsp;=\u0026thinsp;.036).\u003c/p\u003e \u003cp\u003eFirst, larger or endophytically growing renal tumors are often more closely intertwined with critical structures such as renal blood vessels, the ureter, and the renal pelvis[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This proximity makes it particularly important to repair these structures with traditional suturing techniques after damage during surgery, which is difficult to achieve with generally less invasive sutureless techniques. Studies have shown that partial nephrectomy for large or endophytic tumors involves longer operative times and a higher risk of surgical complications compared to radical nephrectomy[\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSecondly, the complexity of blood supply to larger and deeper tumors increases the surgical challenge. These tumors typically have a more intricate vascular network, making intraoperative hemostasis more difficult and increasing the risk of accidental damage to surrounding vessels[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The literature further emphasizes the need for effective bleeding control in these scenarios, using more controllable suturing methods.\u003c/p\u003e \u003cp\u003eThe multivariate analysis identified key factors influencing the likelihood of surgical conversion during partial nephrectomy. These key factors include younger surgical age, higher preoperative eGFR, larger tumor size, and endophytic tumor characteristics. These findings suggest that younger patients, especially those with larger, complex tumors, particularly endophytic tumors, are more prone to surgical conversion.\u003c/p\u003e \u003cp\u003eFor larger renal tumors, especially those with complex anatomical features such as endophytic growth, an increased incidence of surgical conversion during partial nephrectomy is supported by various studies in the field. These studies identified key factors leading to the decision to switch from less invasive, nephron-sparing surgical approaches to more traditional surgical techniques.\u003c/p\u003e \u003cp\u003eResearch from the Michigan Urological Surgery Improvement Collaborative (MUSIC) and another study highlighted factors influencing the conversion from robotic partial nephrectomy to robotic-assisted radical nephrectomy. MUSIC found tumor size and complexity as key determinants, while the latter study pointed to patient-specific factors like age, BMI, and comorbidity index, rather than tumor characteristics, as significant predictors of surgical conversion. These insights emphasize the need for comprehensive pre-surgical assessments considering both tumor and patient health status[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTogether, these studies indicate that while tumor size and endophytic characteristics are important considerations, the overall demographic characteristics of the patient also play a significant role in surgical decision-making. This highlights the importance of comprehensive preoperative evaluation to predict surgical challenges and adjust approaches accordingly.\u003c/p\u003e \u003cp\u003eDuring the evaluation of perioperative characteristics between the conversion group and the no conversion group, a significant difference in EBL was noted. The median EBL for the conversion group was 91 mL, while for the control group, it was 77 mL, showing a statistically significant difference (P\u0026thinsp;=\u0026thinsp;.039). Additionally, the conversion group faced significant prolongation in surgery time due to difficulties in achieving hemostasis, with a median time of 125 minutes compared to 109 minutes for the control group (P\u0026thinsp;=\u0026thinsp;.021). This increase in duration is not only due to the time required to manage bleeding but also reflects the inherently time-consuming nature of traditional suturing techniques compared to the originally planned procedures. Literature indicates that intraoperative blood loss and extended surgery times are independent risk factors for postoperative complications. Despite employing effective hemostasis techniques, the conversion group continued to encounter challenges with ongoing bleeding and the limitations inherent in the techniques used. Similarly, prolonged surgeries increase oxygen debt, risk of organ failure, sepsis, and death, particularly in high-risk patients. Laparoscopic surgeries, involving carbon dioxide insufflation, can alter hemodynamics and stress hormones, posing risks, especially for the elderly or those with comorbidities[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Shorter operations, like SLPN, are crucial for minimizing surgical impact and enhancing recovery. Additionally, extended surgery durations strain resources and staff, potentially worsening patient outcomes, underscoring the need for refined surgical methods and intraoperative efficiency.