The ‘Upside-Down’ Technique in Transperitoneal Robotic Partial Nephrectomy: Visual Standardization and Clinical Outcomes in 50 Consecutive Dorsally Located Renal Masses

The ‘Upside-Down’ Technique in Transperitoneal Robotic Partial Nephrectomy: Visual Standardization and Clinical Outcomes in 50 Consecutive Dorsally Located Renal Masses | 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 The ‘Upside-Down’ Technique in Transperitoneal Robotic Partial Nephrectomy: Visual Standardization and Clinical Outcomes in 50 Consecutive Dorsally Located Renal Masses Amr Ahmed, Aleksa Zubelic, Steffen Lebentrau, Ivan Soldatovic, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8778464/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Mar, 2026 Read the published version in Journal of Robotic Surgery → Version 1 posted 13 You are reading this latest preprint version Abstract An ideal partial nephrectomy (PN) should achieve optimal perioperative, functional, and oncological outcomes. We adapted a robotic-assisted transperitoneal technique for the management of dorsally positioned renal masses across all tumor locations. Drawing inspiration from kidney transplantation surgery, we have termed this technique the “ upside-down ” PN. This single-center retrospective cohort study included 50 consecutive patients with dorsally located renal tumors who underwent robotic-assisted PN using the “ upside-down ” transperitoneal approach. Tumor complexity was assessed using the PADUA score. Trifecta outcomes were evaluated and compared across tumor complexity and tumor locations. The cohort was dominated by high-complexity tumors, with 44% exhibiting a PADUA score ≥10, and 35.3% of malignant tumors classified as pT1b grade postoperative. Mean operative time was 148.6 ± 29.3 minutes, with a mean console time of 69.7 ± 6.9 minutes, without significant differences among PADUA complexity groups. Negative surgical margins (R0) were achieved in all cases (100%). Overall, Trifecta outcomes were achieved in 78% of patients and in 61% of those with a hilar tumor. A PADUA score ≥ 10 was significantly associated with reduced Trifecta outcome, although Trifecta was still achieved in 59.1% of cases. Hilar tumors and larger tumor size were significantly associated with lower Trifecta rates. The “ upside-down ” transperitoneal technique for robotic-assisted PN provides satisfactory perioperative, functional, and oncological outcomes for dorsally positioned renal masses, including complex and hilar tumors. Despite limitations related to its single-center design and sample size, this study offers a visually reproducible workflow of the technique, providing a structured guide for centers managing complex dorsal renal tumors via a transperitoneal approach. partial nephrectomy upside-down dorsal kidney tumors robotic-assisted Figures Figure 1 Figure 2 1. Introduction The ideal partial nephrectomy (PN) should ensure satisfactory perioperative, functional, and oncological outcomes across all anatomical tumor locations [1]. Robotic partial nephrectomy (RPN), facilitated by advanced robotic surgical platforms, has become the preferred minimally invasive modality. This preference is largely attributed to its enhanced surgical capabilities, lower complication rates, especially in highly complex cases, improved visualization of the operative field, superior ergonomics, and a more favorable learning curve compared with laparoscopic partial nephrectomy (LPN) [2-4]. The transperitoneal approach to renal masses (TPPN) is traditionally used in RPN and offers advantages such as easy trocar placement, a larger working space, and reduces instrument collisions. However, transperitoneal access to dorsally located tumors can be challenging [5]. The retroperitoneal approach (RPPN) is a feasible alternative for accessing dorsal tumors, and studies have shown that, in selected patients, it provides similar or even superior perioperative, functional, and oncological outcomes compared with TPPN [6]. Nevertheless, due to the larger working space and superior anatomical orientation, available data indicate that TPPN is still more commonly applied in patients with larger and more complex tumors [7]. Achieving an optimal field of vision and proper kidney