Selective by design: Early Adoption Patterns of Single-Port Off-Clamp Robotic Partial Nephrectomy in a High-Volume Center

Selective by design: Early Adoption Patterns of Single-Port Off-Clamp Robotic Partial Nephrectomy in a High-Volume Center | 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 Selective by design: Early Adoption Patterns of Single-Port Off-Clamp Robotic Partial Nephrectomy in a High-Volume Center Umberto Anceschi, Salvatore Basile, Gabriele Tuderti, Aldo Brassetti, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8224240/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Dec, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted 10 You are reading this latest preprint version Abstract Background Introduction of single-port (SP) technology into centers with a consolidated multi-port experience in robot-assisted partial nephrectomy (MP-RAPN) represents a conceptual shift rather than a natural transition. We analyzed the early institutional adoption of the SP platform, assessing its impact on case complexity, perioperative outcomes, and determinants of surgical selection within a purely off-clamp RAPN framework compared with the established MP standard. Material and Methods All consecutive RAPN performed at our tertiary referral center between May 2024 and October 2025 were analyzed (n = 372). All procedures were performed using a standardized off-clamp technique, irrespective of tumor features. After SP platform introduction, cases were stratified as multi-port (MP, n = 294) or single-port (SP, n = 78). Baseline, anatomical, and perioperative variables were prospectively collected. Tumor complexity was graded using the RENAL score, and renal function was assessed through serial eGFR measurements. Continuous and categorical variables were analyzed with Mann–Whitney U and χ²/Fisher tests; SMD > 0.20 denoted clinical imbalance. Univariable and multivariable Firth logistic regression identified independent predictors of SP adoption. Results Baseline characteristics were similar (each p > 0.2), except for tumor size and RENAL score, which were lower in SP cases (2.8 vs 4.1 cm; 6.4 vs 7.8; each p 0.05). SP tumors showed higher Fuhrman 1 (20.5% vs 4.9%, p = 0.008) and pT1a stage (78.8% vs 52.9%, p = 0.003). A lower RENAL score (OR 0.64, p < 0.001) independently predicted SP selection (C-index = 0.77). Conclusions In a center routinely performing purely off-clamp RAPN, adoption of the single-port robotic platform proved technically feasible and oncologically safe, achieving perioperative and functional outcomes equivalent to the multi-port approach during its early institutional phase. Single-port robotic partial nephrectomy off-clamp renal cancer nephron-sparing multi-port Figures Figure 1 Figure 2 Figure 3 Introduction Robot-assisted partial nephrectomy (RAPN) has progressively become the reference standard for the management of localized renal masses, combining oncologic efficacy with maximal preservation of renal function. Over the last decade, the multi-port robotic platform has provided surgeons with refined dexterity, tridimensional vision, and stable ergonomics, establishing an optimal environment for precise parenchymal dissection and renorrhaphy. Within this evolution, high-volume centers have progressively refined their surgical protocols, expanding the indications for minimally invasive nephron-sparing surgery to increasingly complex scenarios. The introduction of single-port robotic technology marks the latest step in this gradual continuum of refinement [ 1 , 2 ]. By bringing the entire system through a single access point, the platform was conceived to further reduce invasiveness and optimize cosmesis while preserving the technical advantages of robotics [ 3 ]. Yet, the single-port setting deeply alters the intra-abdominal dynamics that have long promoted the multi-port technique[ 4 ]. The redistribution of instruments through a single entry point modifies depth perception, the degree of triangulation, and minimizes the role of the bedside assistant, thereby reshaping how exposure, traction, and hemostasis are achieved during parenchymal resection. In this respect, the single-port approach is better seen not as a linear evolution but as a conceptual rethinking of the robotic act itself [ 5 ]. Among nephron-sparing strategies, the off-clamp technique ranks a distinctive and challenging position[ 6 , 7 ]. While its rationale—avoiding ischemia to maximize functional preservation—is well established, the lack of hilar control and the higher potential bleeding have traditionally discouraged its widespread use, confining it to a few expert centers[ 8 , 9 ]. As a result, the interaction between the single-port system and an exclusively off-clamp approach remains largely unexplored[ 10 , 11 ]. Whether the constraints inherent to a single robotic access can accommodate the technical demands of unclamped renal resection is still an open question, particularly when hemostasis relies on continuous suction, irrigation, and precise coordination with the assistant surgeon [ 12 ]. In this context, we sought to analyze the early institutional integration of single-port technology within a high-volume centre that has long encouraged a purely off-clamp RAPN policy[ 13 , 14 ]. Our aim was to describe the early patterns of adoption, characterize the surgical selection process, and identify the determinants influencing the transition from the multi-port to the single-port platform. By focusing on an experienced off-clamp RAPN environment, this study delineates the pragmatic limits and opportunities of single-port implementation under one of the most functionally demanding robotic scenarios [ 15 ]. Materials and methods Study design and population Data were extracted from our prospectively maintained RAPN registry. The database includes all robot-assisted partial nephrectomies (RAPN) performed by our unit, with systematic collection of pre-, intra-, and postoperative variables. For this analysis, we selected all consecutive procedures performed between May 2024 and October 2025, corresponding to the institutional phase of single-port (SP) platform introduction. The aim was to assess changes in case selection and perioperative outcomes after implementation of the SP system within an established off-clamp robotic program. A total of 372 cases were included: 294 multi-port (MP) and 78 single-port (SP) procedures. All interventions were performed with a purely off-clamp technique, which represents our institutional standard and it is applied irrespective of tumor size or location[16]. SP-RAPN was carried out exclusively by one high-volume surgeon (G.S.), while MP procedures were performed by multiple experienced operators from the same robotic team[17]. Surgical technique MP-RAPN was conducted exclusively via a transperitoneal approach, following the standardized technique adopted in our center[18]. In complex cases—such as large, hilar, or purely endophytic tumors, or those with irregular margins—LigaSure Atlas® was used to assist precise hemostatic dissection[12, 19]. SP-RAPN was performed in a supine anterior-lateral position, according to the SARA configuration[20]. A short oblique incision was made just above the iliac crest along the lumbar line to provide direct open access to the retroperitoneum. The space was developed bluntly under vision. An Alexis wound protector was positioned, and the Intuitive “fish-bowl” single-port system was secured on it to allow docking of the robotic arm. AirSeal® insufflation was used throughout the procedure to maintain a stable pneumoretroperitoneum. The fish-bowl port includes an auxiliary trocar through which sutures or Hem-o-lok clips were introduced when required. Dissection proceeded along the psoas margin until the renal capsule was exposed. In the absence of a dedicated single-port suction/irrigation device such as the ROSI system, continuous visibility was maintained using a customized dual-Nelaton system, composed of two small catheters tied together with 0-silk, providing simultaneous irrigation and suction. Tumor excision in the SP group was performed avoiding intentionally hilar control using monopolar energy under continuous irrigation. Small feeding vessels were coagulated selectively, and the resection bed was inspected in dry conditions. Renorrhaphy, when required, was performed with a 2-0 Monocryl suture using the sliding-Weck technique, always in a single-layer fashion and rarely in double-layer configuration (medullary and cortical closure). Whenever anatomically feasible, the margins of Gerota’s fascia were re-approximated within the retroperitoneal space to enhance local hemostasis and containment [21, 22]. Data and endpoints For each patient, demographic, clinical, and anatomical variables were prospectively recorded. Tumor size, side, and RENAL nephrometry score were extracted from operative records. Perioperative outcomes included operative time, hemoglobin drop, transfusion rate, complications graded according to Clavien–Dindo, and length of stay[23]. Pathological data comprised histology, Fuhrman grade, and pathologic T stage. Postoperative renal function was evaluated through serial eGFR measurements relative to baseline[24]. Statistical analysis Continuous variables were summarized as median [IQR] and categorical variables as number (%). Group comparisons were performed using the Mann–Whitney U or χ²/Fisher exact tests as appropriate. Baseline balance was assessed by standardized mean difference (SMD), with SMD > 0.20 considered clinically relevant. Independent predictors of SP adoption were identified using univariable and multivariable logistic regression models with Firth’s penalized likelihood correction. Model discrimination and calibration were evaluated by concordance index (C-index), variance inflation factor (VIF), and calibration plot. Monthly SP/MP ratios were used to describe temporal adoption trends. All analyses were performed in R Studio v4.2.3 (R Foundation for Statistical Computing, Vienna, Austria). A two-sided p < 0.05 was considered statistically significant. Ethics This observational study was conducted using data from a prospectively maintained institutional registry. The Ethics Committee of IRCCS Regina Elena National Cancer Institute (Rome, Italy) reviewed the study protocol and confirmed that formal