\u003c/p\u003e \u003cp\u003eThis study on SLPN offers crucial insights but has notable limitations, such as a small, institutionally-bound sample, potentially limiting broader applicability. Its retrospective design may introduce biases from incomplete or inconsistent records limits a full evaluation of SLPN's effectiveness. Additionally, variations in surgical techniques and surgeon expertise, which can significantly affect outcomes, were not thoroughly examined. Future research should focus on multicenter, diverse, and randomized controlled trials to enhance the reliability and generalizability of findings, alongside a detailed assessment of surgical methods and the refinement of surgeon skills to advance SLPN's safety and efficacy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study revealed that between 2016 and 2023, the conversion rate from SLPN to SPN was 5.9%, with LPN showing a higher conversion rate than RPN. Key factors influencing conversion included younger surgical age, higher preoperative eGFR, larger tumor size, and intrinsic tumor characteristics, underscoring the importance of individualized considerations in surgical planning and patient counseling. Furthermore, comprehensive preoperative assessment's role in anticipating surgical challenges and adjusting strategies was highlighted, offering valuable insights into enhancing the safety and efficacy of nephron-sparing surgeries.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRenal Cell Carcinoma\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePartial Nephrectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSLPN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSutureless Partial Nephrectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandard Partial Nephrectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInterquartile Range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLPN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLaparoscopic Partial Nephrectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRPN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRobotic-assisted Partial Nephrectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEGFR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEstimated Glomerular Filtration Rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody Mass Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCharlson Comorbidity Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Society of Anesthesiologists\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEBL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStimated Blood Loss\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of Shanghai Ninth People\u0026rsquo;s Hospital (SH9H-2022-T359-1). All patients were given informed consent. All experiments were performed in accordance with relevant guidelines and regulations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026apos;s contribution\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWL: project development, manuscript writing and editing. BH: manuscript writing and editing. SS: data analysis. WP: data collection. QY: manuscript writing and data analysis. BX: project development, manuscript writing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThanks for patients helping this study. Many thanks for Dr. Bao Hua and Qing Yang.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBukavina L, Bensalah K, Bray F, et al. Epidemiology of Renal Cell Carcinoma: 2022 Update. Eur Urol. 2022;82(5):529\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer AR, Carducci MA, Denmeade SR, et al. Improved identification of patients with oligometastatic clear cell renal cell carcinoma with PSMA-targeted (18)F-DCFPyL PET/CT. Ann Nucl Med. 2019;33(8):617\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang S, Liu Z, Zhang D, Xiang F, et al. The incidence and risk factors of chronic kidney disease after radical nephrectomy in patients with renal cell carcinoma. BMC Cancer. 2022;22(1):1138.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMir MC, Derweesh I, Porpiglia F, et al. Partial Nephrectomy Versus Radical Nephrectomy for Clinical T1b and T2 Renal Tumors: A Systematic Review and Meta-analysis of Comparative Studies. Eur Urol. 2017;71(4):606\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTiscione D, Cai T, Luciani LG, et al. Sutureless laparoscopic partial nephrectomy using fibrin gel reduces ischemia time while preserving renal function. Arch Ital Urol Androl. 2019;91(1):30\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakamura K, Imamura Y, Yamamoto S, et al. Soft coagulation in robot-assisted partial nephrectomy without renorrhaphy: Comparison with standard suture. Int J Urol. 2020;27(4):352\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePacheco M, Barros AA, Aroso IM, et al. Use of hemostatic agents for surgical bleeding in laparoscopic partial nephrectomy: Biomaterials perspective. J Biomed Mater Res B Appl Biomater. 