positioning for tumor resection and subsequent suturing of the tumor bed are key factors for successful TPPN in complex, dorsally positioned renal masses, particularly those located in the hilar region. With this objective in mind, several surgical techniques have been proposed to facilitate access to dorsally positioned renal tumors. After posterolateral dissection of the perinephric space and opening of Gerota’s fascia, Harris et al. proposed anteromedial rotation of the kidney [8]. Alternatively, placement of additional robotic ports in the lumbar region before tumor resection, as suggested by Timsit et al. in their hybrid approach to RPN, may facilitate access to dorsal renal masses [9]. Experimenting with more extensive renal mobilization, Nouralizadeh et al. and Kaplan et al. independently evaluated, in small LPN and RPN case series, a technique involving 180-degree rotation of the kidney around its vascular pedicle to access dorsal upper pole tumors, repositioning them anteriorly and inferiorly to facilitate resection during TPPN [10,11]. At the same time, ventral renal pedicle rotation has been shown to be a safe and feasible approach for treating ventrally located renal masses using RPPN [12,13]. Building on and optimizing this experience, we propose and demonstrate a broader implementation of the 180-degree pedicle rotation technique for the robotic-assisted management of dorsally positioned renal masses in all locations, including hilar tumors, using a transperitoneal approach. Drawing inspiration from kidney transplantation surgery, we have termed this variant of the technique the “upside-down” PN. Most commonly used term to describe the primary goals of PN is called Trifecta [14]. A recent multicenter prospective study provided a comprehensive analysis of Trifecta outcomes in 3,449 patients undergoing robotic-assisted partial nephrectomy (RAPN) across various anatomical tumor locations [15]. The overall Trifecta rate, defined as warm ischemia time under 25 minutes, negative surgical margins, and absence of major complications, was 62.4% (2,153 out of 3,449 patients). Notably, the study demonstrated a significantly lower Trifecta rate for hilar tumors (55.0%) compared to non-hilar tumors (64.2%, p < 0.01), highlighting the technical challenges associated with centrally located renal masses. We hypothesized that the “upside-down” technique enables safe and effective resection of dorsally positioned renal tumors in all locations, including hilar masses, using a transperitoneal robotic approach, even during the early phase of its clinical adoption. This study presents a consecutive series of the 50 patients treated with this technique by a single surgeon with longstanding experience in RPN. We anticipated that Trifecta outcomes would be comparable to those reported in recent prospective multicenter trials. Specifically, we expected an overall Trifecta rate in at least two out of three patients, with rates of 60% or higher in hilar tumors and above 70% in non-hilar tumors, reflecting the feasibility and safety of this novel strategy in expert hands. 2. Materials and Methods This single-center retrospective cohort study analyzed data from 50 patients with dorsally located renal masses who underwent robotic-assisted partial nephrectomy via a transperitoneal approach using our “upside-down” technique between June 2021 and July 2024. The study was approved by the local ethics committee. All surgeries were performed by a single surgeon with extensive prior experience in robotic partial nephrectomy (RPN). 2.1 Participants Patients were selected consecutively over a three-year period. Since the introduction of the “upside-down” technique in June 2021 in our center (the surgeon was previously experienced in using 180-degree pedicle rotation), all patients with dorsally located renal tumors were assigned to this technique group based on preoperative imaging with contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI). In exceptional cases, the decision to use the “upside-down” technique was made intraoperatively if deviations from preoperative imaging were observed. Apart from tumor location, no additional inclusion or exclusion criteria were applied. No control group was included in this study. Short-term follow-up was performed during the hospital stay, a 30-day follow-up (to collect information on potential complications required to define trifecta outcomes) as well as a 180-day follow-up were conducted through direct communication with patients or their urologists to obtain relevant clinical information. 