approval was not required, as all analyses were performed on anonymized data without impact on patient management. Informed consent Written informed consent for the use of anonymized clinical data for research purposes was obtained from all patients in accordance with institutional policy and national data protection regulations. Consent to publish This manuscript does not contain any individual person’s data in any form (including images, videos, or identifiable clinical details). Therefore, consent for publication was not required. Results Over the study period, 372 consecutive off-clamp RAPN were performed and included in the analysis, of which 294 (79.0%) were carried out with the multi-port platform and 78 (21.0%) with the single-port system. Baseline characteristics are reported in Table 1. Median age was similar between groups (63 [54–71] vs 64 [58–72] years for MP and SP, respectively; p = 0.28; SMD = 0.14), as were gender distribution (male 62.9% vs 67.9%; p = 0.34; SMD = 0.11) and body-mass index (26.9 [23.6–29.5] vs 26.7 [23.9–28.9] kg/m²; p = 0.67; SMD = 0.06). The prevalence of ASA ≥ 3, hypertension, and diabetes was comparable in the two cohorts (all p ≥ 0.30; all SMD ≤ 0.13). Preoperative hemoglobin (13.8 [13.0–14.6] vs 13.5 [12.8–14.3] g/dL; p = 0.29; SMD = 0.15) and baseline eGFR (89.1 [71–104] vs 87.9 [72–101] mL/min/1.73 m²; p = 0.63; SMD = 0.06) did not differ significantly. Conversely, tumor-related variables showed a systematic difference between groups. Median tumor size was 4.1 (2.8–5.0) cm in the MP series and 2.8 (1.9–3.3) cm in the SP cohort (p < 0.001; SMD = 0.74), and median RENAL nephrometry score was 7.8 ± 1.7 versus 6.4 ± 1.3, respectively (p < 0.001; SMD = 0.96). Tumor side was evenly distributed (right side 47.8% vs 50.0%; p = 0.73; SMD = 0.04), and surgery year did not differ (2024 ± 1 vs 2024 ± 1; p = 0.81; SMD = 0.04) (Table 1). No baseline variable other than tumor size and RENAL score exceeded the predefined SMD threshold of 0.20. Intraoperative and perioperative outcomes are summarized in Table 2. Overall, the median hemoglobin drop at discharge was –1.1 [–1.6 – –0.6] g/dL, with no significant difference between MP and SP cases (–1.0 [–1.5 – –0.5] vs –1.2 [–1.8 – –0.7] g/dL; p = 0.28; SMD = 0.19). Renorrhaphy was performed in 39.7% of cases, with similar rates in MP and SP cohorts (41.2% vs 34.2%; p = 0.26; SMD = 0.14). Intraoperative transfusion was rare, occurring in 1 patient (0.3%) in the MP group and in none of the SP cases (p = 1.00); no postoperative transfusion was required in either cohort. Median length of stay was 2 days in both arms; the interquartile range was 2–3 days for MP and 2–2 days for SP (p = 0.06; SMD = 0.21). The overall complication rate was 7.8% (23/294 MP vs 6/78 SP; p = 1.00; SMD = 0.01), and major complications (Clavien–Dindo ≥ III) were uncommon (0.7% vs 0.0%; p = 1.00; SMD = 0.03) (Table 2). Pathologic and early functional outcomes are reported in Table 3. The overall distribution of benign histologies (angiomyolipoma/other benign entities and oncocytoma) and malignant tumors was similar between groups: malignant lesions accounted for 74.4% of the entire cohort (75.8% MP vs 69.7% SP; p = 0.299). Among malignant cases, Fuhrman grade showed a different distribution, with grade 1 tumors more frequently observed in the SP cohort (20.5% vs 4.9%; p = 0.008), while the proportions of grades 2–4 were comparable. Pathologic stage was also more favorable in the SP group: pT1a disease was present in 78.8% of SP versus 52.9% of MP procedures, whereas pT1b and pT2–T3 stages were more frequent in the MP series (pT1b 34.0% vs 17.3%; pT2–T3 13.1% vs 3.8%; overall p = 0.003). No positive surgical margins were recorded in either group. Early postoperative renal function was preserved in both cohorts. Median early ΔeGFR was 93.7% [84.0–102.9] of baseline overall, with values of 92.8% [82.8–102.1] in MP and 96.0% [88.0–103.2] in SP cases (p = 0.080). The proportion of patients with ≥90% eGFR preservation was 54.6% in the MP cohort and 67.1% in the SP cohort (p = 0.066) (Table 3). Predictors of SP platform utilization are presented in Table 4 and Figure 4. On univariable analysis, age, BMI, ASA ≥ 3 status, hypertension, diabetes, baseline eGFR, and tumor side were not significantly associated with the likelihood of SP access (all p ≥ 0.14). Tumor size and RENAL score showed a trend toward lower values in SP cases, but only RENAL score approached statistical significance at the univariable level (OR 0.68, 95% CI 0.45–1.00; p = 0.050), whereas tumor size did not (OR 0.86, 95% CI 0.59–1.21; p = 0.388) (Table 4). In the multivariable Firth logistic regression, including clinical and anatomical covariates in a complete-case dataset (n ≈ 220), RENAL score emerged as the only independent predictor of SP adoption (OR 0.64, 95% CI 0.51–0.79; p < 0.001). Age, BMI, ASA ≥ 3, baseline eGFR, and tumor side were not significantly associated with SP access in the adjusted model (all p ≥ 0.36). The model showed good discrimination with a C-index of 0.77 and no relevant collinearity (all VIF < 1.4; Table 4) Adoption dynamics by tumor complexity and size are detailed in Table 5. For lesions with RENAL ≤ 6, the proportion of SP use exceeded 50% for small masses: SP accounted for 52.2% of procedures in tumors < 2 cm (SP:MP ratio 1.09) and 61.1% in those 2–3.9 cm (SP:MP ratio 1.57). In the same complexity stratum, SP utilization was 50.0% for tumors ≥ 4 cm. For RENAL 7 lesions, SP use ranged from 57.1% in tumors < 2 cm (SP:MP ratio 1.33) to 42.9% and 25.0% in the 2–3.9 cm and ≥ 4 cm categories, respectively. In contrast, for RENAL ≥ 8, SP access was uncommon, with SP proportions of 0.0% for tumors < 2 cm, 18.9% for 2–3.9 cm (SP:MP ratio 0.23), and 6.1% for ≥ 4 cm masses (SP:MP ratio 0.06) (Table 5). Temporal patterns of platform use are illustrated in Figures 1–3. Throughout the study window, the multi-port system remained predominant, with higher absolute monthly case numbers in all observed months (Figure 1). The relative share of SP-RAPN fluctuated between approximately 10% and 20% of monthly RAPN volume, without evidence of abrupt shifts or replacement of the MP platform (Figure 2). Monthly distributions of SP and MP cases confirmed a stable but limited integration of SP procedures within a consistently MP-dominant activity, with SP cases interspersed throughout the observation period rather than clustered in isolated timeframes (Figure 3). Discussion To our knowledge, the present study represents one of the first institutional analyses of single-port robot-assisted partial nephrectomy performed exclusively with an off-clamp technique. Within a high-volume robotic program that has adopted off-clamp resection as a consolidated standard for more than a decade, the transition from multi-port to single-port systems provided an opportunity to test the reproducibility of a technically demanding approach under an alternative robotic system [4]. While on-clamp SP-RAPN has been previously reported, its performance within a purely off-clamp framework—where hemostatic control relies on continuous vision, suction, and precise dissection rather than hilar clamping—had not been systematically evaluated [25–27]. In our experience, the early institutional adoption of the SP platform followed a careful and selective path [25, 28]. Case allocation favored smaller and less complex renal masses, as reflected by significantly lower median tumor size and RENAL score in SP cases (each p < 0.001), a pattern consistent with the initial phase of implementation of a new technology. Despite this deliberate selection, perioperative and functional outcomes were fully comparable to those of the established multi-port cohort. The absence of significant differences in hemoglobin drop, transfusion rates, or complication profiles (each p > 0.2) shows that, when performed by an experienced surgeon, the transition to single-port access can be completed without compromising perioperative safety, even in the absence of hilar or selective clamping. Technically, the comparable intraoperative and early functional outcomes between SP and MP procedures highlight the robustness of the off-clamp technique when applied by surgeons with extensive prior off-clamp experience [29]. The use of monopolar energy under continuous irrigation, selective coagulation of feeding vessels, single-layer sliding-Weck renorrhaphy, and systematic reconstruction of Gerota’s fascia when feasible provided adequate hemostatic control despite the lack of hilar clamping[30, 31]. The similar ΔeGFR and proportion of patients maintaining ≥90% postoperative renal function (each p > 0.06) further support the preservation of renal parenchyma inherent to the off-clamp strategy, irrespective of the robotic platform. These results suggest that SP-RAPN can reproduce the hemodynamic and functional profile of MP off-clamp surgery, provided that case selection remains careful and technical expertise is in place[10]. Pathologic comparisons further delineate the pattern of an early adoption. The over-representation of Fuhrman grade 1 and pT1a tumors within the SP cohort (p = 0.008 and p = 0.003, respectively) is consistent with an institutional policy of introducing the SP system in oncologically selected cases. Nevertheless, the absence of positive surgical margins across both groups indicates that oncologic control was maintained even during the early SP experience. Importantly, the multivariable analysis identified RENAL complexity as the only independent determinant of SP selection, whereas patient-related and functional parameters did not influence platform choice. This finding suggests that surgical judgment, directed primarily by anatomical complexity, guided case allocation more than concerns about baseline renal function[32]. The C-index of 0.77 and the good calibration of the Firth model confirm the internal consistency of this selection design. The adoption trend observed in our study remained stable but limited, with SP procedures accounting for approximately 10–20% of monthly RAPN volume. This steady proportion, without evidence of displacement of multi-port cases, indicates that the SP platform currently acts as a complement rather than a replacement within a mature robotic experience [33]. This plateau likely reflects intrinsic limitations of