2020;108(8):3099\u0026ndash;123.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang F, Gao S, Chen XN, et al. Clampless and sutureless laparoscopic partial nephrectomy using monopolar coagulation with or without N-butyl-2-cyanoacrylate. World J Surg Oncol. 2019;17(1):72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTarim K, Kilic M, Koseoglu E, et al. Feasibility, safety and efficacy of argon beam coagulation in robot-assisted partial nephrectomy for solid renal masses\u0026thinsp;\u0026le;\u0026thinsp;7 cm in size. J Robot Surg. 2021;15(5):671\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu P, Li Y, Shi B et al. The Outcome of Sutureless in Partial Nephrectomy: A Systematic Review and Meta-Analysis. Biomed Res Int. 2022; 2022: 5260131.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang W, Che B, Xu S, et al. Comparison of Sutureless Versus Suture Partial Nephrectomy for Clinical T1 Renal Cell Carcinoma: A Meta-Analysis of Retrospective Studies. Front Oncol. 2021;11:713645.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang F, Gao S, Zhao Y, et al. Comparison of Sutureless and Conventional Laparoscopic Partial Nephrectomy: A Propensity Score-Matching Analysis. Front Oncol. 2021;11:649356.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarinha R, Rosiello G, Paludo AO, et al. Selective Suturing or Sutureless Technique in Robot-assisted Partial Nephrectomy: Results from a Propensity-score Matched Analysis. Eur Urol Focus. 2022;8(2):506\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeow JJ, Heah NH, Chang SL, et al. Outcomes of Robotic versus Laparoscopic Partial Nephrectomy: an Updated Meta-Analysis of 4,919 Patients. J Urol. 2016;196(5):1371\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePavan N, Derweesh IH, Mir CM, et al. Outcomes of Laparoscopic and Robotic Partial Nephrectomy for Large (\u0026gt;\u0026thinsp;4 Cm) Kidney Tumors: Systematic Review and Meta-Analysis. Ann Surg Oncol. 2017;24(8):2420\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi JE, You JH, Kim DK, et al. Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol. 2015;67(5):891\u0026ndash;901.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArora S, Chun B, Ahlawat RK, et al. Conversion of Robot-assisted Partial Nephrectomy to Radical Nephrectomy: A Prospective Multi-institutional Study. Urology. 2018;113:85\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoejima K, Sato H, Hisaka A. Age-Related Change in Hepatic Clearance Inferred from Multiple Population Pharmacokinetic Studies: Comparison with Renal Clearance and Their Associations with Organ Weight and Blood Flow. Clin Pharmacokinet. 2022;61(2):295\u0026ndash;305.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakagi T, Yoshida K, Kondo T, et al. Comparisons of surgical outcomes between transperitoneal and retroperitoneal approaches in robot-assisted laparoscopic partial nephrectomy for lateral renal tumors: a propensity score-matched comparative analysis. J Robotic Surg. 2021;15(1):99\u0026ndash;104.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNi YX, Yang XH. A Systematic Review and Meta-Analysis of Comparison of Outcomes of Robot-Assisted versus Open Partial Nephrectomy in Clinical T1 Renal Cell Carcinoma Patients. Urol Int. 2022;106(8):757\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuo SJ, Wei LC, Zhuo SQ, et al. [Clinical analysis of three-dimensional surgical planning system for guiding robot-assisted selective artery clamping partial nephrectomy in completely endophytic renal tumor]. Zhonghua Wai Ke Za Zhi. 2022;60(11):992\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXiong S, Jiang M, Jiang Y, et al. Partial Nephrectomy Versus Radical Nephrectomy for Endophytic Renal Tumors: Comparison of Operative, Functional, and Oncological Outcomes by Propensity Score Matching Analysis. Front Oncol. 2022;12:916018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeltrini R, Iacone B, Pacella D, et al. Laparoscopic Radical Nephrectomy with Transperitoneal Approach for Large Renal Tumors: Standardized Surgical Technique and Outcomes. J Laparoendosc Adv Surg Tech A. 2023;33(9):879\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen XB, Li YG, Wu T, et al. Perioperative, oncologic, and functional outcomes of robot-assisted partial nephrectomy for special types of renal tumors (hilar, endophytic, or cystic): an evidence-based analysis of comparative outcomes. Front Oncol. 2023;13:1178592.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu SY, Chung HJ, Huang EY, et al. The perioperative outcomes between renal hilar and non-hilar tumors following robotic-assisted partial nephrectomy (RAPN). J Chin Med Assoc. 