180-day follow-up data could not be obtained for five patients. 2.2. Study endpoints The primary endpoint was achievement of the Trifecta outcome using the “upside-down” technique. Trifecta outcome was defined as negative surgical margins (R0), no major complications within 30 days postoperatively (Clavien-Dindo classification ≥ 3) and warm ischemia time (WIT) < 25 minutes. Negative surgical margins (R0) were also defined for benign pathology. R0 resection was defined by the pathologist as a complete excision without entry into tumor (no residual lesion). Therefore, the Trifecta outcome could be calculated for the entire cohort. We also tested the hypothesis that, when using the “upside-down” technique, Trifecta outcomes are independent of the PADUA score. Secondary endpoints included: R0 resection rate, WIT, postoperative and 180-day renal function, actual blood loss, Clavien-Dindo complication rates, operative time (OT), and console time. Additional documented variables included: ASA Score, length of hospital stay, hemoglobin levels (pre- and postoperative) and postoperative histology. 2.3. Data collection Data on patient demographics, clinical characteristics, operative details, and postoperative outcomes were collected from medical records. Preoperative imaging with contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) was performed for all patients. Dorsal tumor location was defined according to the PADUA nephrometry score [16] by reviewing axial CT or MRI slices, with the entire tumor or the bulk of an endophytic mass positioned posterior to the kidney’s midline on axial imaging (defined as posterior according to the PADUA nephrometry score). The PADUA nephrometry score, tumor size in centimeters, and tumor location (hilar vs. non-hilar) were assigned by a single experienced radiologist to ensure consistency. Patients were then classified into low-complexity (PADUA 6–7), moderate-complexity (PADUA 8–9), and high-complexity (PADUA ≥10) groups [3,16]. Postoperative and long-term renal function was assessed using serum creatinine values, and estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI formula [17]. Intraoperative blood loss was calculated using the actual blood loss (ABL) method described by McCullough et al. [18] to improve accuracy compared with estimated blood loss (EBL). Postoperative complications were graded using the Clavien-Dindo classification system [19]. Data collection was completed after enrollment of 50 consecutive patients in July 2024. This number was considered sufficient to allow statistical analysis of the study endpoints while maintaining the feasibility of complete data collection and follow-up of up to 180 days. The “upside-down” technique continues to be routinely used in clinical practice. 2.4. Upside-Down Surgical Technique All procedures were performed using the da Vinci Xi robotic system (Intuitive Surgical Inc., Sunnyvale, CA, USA) with pneumoperitoneum maintained at 15–20 mmHg. Patients were positioned in the flank position utilizing table flexion to optimize port placement. A 12 mm assistant port was placed near the umbilicus (or lateral to the rectus in obese patients), followed by four 8 mm robotic ports along the midclavicular line below the costal margin. After standard bowel mobilization, the ureter and gonadal vein were identified and traced to the renal hilum. The renal vein and artery were dissected and marked, and 20 mg of intravenous furosemide was administered prior to arterial dissection to prevent spasm. The kidney was then completely mobilized ( Figure 1 ), and rotated 180 degrees around the renal pedicle to optimize exposure of dorsally located tumors ( Figure 2 ), a maneuver feasible in all patients with up to three hilar arteries. Intraoperative ultrasonography was used to localize the tumor and define resection margins, which were marked with cautery. The renal artery was clamped with a laparoscopic bulldog clamp