the SP system and the high technical demands of off-clamp RAPN [34, 35]. In the absence of dedicated single-port suction/irrigation devices such as ROSI®, customized solutions like the dual-Nelaton system may remain necessary to ensure adequate visibility and hemostasis during unclamped resections. This study is not devoid of limitations. The retrospective nature of the analysis, despite prospective data collection, and the relatively small number of SP cases inevitably introduce a potential selection bias, amplified by the prudent allocation of early SP cases to less complex tumors. The concentration of all SP procedures in the hands of a single expert surgeon reduces inter-operator variability but limits generalizability, as outcomes achieved in an oncologic high-volume center with long-standing off-clamp expertise may not be immediately reproducible in other settings. Moreover, the observational window of 18 months preclude definitive conclusions regarding functional or oncologic equivalence. Finally, the purely off-clamp technique, while eliminating variability in ischemia time, may restrict external comparability, as most contemporary series still rely on clamping strategies. These considerations underline that our results reflect an institutional model rather than a universally applicable standard[15, 36]. Despite these limitations, a few strengths are worth highlighting. This analysis derives from a prospectively maintained registry, with uniform surgical policy and detailed perioperative and functional data. It represents, to our knowledge, the first series focusing specifically on SP-RAPN within a purely off-clamp framework and one of the few to explore adoption patterns rather than only perioperative feasibility. The use of standardized mean difference to quantify baseline imbalances and Firth logistic regression to explore predictors of SP selection reinforces the robustness of the analytical approach. The consistent perioperative outcomes, absence of transfusion in the SP group, and lack of major complications during the early adoption phase support the safety and reproducibility of SP off-clamp RAPN when implemented in an experienced environment. Future series should explore whether SP-RAPN can be safely extended to higher RENAL complexity and larger tumors, particularly in retroperitoneal settings, and to what extent dedicated single-port instruments may modify current selection thresholds[10, 35, 37]. Cost-effectiveness analyses and longer-term functional and oncologic follow-up will be essential to determine the precise role of SP platform within the broader landscape of nephron-sparing surgery[38]. In this perspective, the combination of minimized access and zero ischemia may represent a convergent evolution of robotic kidney surgery, with single-port off-clamp RAPN as a potential starting grid for further refinements. Conclusions In a high-volume center with longstanding expertise in off-clamp partial nephrectomy, the transition from multi-port to single-port robotic surgery proved technically feasible and oncologically safe. Despite selective early adoption for smaller and less complex tumors, perioperative and functional outcomes remained equivalent across approaches, confirming the reproducibility of the off-clamp strategy within the single-port robotic approach. These findings delineate a steady but cautious integration of SP technology, which currently complements rather than replaces the multi-port platform. As the field evolves, refinements in single-port ergonomics and instrumentation may further extend the boundaries of off-clamp renal surgery toward increasingly complex scenarios. Declarations The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. U.A. and S.B. contributed to study conception and design, data curation, statistical analysis, drafting of the manuscript, and critical revision of all scientific sections. G.T. and A.B. contributed to data collection, dataset verification, and preparation of tables and figures. R.M. and E.B. assisted with perioperative data extraction, surgical dataset handling, and methodological refinement. L.C.L., R.S.F., A.M.B. and M.F. conducted the literature review, supported manuscript drafting, and contributed to the interpretation of findings. F.P. and S.G. provided critical intellectual input, validated the clinical interpretation, and revised the discussion for accuracy. C.L. and G.S. supervised the entire project, provided senior oversight, ensured methodological rigor, and approved the final version of the manuscript. References Biasatti A, Soputro NA, Porpiglia F et al (2025) The current landscape of single-port robotic surgery in urology. 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J Urol 202:62–67 Antonelli A, Cindolo L, Sandri M et al (2020) Safety of on- vs off-clamp robotic partial nephrectomy: per-protocol analysis from the data of the CLOCK randomized trial. World J Urol 38:1101–1108. https://doi.org/10.1007/s00345-019-02879-4 Simone G, Capitanio U, Tuderti G et al (2019) On-clamp versus off-clamp partial nephrectomy: Propensity score-matched comparison of long-term functional outcomes. Int J Urol. https://doi.org/10.1111/iju.14079 Kim J, Na JC, Lee JS et al (2022) Clinical Implications for da Vinci SP Partial Nephrectomy in High-Complexity Tumors: Propensity Score-Matching Analysis. J Endourol 36:1290–1295. https://doi.org/10.1089/END.2022.0203 Nguyen TT, Ngo XT, Duong NX et al (2024) Single-Port vs Multiport Robot-Assisted Partial Nephrectomy: A Meta-Analysis. J Endourol 38:253–261. https://doi.org/10.1089/END.2023.0505 Xu MC, Hemal AK (2025) Single-Port vs Multiport Robotic Surgery in Urologic Oncology: A Narrative Review. J Endourol 39:271–284. https://doi.org/10.1089/END.2024.0528 Celotto F, Ramacciotti N, Mangano A et al (2024) Da Vinci single-port robotic system current application and future perspective in general surgery: A scoping review. Surg Endosc 38:4814–4830. https://doi.org/10.1007/S00464-024-11126-W Mehrazin R, Ranti D, Altschuler J (2023) Early perioperative outcomes of single-port compared to multi-port robot-assisted laparoscopic partial nephrectomy. J Robot Surg 17:2409–2414. https://doi.org/10.1007/S11701-023-01617-8 Capozzi VA, Armano G, Rosati A et al (2021) The robotic single-port platform for gynecologic surgery: a systematic review of the literature and meta-analysis. Updates Surg 73:1155–1167. https://doi.org/10.1007/S13304-020-00812-8 Abaza R, Murphy C, Bsatee A et al (2021) Single-port Robotic Surgery Allows Same-day Discharge in Majority of Cases. Urology 148:159–165. https://doi.org/10.1016/J.UROLOGY.2020.08.092 Tables Table 1. Baseline characteristics of patients undergoing single-port versus multi-port robot-assisted partial nephrectomy after adoption of the single-port platform at a tertiary referral center (May 2024) Variable Overall (n = 372) Multi-port (n = 294) Single-port (n = 78) p SMD Age, years 63 (54–71) 63 (54–71) 64 (58–72) 0.28 0.14 Gender, male (%) 63.8 62.9 67.9 0.34 0.11 BMI, kg/m² 26.9 (23.7–29.6) 26.9 (23.6–29.5) 26.7 (23.9–28.9) 0.67 0.06 ASA ≥ 3 (%) 20.9 20.0 24.4 0.40 0.10 Hypertension, % 56.0 56.8 52.6 0.50 0.09 Diabetes, % 12.1 11.3 15.6 0.30 0.13 Pre-op Hemoglobin, g/dL 13.7 (12.9–14.5) 13.8 (13.0–14.6) 13.5 (12.8–14.3) 0.29 0.15 Pre-op eGFR, mL/min/1.73 m² 88.9 (71–103) 89.1 (71–104) 87.9 (72–101) 0.63 0.06 Tumor size, cm 3.8 (2.6–4.8) 4.1 (2.8–5.0) 2.8 (1.9–3.3) < 0.001 0.74 RENAL score 7.4 ± 1.8 7.8 ± 1.7 6.4 ± 1.3 < 0.001 0.96 Tumor side, Right (%) 48.4 47.8 50.0 0.73 0.04 Surgery year 2024 ± 1 2024 ± 1 2024 ± 1 0.81 0.04 Continuous variables are presented as median [interquartile range], categorical variables as number (percentage). Comparisons were performed using the Mann–Whitney U or χ²/Fisher exact test, as appropriate. Standardized mean difference (SMD) > 0.20 was considered clinically relevant. Tumor size and RENAL score showed the largest imbalance, indicating a tendency toward the selection of smaller and less complex lesions for the single-port approach during the early adoption phase . Table 2. Intraoperative and perioperative outcomes after single-port (SP) and multi-port (MP) robot-assisted partial nephrectomy (May 2024 – Oct 2025) Variable Overall (n = 372) Multi-port (n = 294) Single-port (n = 78) p SMD Δ Hemoglobin, g/dL (discharge – pre-op) (median [IQR]) –1.1 [–1.6 – –0.6] –1.0 [–1.5 – –0.5] –1.2 [–1.8 – –0.7] 0.28 0.19 Renorrhaphy, n (%) 148 (39.7) 121 (41.2) 27 (34.2) 0.26 0.14 Intra-operative transfusion, n (%) 1 (0.3) 1 (0.3) 0 (0.0) 1.00 <0.01 Post-operative transfusion, n (%) 0 (0.0) 0 (0.0) 0 (0.0) — — Length of stay, days (median [IQR]) 2 [2–3] 2 [2–3] 2 [2–2] 0.06 0.21 Any complication, n (%) 29 (7.8) 23 (7.8) 6 (7.6) 1.00 0.01 Major complication (Clavien ≥ III), n (%) 2 (0.5) 2 (0.7) 0 (0.0) 1.00 0.03 Table 3. Pathologic and functional outcomes by approach after SP adoption Variable Overall (n=372) Multi-port (n=294) Single-port (n=78) p AML/Other 16 (4.4) 12 (4.2) 4 (5.2) 0.268 Oncocytoma 70 (19.4) 50 (17.6) 20 (26.0) — Other 271 (75.1) 219 (77.1) 52 (67.5) — Papillary RCC 4 (1.1) 3 (1.1) 1 (1.3) — Malignant tumor, n (%) 253 (74.4) 200 (75.8) 53 (69.7) 0.299 Fuhrman grade 1 15 (8.2) 7 (4.9) 8 (20.5) 0.008 Fuhrman grade 2 129 (70.9) 107 (74.8) 22 (56.4) — Fuhrman grade 3 36 (19.8) 28 (19.6) 8 (20.5) — Fuhrman grade 4 2 (1.1) 1 (0.7) 1 (2.6) — Pathologic T stage — T1a , n (%) 142 (58.4) 101 (52.9) 41 (78.8) 0.003 Pathologic T stage — T1b , n (%) 74 (30.5) 65 (34.0) 9 (17.3) — Pathologic T stage — T2–T3 , n (%) 27 (11.1) 25 (13.1) 2 (3.8) — Positive surgical margins (PSM), n (%) 0 (0.0) 0 (0.0) 0 (0.0) — ΔeGFR early (%), median [IQR] 93.7 [84.0–102.9] 92.8 [82.8–102.1] 96.0 [88.0–103.2] 0.080 Renal function preserved ≥ 90 %, n (%) 199 (57.3) 148 (54.6) 51 (67.1) 0.066 Table 4. Univariable and multivariable logistic regression predicting Single-Port access Variable OR (95 % CI) — Univariable p OR (95 % CI) — Multivariable (Firth) p Age at surgery (per year) 0.99 (0.95–1.04) 0.716 1.01 (0.98–1.05) 0.362 BMI (kg/m²) 1.02 (0.92–1.14) 0.679 0.98 (0.91–1.05) 0.516 ASA ≥ 3 0.45 (0.14–1.29) 0.148 0.82 (0.35–1.87) 0.643 Hypertension (yes) 1.90 (0.78–4.78) 0.164 — — Diabetes (yes) 1.17 (0.39–3.53) 0.769 — — Tumor size (cm) 0.86 (0.59–1.21) 0.388 — — RENAL score (continuous) 0.68 (0.45–1.00) 0.050 0.64 (0.51–0.79) < 0.001 eGFR (mL/min/1.73 