2018;81(8):676\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoldman B, Rudoff M, Qi J, et al. Factors Affecting Robotic Partial Nephrectomy Conversion to Radical Nephrectomy: A Retrospective Multi-Institutional Analysis in the Michigan Urologic Surgery Improvement Collaborative (MUSIC). Cureus. 2021;13(12):e20477.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetros FG, Keskin SK, Yu KJ, et al. Intraoperative Conversion From Partial to Radical Nephrectomy: Incidence, Predictive Factors, and Outcomes. Urology. 2018;116:114\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"partial nephrectomy, renal cell carcinoma, suture, sutureless","lastPublishedDoi":"10.21203/rs.3.rs-4207031/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4207031/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo assess the rate at which sutureless partial nephrectomy (SLPN) transitions to standard partial nephrectomy (SPN), focusing on preoperative factors that might prompt such conversions.\u003c/p\u003e\u003ch2\u003ePatients and methods\u003c/h2\u003e \u003cp\u003eIn this retrospective study, we analyzed the efficacy of SLPN performed on adults at our institution from 2016 to 2023. The subjects were patients diagnosed with localized solid renal tumors. The primary technique employed was wedge resection, complemented by intraoperative ultrasound localization and argon beam coagulation for hemostasis, with suturing techniques used only when necessary. Predictive factors necessitating conversion to SPN were identified, and the associations among multiple variables were explored using various statistical analysis methods, including logistic regression, to identify key preoperative predictive factors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOur institution performed 353 SLPN, with 21 cases (5.9%) necessitating conversion to SPN. The conversion rates for the Laparoscopic Partial Nephrectomy (LPN) subgroup and the Robotic-assist Partial Nephrectomy (RPN) subgroup were 7.9% (17/215) and 2.9% (4/138), respectively, nearing statistical significance (P\u0026thinsp;=\u0026thinsp;.066). Significant differences were observed between the conversion group and the no conversion group in terms of preoperative estimated Glomerular Filtration Rate (eGFR), age at surgery, tumor size, and exophytic/endophytic characteristics. Multivariate analysis identified age at surgery, preoperative eGFR, radiological tumor size, and tumor exophytic/endophytic nature as significant predictors for conversion to SPN.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis investigation highlights the efficacy and feasibility of SLPN while identifying critical factors influencing the necessity for conversion to SPN. The identified predictors, including younger surgical age, superior preoperative eGFR, and specific tumor characteristics, provide valuable insights for refining surgical strategies.\u003c/p\u003e","manuscriptTitle":"From Sutureless to Standard: A Comprehensive Analysis of Conversion Rates in Laparoscopic Partial Nephrectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-17 20:35:35","doi":"10.21203/rs.3.rs-4207031/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-23T17:34:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-22T23:09:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-14T13:35:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75585955877128969641899751785004818706","date":"2024-07-10T17:24:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"112410624987966949753659725256157504903","date":"2024-07-06T08:20:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"e493ce3d-0e9a-40ca-884f-9597904a217b","date":"2024-04-12T11:16:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"a7711c08-c480-484a-a004-b5c6f0ca0e20","date":"2024-04-08T15:28:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-07T10:37:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-04-04T08:09:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-04T08:08:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-04T08:08:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2024-04-02T13:27:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"84f8b34d-a75c-4046-9bb4-784bc32b9be8","owner":[],"postedDate":"April 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-02T16:03:23+00:00","versionOfRecord":{"articleIdentity":"rs-4207031","link":"https://doi.org/10.1186/s12894-024-01578-6","journal":{"identity":"bmc-urology","isVorOnly":false,"title":"BMC Urology"},"publishedOn":"2024-08-28 15:57:46","publishedOnDateReadable":"August 28th, 2024"},"versionCreatedAt":"2024-04-17 20:35:35","video":"","vorDoi":"10.1186/s12894-024-01578-6","vorDoiUrl":"https://doi.org/10.1186/s12894-024-01578-6","workflowStages":[]},"version":"v1","identity":"rs-4207031","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4207031","identity":"rs-4207031","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}