through the 12 mm assistant port, leaving the vein open. Correct clamp placement and perfusion were verified using indocyanine green (ICG) , ensuring no accessory arteries were missed. Tumor excision was performed using robotic scissors with negative parenchymal margins. Renorrhaphy was completed using 4-0 PDS for deep layers, followed by capsulorrhaphy with 3-0 Vicryl interrupted sutures, secured with Hem-o-lok clips to optimize hemostasis. Absorbable hemostatic gauze (oxidized regenerated cellulose, Tabotamp, Johnson & Johnson) was applied over the defect. The kidney was then rotated back to its normal position, the clamp removed, and perfusion reconfirmed with ICG. Finally, the kidney was retroperitonealized, the specimen retrieved in an entrapment bag, and hemostasis confirmed before placement of a Foley drain. Results are presented as counts (%), means ± standard deviation, or medians (25 th –75 th percentile), depending on data type and distribution. Groups were compared using parametric tests (t-test, ANOVA) and nonparametric tests (Chi-square test, Fisher’s exact test, Fisher–Freeman–Halton test, Mantel–Haenszel test for trend, Mann–Whitney U test, and Kruskal–Wallis test), as appropriate for data type and distribution. Data distribution was assessed using descriptive statistics, graphical methods (histograms, boxplots, and Q–Q plots), and tests (Shapiro–Wilk) methods. Continuous variables (age and BMI) were dichotomized using predefined cutoffs (BMI 25 kg/m²) or the median value (age) to improve interpretability of the modeling predictors. Logistic regression analyses were performed to evaluate the association between the dependent variable (trifecta outcome) and independent variables, which were predefined based on clinical experience or selected using a p-value < 0.2. Modeling was conducted in two steps: univariable analysis (one predictor per model) and multivariable analysis (all relevant predictors included simultaneously). The total sample size was 50, with 39 subjects achieving trifecta, which limited the number of predictors included in the multivariable model. Therefore, the multivariable model included four predictors, following the rule of 10 events per predictor. All p-values < 0.05 were considered statistically significant. Given the limited number of events, the multivariable model should be interpreted as exploratory and is primarily intended for hypothesis generation. At the 180-day follow-up, data were available for 45 patients (5 missing). Analyses of 180-day outcomes, including tumor recurrence and renal function parameters, were performed only in patients with available data. All analyses were performed using SPSS 31.0 (IBM Corp. Released 2023. IBM SPSS Statistics for Windows, Version 29.0. Armonk, NY: IBM Corp.) and R 4.5.0. (R Core Team (2017). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/.). 2.6. STROBE Statement This study is reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for cohort studies. The design, participant selection, data collection, study variables, endpoints, and statistical methods were structured to ensure transparency, reproducibility, and completeness of reporting. 3. Results A total of 50 patients successfully underwent transperitoneal robotic-assisted partial nephrectomy using the “upside-down” technique, without the need for conversion or additional port placement. Based on the PADUA score, patients were classified as low (20%), moderate (36%), or high complexity (44%), with high-complexity tumors predominating. No statistically significant differences were observed among PADUA groups in preoperative characteristics, including sex, age, BMI, ASA score, prior abdominal surgery, tumor laterality, preoperative creatinine levels, or maximal tumor size (mean 4.0 ± 1.5 cm). Malignant histology was identified in 68% of cases, most commonly clear cell renal cell carcinoma. Among malignant tumors, the predominant postoperative stage was pT1a, although pT1b disease was present in 35.3% of patients ( Table 1 ). Table 1. General characteristics of participants. Total PADUA p value Low (n=10) Moderate (n=18) High (n=22) Sex (male) 32 (64%) 6 (60%) 9 (50%) 17 (77.3%) 0.194 Age 67±15.5 69±11.6 70.78±13.9 63±17.7 0.258 BMI (kg/m2) 29.1±6.8 28.7±7.1 