m²) 0.99 (0.96–1.01) 0.216 1.00 (0.98–1.02) 0.785 Tumor side: Right vs Left 1.04 (0.66–1.65) 0.850 0.98 (0.51–1.87) 0.958 Note. Outcome = SP (1) vs MP (0). Multivariable model fitted with Firth’s penalized likelihood to reduce small-sample bias. Complete-case analysis (n ≈ 220). Model C-index = 0.77; all VIF < 1.4; calibration adequate. Table 5. Relative adoption of single-port (SP) versus multi-port (MP) partial nephrectomy according to RENAL complexity and tumor size RENAL complexity Tumor size SP:MP ratio % SP ≤ 6 < 2 cm 1.09 52.2 % ≤ 6 2–3.9 cm 1.57 61.1 % ≤ 6 ≥ 4 cm 1.00 50.0 % 7 < 2 cm 1.33 57.1 % 7 2–3.9 cm 0.75 42.9 % 7 ≥ 4 cm 0.33 25.0 % ≥ 8 < 2 cm 0.00 0.0 % ≥ 8 2–3.9 cm 0.23 18.9 % ≥ 8 ≥ 4 cm 0.06 6.1 % Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Dec, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 11 Dec, 2025 Reviews received at journal 11 Dec, 2025 Reviews received at journal 09 Dec, 2025 Reviewers agreed at journal 07 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers invited by journal 05 Dec, 2025 Editor assigned by journal 28 Nov, 2025 Submission checks completed at journal 28 Nov, 2025 First submitted to journal 27 Nov, 2025 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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1","display":"","copyAsset":false,"role":"figure","size":21985,"visible":true,"origin":"","legend":"\u003cp\u003eMonthly adoption trend of single-port versus multi-port robot-assisted partial nephrectomy (RAPN) since SP platform introduction\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMonthly distribution of single-port (SP, red line) and multi-port (MP, blue line) RAPN performed after SP platform introduction at our institution. Each point represents the total number of procedures per month, showing a consistently higher use of the multi-port system throughout the study period, with a gradual but limited uptake of the SP approach (≈10–20% of monthly cases).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8224240/v1/739860984511be0c1fe19692.png"},{"id":97722068,"identity":"91e5ed6b-163d-49b9-9b9e-c191fd1d3013","added_by":"auto","created_at":"2025-12-08 15:39:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":26344,"visible":true,"origin":"","legend":"\u003cp\u003eMonthly proportional share of single-port versus multi-port RAPN since SP platform adoption (May 2024–October 2025).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMonthly relative proportion of single-port (SP, red line) and multi-port (MP, blue line) RAPN procedures performed after SP platform introduction. Despite progressive adoption, SP consistently accounted for a minority of cases—approximately 10–20% of all partial nephrectomies—confirming a persistent predominance of the multi-port approach throughout the observation period.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8224240/v1/fa418506e3d7ce6e3b63585d.png"},{"id":97722029,"identity":"d8b52857-da40-435d-9df8-551746b5382f","added_by":"auto","created_at":"2025-12-08 15:39:01","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":15557,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMonthly relative proportion of single-port (SP, red line) and multi-port (MP, blue line) RAPN procedures performed after SP platform introduction. Despite progressive adoption, SP consistently accounted for a minority of cases—approximately 10–20% of all partial nephrectomies—confirming a persistent predominance of the multi-port approach throughout the observation period.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-8224240/v1/c8438ec1e73cdd995ca5e03c.png"},{"id":99173113,"identity":"987b3b25-d972-4107-8c34-bdfc5a593883","added_by":"auto","created_at":"2025-12-29 16:12:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1287444,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8224240/v1/54eaf201-d88b-41e0-ba15-712bec43a3af.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Selective by design: Early Adoption Patterns of Single-Port Off-Clamp Robotic Partial Nephrectomy in a High-Volume Center","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRobot-assisted partial nephrectomy (RAPN) has progressively become the reference standard for the management of localized renal masses, combining oncologic efficacy with maximal preservation of renal function. Over the last decade, the multi-port robotic platform has provided surgeons with refined dexterity, tridimensional vision, and stable ergonomics, establishing an optimal environment for precise parenchymal dissection and renorrhaphy. Within this evolution, high-volume centers have progressively refined their surgical protocols, expanding the indications for minimally invasive nephron-sparing surgery to increasingly complex scenarios.\u003c/p\u003e\u003cp\u003eThe introduction of single-port robotic technology marks the latest step in this gradual continuum of refinement [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. By bringing the entire system through a single access point, the platform was conceived to further reduce invasiveness and optimize cosmesis while preserving the technical advantages of robotics [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Yet, the single-port setting deeply alters the intra-abdominal dynamics that have long promoted the multi-port technique[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The redistribution of instruments through a single entry point modifies depth perception, the degree of triangulation, and minimizes the role of the bedside assistant, thereby reshaping how exposure, traction, and hemostasis are achieved during parenchymal resection. In this respect, the single-port approach is better seen not as a linear evolution but as a conceptual rethinking of the robotic act itself [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Among nephron-sparing strategies, the off-clamp technique ranks a distinctive and challenging position[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. While its rationale\u0026mdash;avoiding ischemia to maximize functional preservation\u0026mdash;is well established, the lack of hilar control and the higher potential bleeding have traditionally discouraged its widespread use, confining it to a few expert centers[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. As a result, the interaction between the single-port system and an exclusively off-clamp approach remains largely unexplored[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Whether the constraints inherent to a single robotic access can accommodate the technical demands of unclamped renal resection is still an open question, particularly when hemostasis relies on continuous suction, irrigation, and precise coordination with the assistant surgeon [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In this context, we sought to analyze the early institutional integration of single-port technology within a high-volume centre that has long encouraged a purely off-clamp RAPN policy[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Our aim was to describe the early patterns of adoption, characterize the surgical selection process, and identify the determinants influencing the transition from the multi-port to the single-port platform. By focusing on an experienced off-clamp RAPN environment, this study delineates the pragmatic limits and opportunities of single-port implementation under one of the most functionally demanding robotic scenarios [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e\u003cem\u003eStudy design and population\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData were extracted from our prospectively maintained RAPN registry. The database includes all robot-assisted partial nephrectomies (RAPN) performed by our unit, with systematic collection of pre-, intra-, and postoperative variables.\u003c/p\u003e\n\u003cp\u003eFor this analysis, we selected all consecutive procedures performed between May 2024 and October 2025, corresponding to the institutional phase of single-port (SP) platform introduction. The aim was to assess changes in case selection and perioperative outcomes after implementation of the SP system within an established off-clamp robotic program. A total of 372 cases were included: 294 multi-port (MP) and 78 single-port (SP) procedures. All interventions were performed with a purely off-clamp technique, which represents our institutional standard and it is applied irrespective of tumor size or location[16]. SP-RAPN was carried out exclusively by one high-volume surgeon (G.S.), while MP procedures were performed by multiple experienced operators from the same robotic team[17].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSurgical technique\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMP-RAPN was conducted exclusively via a transperitoneal approach, following the standardized technique adopted in our center[18]. In complex cases\u0026mdash;such as large, hilar, or purely endophytic tumors, or those with irregular margins\u0026mdash;LigaSure Atlas\u0026reg; was used to assist precise hemostatic dissection[12, 19]. SP-RAPN was performed in a supine anterior-lateral position, according to the SARA configuration[20]. A short oblique incision was made just above the iliac crest along the lumbar line to provide direct open access to the retroperitoneum. The space was developed bluntly under vision. An Alexis wound protector was positioned, and the Intuitive \u0026ldquo;fish-bowl\u0026rdquo; single-port system was secured on it to allow docking of the robotic arm. AirSeal\u0026reg; insufflation was used throughout the procedure to maintain a stable pneumoretroperitoneum. The fish-bowl port includes an auxiliary trocar through which sutures or Hem-o-lok clips were introduced when required. Dissection proceeded along the psoas margin until the renal capsule was exposed. In the absence of a dedicated single-port suction/irrigation device such as the ROSI system, continuous visibility was maintained using a customized dual-Nelaton system, composed of two small catheters tied together with 0-silk, providing simultaneous irrigation and suction. Tumor excision in the SP group was performed avoiding intentionally hilar control using monopolar energy under continuous irrigation. Small feeding vessels were coagulated selectively, and the resection bed was inspected in dry conditions. Renorrhaphy, when required, was performed with a 2-0 Monocryl suture using the sliding-Weck technique, always in a single-layer fashion and rarely in double-layer configuration (medullary and cortical closure). Whenever anatomically feasible, the margins of Gerota\u0026rsquo;s fascia were re-approximated within the retroperitoneal space to enhance local hemostasis and containment [21, 22].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData and endpoints\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor each patient, demographic, clinical, and anatomical variables were prospectively recorded. Tumor size, side, and RENAL nephrometry score were extracted from operative records. Perioperative outcomes included operative time, hemoglobin drop, transfusion rate, complications graded according to Clavien\u0026ndash;Dindo, and length of stay[23]. Pathological data comprised histology, Fuhrman grade, and pathologic T stage. Postoperative renal function was evaluated through serial eGFR measurements relative to baseline[24].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eContinuous variables were summarized as median [IQR] and categorical variables as number (%). Group comparisons were performed using the Mann\u0026ndash;Whitney U or \u0026chi;\u0026sup2;/Fisher exact tests as appropriate. Baseline balance was assessed by standardized mean difference (SMD), with SMD \u0026gt; 0.20 considered clinically relevant. Independent predictors of SP adoption were identified using univariable and multivariable logistic regression models with Firth\u0026rsquo;s penalized likelihood correction. Model discrimination and calibration were evaluated by concordance index (C-index), variance inflation factor (VIF), and calibration plot. Monthly SP/MP ratios were used to describe temporal adoption trends. All analyses were performed in R Studio v4.2.3 (R Foundation for Statistical Computing, Vienna, Austria). A two-sided p \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis observational study was conducted using data from a prospectively maintained institutional registry. The Ethics Committee of IRCCS Regina Elena National Cancer Institute (Rome, Italy) reviewed the study protocol and confirmed that formal approval was not required, as all analyses were performed on anonymized data without impact on patient management.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInformed consent\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for the use of anonymized clinical data for research purposes was obtained from all patients in accordance with institutional policy and national data protection regulations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent to publish\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis manuscript does not contain any individual person\u0026rsquo;s data in any form (including images, videos, or identifiable clinical details). Therefore, consent for publication was not required.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOver the study period, 372 consecutive off-clamp RAPN were performed and included in the analysis, of which 294 (79.0%) were carried out with the multi-port platform and 78 (21.0%) with the single-port system. Baseline characteristics are reported in Table 1. Median age was similar between groups (63 [54\u0026ndash;71] vs 64 [58\u0026ndash;72] years for MP and SP, respectively; p = 0.28; SMD = 0.14), as were gender distribution (male 62.9% vs 67.9%; p = 0.34; SMD = 0.11) and body-mass index (26.9 [23.6\u0026ndash;29.5] vs 26.7 [23.9\u0026ndash;28.9] kg/m\u0026sup2;; p = 0.67; SMD = 0.06). The prevalence of ASA \u0026ge; 3, hypertension, and diabetes was comparable in the two cohorts (all p \u0026ge; 0.30; all SMD \u0026le; 0.13). Preoperative hemoglobin (13.8 [13.0\u0026ndash;14.6] vs 13.5 [12.8\u0026ndash;14.3] g/dL; p = 0.29; SMD = 0.15) and baseline eGFR (89.1 [71\u0026ndash;104] vs 87.9 [72\u0026ndash;101] mL/min/1.73 m\u0026sup2;; p = 0.63; SMD = 0.06) did not differ significantly. Conversely, tumor-related variables showed a systematic difference between groups. Median tumor size was 4.1 (2.8\u0026ndash;5.0) cm in the MP series and 2.8 (1.9\u0026ndash;3.3) cm in the SP cohort (p \u0026lt; 0.001; SMD = 0.74), and median RENAL nephrometry score was 7.8 \u0026plusmn; 1.7 versus 6.4 \u0026plusmn; 1.3, respectively (p \u0026lt; 0.001; SMD = 0.96). Tumor side was evenly distributed (right side 47.8% vs 50.0%; p = 0.73; SMD = 0.04), and surgery year did not differ (2024 \u0026plusmn; 1 vs 2024 \u0026plusmn; 1; p = 0.81; SMD = 0.04) (Table 1). No baseline variable other than tumor size and RENAL score exceeded the predefined SMD threshold of 0.20.\u003c/p\u003e\n\u003cp\u003eIntraoperative and perioperative outcomes are summarized in Table 2. Overall, the median hemoglobin drop at discharge was \u0026ndash;1.1 [\u0026ndash;1.6 \u0026ndash; \u0026ndash;0.6] g/dL, with no significant difference between MP and SP cases (\u0026ndash;1.0 [\u0026ndash;1.5 \u0026ndash; \u0026ndash;0.5] vs \u0026ndash;1.2 [\u0026ndash;1.8 \u0026ndash; \u0026ndash;0.7] g/dL; p = 0.28; SMD = 0.19). Renorrhaphy was performed in 39.7% of cases, with similar rates in MP and SP cohorts (41.2% vs 34.2%; p = 0.26; SMD = 0.14). Intraoperative transfusion was rare, occurring in 1 patient (0.3%) in the MP group and in none of the SP cases (p = 1.00); no postoperative transfusion was required in either cohort. Median length of stay was 2 days in both arms; the interquartile range was 2\u0026ndash;3 days for MP and 2\u0026ndash;2 days for SP (p = 0.06; SMD = 0.21). The overall complication rate was 7.8% (23/294 MP vs 6/78 SP; p = 1.00; SMD = 0.01), and major complications (Clavien\u0026ndash;Dindo \u0026ge; III) were uncommon (0.7% vs 0.0%; p = 1.00; SMD = 0.03) (Table 2).\u003c/p\u003e\n\u003cp\u003ePathologic and early functional outcomes are reported in Table 3. The overall distribution of benign histologies (angiomyolipoma/other benign entities and oncocytoma) and malignant tumors was similar between groups: malignant lesions accounted for 74.4% of the entire cohort (75.8% MP vs 69.7% SP; p = 0.299). Among malignant cases, Fuhrman grade showed a different distribution, with grade 1 tumors more frequently observed in the SP cohort (20.5% vs 4.9%; p = 0.008), while the proportions of grades 2\u0026ndash;4 were comparable. Pathologic stage was also more favorable in the SP group: pT1a disease was present in 78.8% of SP versus 52.9% of MP procedures, whereas pT1b and pT2\u0026ndash;T3 stages were more frequent in the MP series (pT1b 34.0% vs 17.3%; pT2\u0026ndash;T3 13.1% vs 3.8%; overall p = 0.003). No positive surgical margins were recorded in either group.\u003c/p\u003e\n\u003cp\u003eEarly postoperative renal function was preserved in both cohorts. Median early \u0026Delta;eGFR was 93.7% [84.0\u0026ndash;102.9] of baseline overall, with values of 92.8% [82.8\u0026ndash;102.1] in MP and 96.0% [88.0\u0026ndash;103.2] in SP cases (p = 0.080). The proportion of patients with \u0026ge;90% eGFR preservation was 54.6% in the MP cohort and 67.1% in the SP cohort (p = 0.066) (Table 3).\u003c/p\u003e\n\u003cp\u003ePredictors of SP platform utilization are presented in Table 4 and Figure 4. On univariable analysis, age, BMI, ASA \u0026ge; 3 status, hypertension, diabetes, baseline eGFR, and tumor side were not significantly associated with the likelihood of SP access (all p \u0026ge; 0.14). Tumor size and RENAL score showed a trend toward lower values in SP cases, but only RENAL score approached statistical significance at the univariable level (OR 0.68, 95% CI 0.45\u0026ndash;1.00; p = 0.050), whereas tumor size did not (OR 0.86, 95% CI 0.59\u0026ndash;1.21; p = 0.388) (Table 4).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In the multivariable Firth logistic regression, including clinical and anatomical covariates in a complete-case dataset (n \u0026asymp; 220), RENAL score emerged as the only independent predictor of SP adoption (OR 0.64, 95% CI 0.51\u0026ndash;0.79; p \u0026lt; 0.001). Age, BMI, ASA \u0026ge; 3, baseline eGFR, and tumor side were not significantly associated with SP access in the adjusted model (all p \u0026ge; 0.36). The model showed good discrimination with a C-index of 0.77 and no relevant collinearity (all VIF \u0026lt; 1.4; Table 4)\u003c/p\u003e\n\u003cp\u003eAdoption dynamics by tumor complexity and size are detailed in Table 5. For lesions with RENAL \u0026le; 6, the proportion of SP use exceeded 50% for small masses: SP accounted for 52.2% of procedures in tumors \u0026lt; 2 cm (SP:MP ratio 1.09) and 61.1% in those 2\u0026ndash;3.9 cm (SP:MP ratio 1.57). In the same complexity stratum, SP utilization was 50.0% for tumors \u0026ge; 4 cm. For RENAL 7 lesions, SP use ranged from 57.1% in tumors \u0026lt; 2 cm (SP:MP ratio 1.33) to 42.9% and 25.0% in the 2\u0026ndash;3.9 cm and \u0026ge; 4 cm categories, respectively. In contrast, for RENAL \u0026ge; 8, SP access was uncommon, with SP proportions of 0.0% for tumors \u0026lt; 2 cm, 18.9% for 2\u0026ndash;3.9 cm (SP:MP ratio 0.23), and 6.1% for \u0026ge; 4 cm masses (SP:MP ratio 0.06) (Table 5).\u003c/p\u003e\n\u003cp\u003eTemporal patterns of platform use are illustrated in Figures 1\u0026ndash;3. Throughout the study window, the multi-port system remained predominant, with higher absolute monthly case numbers in all observed months (Figure 1). The relative share of SP-RAPN fluctuated between approximately 10% and 20% of monthly RAPN volume, without evidence of abrupt shifts or replacement of the MP platform (Figure 2). Monthly distributions of SP and MP cases confirmed a stable but limited integration of SP procedures within a consistently MP-dominant activity, with SP cases interspersed throughout the observation period rather than clustered in isolated timeframes (Figure 3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, the present study represents one of the first institutional analyses of single-port robot-assisted partial nephrectomy performed exclusively with an off-clamp technique. Within a high-volume robotic program that has adopted off-clamp resection as a consolidated standard for more than a decade, the transition from multi-port to single-port systems provided an opportunity to test the reproducibility of a technically demanding approach under an alternative robotic system [4]. While on-clamp SP-RAPN has been previously reported, its performance within a purely off-clamp framework\u0026mdash;where hemostatic control relies on continuous vision, suction, and precise dissection rather than hilar clamping\u0026mdash;had not been systematically evaluated [25\u0026ndash;27].\u003c/p\u003e\n\u003cp\u003eIn our experience, the early institutional adoption of the SP platform followed a careful and selective path [25, 28]. Case allocation favored smaller and less complex renal masses, as reflected by significantly lower median tumor size and RENAL score in SP cases (each p \u0026lt; 0.001), a pattern consistent with the initial phase of implementation of a new technology. Despite this deliberate selection, perioperative and functional outcomes were fully comparable to those of the established multi-port cohort. The absence of significant differences in hemoglobin drop, transfusion rates, or complication profiles (each p \u0026gt; 0.2) shows that, when performed by an experienced surgeon, the transition to single-port access can be completed without compromising perioperative safety, even in the absence of hilar or selective clamping. Technically, the comparable intraoperative and early functional outcomes between SP and MP procedures highlight the robustness of the off-clamp technique when applied by surgeons with extensive prior off-clamp experience [29]. The use of monopolar energy under continuous irrigation, selective coagulation of feeding vessels, single-layer sliding-Weck renorrhaphy, and systematic reconstruction of Gerota\u0026rsquo;s fascia when feasible provided adequate hemostatic control despite the lack of hilar clamping[30, 31]. The similar \u0026Delta;eGFR and proportion of patients maintaining \u0026ge;90% postoperative renal function (each p \u0026gt; 0.06) further support the preservation of renal parenchyma inherent to the off-clamp strategy, irrespective of the robotic platform. These results suggest that SP-RAPN can reproduce the hemodynamic and functional profile of MP off-clamp surgery, provided that case selection remains careful and technical expertise is in place[10].\u003c/p\u003e\n\u003cp\u003ePathologic comparisons further delineate the pattern of an early adoption. The over-representation of Fuhrman grade 1 and pT1a tumors within the SP cohort (p = 0.008 and p = 0.003, respectively) is consistent with an institutional policy of introducing the SP system in oncologically selected cases. Nevertheless, the absence of positive surgical margins across both groups indicates that oncologic control was maintained even during the early SP experience. Importantly, the multivariable analysis identified RENAL complexity as the only independent determinant of SP selection, whereas patient-related and functional parameters did not influence platform choice. This finding suggests that surgical judgment, directed primarily by anatomical complexity, guided case allocation more than concerns about baseline renal function[32]. The C-index of 0.77 and the good calibration of the Firth model confirm the internal consistency of this selection design. The adoption trend observed in our study remained stable but limited, with SP procedures accounting for approximately 10\u0026ndash;20% of monthly RAPN volume. This steady proportion, without evidence of displacement of multi-port cases, indicates that the SP platform currently acts as a complement rather than a replacement within a mature robotic experience [33]. This plateau likely reflects intrinsic limitations of the SP system and the high technical demands of off-clamp RAPN [34, 35]. In the absence of dedicated single-port suction/irrigation devices such as ROSI\u0026reg;, customized solutions like the dual-Nelaton system may remain necessary to ensure adequate visibility and hemostasis during unclamped resections.\u003c/p\u003e\n\u003cp\u003eThis study is not devoid of limitations. The retrospective nature of the analysis, despite prospective data collection, and the relatively small number of SP cases inevitably introduce a potential selection bias, amplified by the prudent allocation of early SP cases to less complex tumors. The concentration of all SP procedures in the hands of a single expert surgeon reduces inter-operator variability but limits generalizability, as outcomes achieved in an oncologic high-volume center with long-standing off-clamp expertise may not be immediately reproducible in other settings. Moreover, the observational window of 18 months preclude definitive conclusions regarding functional or oncologic equivalence. Finally, the purely off-clamp technique, while eliminating variability in ischemia time, may restrict external comparability, as most contemporary series still rely on clamping strategies. These considerations underline that our results reflect an institutional model rather than a universally applicable standard[15, 36].\u003c/p\u003e\n\u003cp\u003eDespite these limitations, a few strengths are worth highlighting. This analysis derives from a prospectively maintained registry, with uniform surgical policy and detailed perioperative and functional data. It represents, to our knowledge, the first series focusing specifically on SP-RAPN within a purely off-clamp framework and one of the few to explore adoption patterns rather than only perioperative feasibility. The use of standardized mean difference to quantify baseline imbalances and Firth logistic regression to explore predictors of SP selection reinforces the robustness of the analytical approach. The consistent perioperative outcomes, absence of transfusion in the SP group, and lack of major complications during the early adoption phase support the safety and reproducibility of SP off-clamp RAPN when implemented in an experienced environment.\u003c/p\u003e\n\u003cp\u003eFuture series should explore whether SP-RAPN can be safely extended to higher RENAL complexity and larger tumors, particularly in retroperitoneal settings, and to what extent dedicated single-port instruments may modify current selection thresholds[10, 35, 37]. Cost-effectiveness analyses and longer-term functional and oncologic follow-up will be essential to determine the precise role of SP platform within the broader landscape of nephron-sparing surgery[38]. In this perspective, the combination of minimized access and zero ischemia may represent a convergent evolution of robotic kidney surgery, with single-port off-clamp RAPN as a potential starting grid for further refinements.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn a high-volume center with longstanding expertise in off-clamp partial nephrectomy, the transition from multi-port to single-port robotic surgery proved technically feasible and oncologically safe. Despite selective early adoption for smaller and less complex tumors, perioperative and functional outcomes remained equivalent across approaches, confirming the reproducibility of the off-clamp strategy within the single-port robotic approach. These findings delineate a steady but cautious integration of SP technology, which currently complements rather than replaces the multi-port platform. As the field evolves, refinements in single-port ergonomics and instrumentation may further extend the boundaries of off-clamp renal surgery toward increasingly complex scenarios.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003eU.A. and S.B. contributed to study conception and design, data curation, statistical analysis, drafting of the manuscript, and critical revision of all scientific sections.\u003c/p\u003e\n\u003cp\u003eG.T. and A.B. contributed to data collection, dataset verification, and preparation of tables and figures.\u003c/p\u003e\n\u003cp\u003eR.M. and E.B. assisted with perioperative data extraction, surgical dataset handling, and methodological refinement.\u003c/p\u003e\n\u003cp\u003eL.C.L., R.S.F., A.M.B. and M.F. conducted the literature review, supported manuscript drafting, and contributed to the interpretation of findings.\u003c/p\u003e\n\u003cp\u003eF.P. and S.G. provided critical intellectual input, validated the clinical interpretation, and revised the discussion for accuracy.\u003c/p\u003e\n\u003cp\u003eC.L. and G.S. supervised the entire project, provided senior oversight, ensured methodological rigor, and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBiasatti A, Soputro NA, Porpiglia F et al (2025) The current landscape of single-port robotic surgery in urology. 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Surg Endosc 38:4814\u0026ndash;4830. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/S00464-024-11126-W\u003c/span\u003e\u003cspan address=\"10.1007/S00464-024-11126-W\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMehrazin R, Ranti D, Altschuler J (2023) Early perioperative outcomes of single-port compared to multi-port robot-assisted laparoscopic partial nephrectomy. J Robot Surg 17:2409\u0026ndash;2414. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/S11701-023-01617-8\u003c/span\u003e\u003cspan address=\"10.1007/S11701-023-01617-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCapozzi VA, Armano G, Rosati A et al (2021) The robotic single-port platform for gynecologic surgery: a systematic review of the literature and meta-analysis. Updates Surg 73:1155\u0026ndash;1167. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/S13304-020-00812-8\u003c/span\u003e\u003cspan address=\"10.1007/S13304-020-00812-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbaza R, Murphy C, Bsatee A et al (2021) Single-port Robotic Surgery Allows Same-day Discharge in Majority of Cases. Urology 148:159\u0026ndash;165. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/J.UROLOGY.2020.08.092\u003c/span\u003e\u003cspan address=\"10.1016/J.UROLOGY.2020.08.092\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Baseline characteristics of patients undergoing single-port versus multi-port robot-assisted partial nephrectomy after adoption of the single-port platform at a tertiary referral center (May 2024)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eVariable\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall (n = 372)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMulti-port (n = 294)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSingle-port (n = 78)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSMD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAge, years\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e63 (54\u0026ndash;71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e63 (54\u0026ndash;71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e64 (58\u0026ndash;72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGender, male (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e63.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e62.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e67.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eBMI, kg/m\u0026sup2;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e26.9 (23.7\u0026ndash;29.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e26.9 (23.6\u0026ndash;29.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e26.7 (23.9\u0026ndash;28.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eASA \u0026ge; 3 (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e20.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e24.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eHypertension, %\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e56.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e56.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e52.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDiabetes, %\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e11.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e15.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePre-op Hemoglobin, g/dL\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e13.7 (12.9\u0026ndash;14.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e13.8 (13.0\u0026ndash;14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e13.5 (12.8\u0026ndash;14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePre-op eGFR, mL/min/1.73 m\u0026sup2;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e88.9 (71\u0026ndash;103)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e89.1 (71\u0026ndash;104)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e87.9 (72\u0026ndash;101)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTumor size, cm\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e3.8 (2.6\u0026ndash;4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e4.1 (2.8\u0026ndash;5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2.8 (1.9\u0026ndash;3.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.74\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eRENAL score\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e7.4 \u0026plusmn; 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e7.8 \u0026plusmn; 1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e6.4 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.96\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTumor side, Right (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e48.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e47.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSurgery year\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2024 \u0026plusmn; 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2024 \u0026plusmn; 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2024 \u0026plusmn; 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eContinuous variables are presented as median [interquartile range], categorical variables as number (percentage). Comparisons were performed using the Mann\u0026ndash;Whitney U or \u0026chi;\u0026sup2;/Fisher exact test, as appropriate. Standardized mean difference (SMD) \u0026gt; 0.20 was considered clinically relevant. Tumor size and RENAL score showed the largest imbalance, indicating a tendency toward the selection of smaller and less complex lesions for the single-port approach during the early adoption phase\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Intraoperative and perioperative outcomes after single-port (SP) and multi-port (MP) robot-assisted partial nephrectomy (May 2024 \u0026ndash; Oct 2025)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eVariable\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall (n = 372)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMulti-port (n = 294)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSingle-port (n = 78)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSMD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026Delta; Hemoglobin, g/dL (discharge \u0026ndash; pre-op) (median [IQR])\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026ndash;1.1 [\u0026ndash;1.6 \u0026ndash; \u0026ndash;0.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026ndash;1.0 [\u0026ndash;1.5 \u0026ndash; \u0026ndash;0.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026ndash;1.2 [\u0026ndash;1.8 \u0026ndash; \u0026ndash;0.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eRenorrhaphy, n (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e148 (39.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e121 (41.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e27 (34.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eIntra-operative transfusion, n (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePost-operative transfusion, n (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLength of stay, days (median [IQR])\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e2 [2\u0026ndash;3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2 [2\u0026ndash;3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2 [2\u0026ndash;2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAny complication, n (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e29 (7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e23 (7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e6 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMajor complication (Clavien \u0026ge; III), n (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 137px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 5px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 41px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 44px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Pathologic and functional outcomes by approach after SP adoption\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eVariable\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall (n=372)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMulti-port (n=294)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSingle-port (n=78)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAML/Other\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e16 (4.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e12 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e4 (5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.268\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOncocytoma\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e70 (19.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e50 (17.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e20 (26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eOther\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e271 (75.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e219 (77.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e52 (67.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePapillary RCC\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e4 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e3 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMalignant tumor, n (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e253 (74.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e200 (75.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e53 (69.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.299\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eFuhrman grade 1\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e15 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e7 (4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e8 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eFuhrman grade 2\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e129 (70.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e107 (74.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e22 (56.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eFuhrman grade 3\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e36 (19.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e28 (19.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e8 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eFuhrman grade 4\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e1 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePathologic T stage \u0026mdash; T1a , n (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e142 (58.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e101 (52.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e41 (78.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePathologic T stage \u0026mdash; T1b , n (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e74 (30.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e65 (34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e9 (17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePathologic T stage \u0026mdash; T2\u0026ndash;T3 , n (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e27 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e25 (13.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e2 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePositive surgical margins (PSM), n (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026Delta;eGFR early (%), median [IQR]\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e93.7 [84.0\u0026ndash;102.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e92.8 [82.8\u0026ndash;102.1]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e96.0 [88.0\u0026ndash;103.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.080\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eRenal function preserved \u0026ge; 90 %, n (%)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e199 (57.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e148 (54.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e51 (67.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eUnivariable and multivariable logistic regression predicting Single-Port access\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"659\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eVariable\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95 % CI) \u0026mdash; Univariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95 % CI) \u0026mdash; Multivariable (Firth)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eAge at surgery (per year)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e0.99 (0.95\u0026ndash;1.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.716\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e1.01 (0.98\u0026ndash;1.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.362\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eBMI (kg/m\u0026sup2;)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e1.02 (0.92\u0026ndash;1.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.679\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e0.98 (0.91\u0026ndash;1.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.516\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eASA \u0026ge; 3\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e0.45 (0.14\u0026ndash;1.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e0.82 (0.35\u0026ndash;1.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.643\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eHypertension (yes)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e1.90 (0.78\u0026ndash;4.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.164\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDiabetes (yes)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e1.17 (0.39\u0026ndash;3.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.769\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTumor size (cm)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e0.86 (0.59\u0026ndash;1.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.388\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eRENAL score (continuous)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e0.68 (0.45\u0026ndash;1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.050\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.64 (0.51\u0026ndash;0.79)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt; 0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eeGFR (mL/min/1.73 m\u0026sup2;)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e0.99 (0.96\u0026ndash;1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e1.00 (0.98\u0026ndash;1.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.785\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 160px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTumor side: Right vs Left\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\n \u003cp\u003e1.04 (0.66\u0026ndash;1.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e0.850\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e0.98 (0.51\u0026ndash;1.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\n \u003cp\u003e0.958\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 180px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote. Outcome = SP (1) vs MP (0). Multivariable model fitted with Firth\u0026rsquo;s penalized likelihood to reduce small-sample bias. Complete-case analysis (n \u0026asymp; 220). Model C-index = 0.77; all VIF \u0026lt; 1.4; calibration adequate.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5.\u003c/strong\u003e Relative adoption of single-port (SP) versus multi-port (MP) partial nephrectomy according to RENAL complexity and tumor size\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"663\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eRENAL complexity\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSP:MP ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e% SP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026le; 6\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026lt; 2 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e52.2 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026le; 6\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e2\u0026ndash;3.9 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e1.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e61.1 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026le; 6\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026ge; 4 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e50.0 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cem\u003e7\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026lt; 2 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e57.1 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cem\u003e7\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e2\u0026ndash;3.9 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e42.9 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cem\u003e7\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026ge; 4 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e25.0 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ge; 8\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026lt; 2 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e0.0 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ge; 8\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e2\u0026ndash;3.9 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e18.9 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ge; 8\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026ge; 4 cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 166px;\"\u003e\n \u003cp\u003e6.1 %\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\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":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Single-port, robotic partial nephrectomy, off-clamp, renal cancer, nephron-sparing, multi-port","lastPublishedDoi":"10.21203/rs.3.rs-8224240/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8224240/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eIntroduction of single-port (SP) technology into centers with a consolidated multi-port experience in robot-assisted partial nephrectomy (MP-RAPN) represents a conceptual shift rather than a natural transition. We analyzed the early institutional adoption of the SP platform, assessing its impact on case complexity, perioperative outcomes, and determinants of surgical selection within a purely off-clamp RAPN framework compared with the established MP standard.\u003c/p\u003e\u003ch2\u003eMaterial and Methods\u003c/h2\u003e\u003cp\u003eAll consecutive RAPN performed at our tertiary referral center between May 2024 and October 2025 were analyzed (n\u0026thinsp;=\u0026thinsp;372). All procedures were performed using a standardized off-clamp technique, irrespective of tumor features. After SP platform introduction, cases were stratified as multi-port (MP, n\u0026thinsp;=\u0026thinsp;294) or single-port (SP, n\u0026thinsp;=\u0026thinsp;78). Baseline, anatomical, and perioperative variables were prospectively collected. Tumor complexity was graded using the RENAL score, and renal function was assessed through serial eGFR measurements. Continuous and categorical variables were analyzed with Mann\u0026ndash;Whitney U and χ\u0026sup2;/Fisher tests; SMD\u0026thinsp;\u0026gt;\u0026thinsp;0.20 denoted clinical imbalance. Univariable and multivariable Firth logistic regression identified independent predictors of SP adoption.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eBaseline characteristics were similar (each p\u0026thinsp;\u0026gt;\u0026thinsp;0.2), except for tumor size and RENAL score, which were lower in SP cases (2.8 vs 4.1 cm; 6.4 vs 7.8; each p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Perioperative outcomes\u0026mdash;including hemoglobin drop, transfusion rate, complications, and hospital stay\u0026mdash;were equivalent (each p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). SP tumors showed higher Fuhrman 1 (20.5% vs 4.9%, p\u0026thinsp;=\u0026thinsp;0.008) and pT1a stage (78.8% vs 52.9%, p\u0026thinsp;=\u0026thinsp;0.003). A lower RENAL score (OR 0.64, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) independently predicted SP selection (C-index\u0026thinsp;=\u0026thinsp;0.77).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eIn a center routinely performing purely off-clamp RAPN, adoption of the single-port robotic platform proved technically feasible and oncologically safe, achieving perioperative and functional outcomes equivalent to the multi-port approach during its early institutional phase.\u003c/p\u003e","manuscriptTitle":"Selective by design: Early Adoption Patterns of Single-Port Off-Clamp Robotic Partial Nephrectomy in a High-Volume Center","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-08 15:38:25","doi":"10.21203/rs.3.rs-8224240/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-11T22:44:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-11T21:54:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-09T05:37:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"174024642996597645394775538715457994890","date":"2025-12-08T01:54:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168339425560334002542941379319334938360","date":"2025-12-06T00:57:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"207238507105024245881896493484788461707","date":"2025-12-05T13:14:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-05T12:45:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-28T12:51:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-28T11:32:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2025-11-27T17:14:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"fad114e6-990f-4a47-b214-3a0aa49372df","owner":[],"postedDate":"December 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T16:11:42+00:00","versionOfRecord":{"articleIdentity":"rs-8224240","link":"https://doi.org/10.1007/s11701-025-03084-9","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2025-12-26 15:58:25","publishedOnDateReadable":"December 26th, 2025"},"versionCreatedAt":"2025-12-08 15:38:25","video":"","vorDoi":"10.1007/s11701-025-03084-9","vorDoiUrl":"https://doi.org/10.1007/s11701-025-03084-9","workflowStages":[]},"version":"v1","identity":"rs-8224240","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8224240","identity":"rs-8224240","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}