29.7±7.3 28.8±6.5 0.896 ASA score 1 5 (10%) 0 2 (11.1%) 3 (13.6%) 0.879 2 33 (66%) 8 (80%) 11 (61.1%) 14 (63.6%) 3 12 (24%) 2 (20%) 5 (27.8%) 5 (22.7%) Hilar tumor 18 (36%) 0 5 (27.8%) 13 (59.1%) 0.004 PAO* (yes) 18 (36%) 3 (30%) 6 (33.3%) 9 (40.9%) 0.800 Tumor side (right) 26 (52%) 5 (50%) 9 (50%) 12 (54.5%) 0.950 Max. tumor size (cm) 4±1.5 3.8±1.2 3.4±1.5 4.6±1.6 0.053 Tumor histopathology Clear cell RCC 26 (52%) 3 (30%) 12 (66.7%) 11 (50%) Papillary RCC 4 (8%) 0 (0%) 2 (11.1%) 2 (9.1%) Chromophobe RCC 4 (8%) 0 (0%) 1 (5.6%) 3 (13.6%) Oncocytoma 4 (8%) 2 (20%) 1 (5.6%) 1 (4.5%) Angiomyolipoma 3 (6%) 0 (0%) 0 (0%) 3 (13.6%) Renal sarcoma** 1 (2%) 0 (0%) 0 (0%) 1 (4.5%) Nephritis 1 (2%) 1 (10%) 0 (0%) 0 (0%) Renal cyst 7 (14%) 4 (40%) 2 (11.1%) 1 (4.5%) pT stage (among malignant tumors) pT1a 21 (61.8%) 3 (100%) 11 (80%) 7 (43.8%) 0.25 pT1b 12 (35.3%) 0 (0%) 4 (20%) 8 (50%) pT2b 1 (2.9%) 0 (0%) 0 (0%) 1 (6.2%) Results are presented as count (%), means ± standard deviation, or medians (25th–75th percentile) depending on data type and distribution . *PAO – Previous abdominal operation **For this patient, the pT stage was not provided postoperatively by the pathologist; only the R0 resection status was reported. The mean OT (skin incision to closure) was 148.6 ± 29.3 minutes, with a console time of 69.7 ± 6.9 minutes, without significant differences among PADUA complexity groups. The mean warm ischemia time was 23.1 ± 6.0 minutes and was significantly longer in the high-complexity group ( Table 2 ). The average ABL was 158 mL. Table 2. Laboratory findings, intraoperative data and postoperative course. Total PADUA p value Low (n=10) Moderate (n=18) High (n=22) Laboratory Creatinine Preop. (mg/dL) 71.6 (29.2) 56.6 (24.8) 0.88 (0.54) 77.8 (47.7) 0.155 Creatinine Postop. 1D 102.5 (39.8) 84.9 (21.2) 114.0 (62.8) 113.0 (30.1) 0.052 Creatinine Postop. 5D* 91.9 (33.6) 80.4 (8.8) 104.3 (53.9) 99.8 (55.7) 0.007 % of change (5D-Preop.) +42.1 (47.4) +40.7 (53.6) +33.8 (36.3) +50.1 (80.2) 0.136 eGFR Preop. (mL/min/1.73 m²) 90 (15.8) 90 (0) 82.6 (46.2) 90 (2.5) 0.027 eGFR Postop. 1D 58.75 (26.2) 69.25 (31.2) 46.8 (33.6) 59.25 (19.3) 0.119 eGFR Postop. 5D* 64.8 (37.2) 82.5 (25.3) 56.4 (43.7) 65.65 (37.6) 0.060 % of change (5D-Preop.) -23.0 (26.1) -4.1 (26.2) -17.7 (25.7) -26.9 (28.3) 0.056 Hb Preop. (g/L) 140.2±17.3 139.3±18 140.3±17 140.4±18.1 0.985 Hb Postop. 1D 125.3±17.5 127.7±16.6 124.1±19.4 125.3±17 0.875 % of change (1D-Preop.) -10.6±5.7 -8.3±3.5 -11.8±6.2 -10.7±5.9 0.292 Postop. Complications** Infection 3 (6%) 1 (10%) 1 (5.6%) 1 (4.5%) 0.788 Urinoma 3 (6%) 0 (0%) 1 (5.6%) 2 (9.1%) 1.000 Transfusion 3 (6%) 0 (0%) 1 (5.6%) 2 (9.1%) 1.000 Clavien-Dindo grade 0 42 (84%) 9 (90%) 14 (77.8%) 19 (86.4%) 0.671 2 5 (10%) 1 (10%) 3 (16.7%) 1 (4.5%) 3a 3 (6%) 0 (0%) 1 (5.6%) 2 (9.1%) Console time (min) 69.7±6.9 66.3±6.7 69.1±4.03 71.7±8.3 0.111 WIT (min) 23.1±5.6 20±4.6 21.8±3.4 25.5±7.2 0.032 Operation time (min) 148.6±29.3 130.1±26.9 149.8±31.2 156.1±26.3 0.064 Hospital stay (days) 6.4±2 5.9±1 6.4±2 6.5±2.2 0.726 Results are presented as count (%), means ± standard deviation, or medians (25th–75th percentile) depending on data type and distribution . * 5D – fifth postoperative day, or the day of discharge for patients discharged before the fifth hospital day. **Complications observed in the postoperative period up to 30 days after surgery (as part of the trifecta criteria). Negative surgical margins (R0) were achieved in all cases. Major postoperative complications (Clavien–Dindo grade ≥ 3) occurred in three patients, all of whom developed urinomas within the 30-day follow-up period. These were successfully managed with double-J stent placement, with stent removal 12 weeks after resolution. No additional complications related to the operation were identified between the 30- and 180-day follow-up periods. No intraoperative hilar vessel injury or postoperative, 30- or 180-day adverse events, including infarction or vessel thrombosis, occurred as a result of the 180° pedicle rotation. Postoperative and 180-day follow-up of renal function ( Table 3 ) demonstrated successful preservation of kidney function, with no statistically significant differences in measured parameters (eGFR and creatinine) across PADUA complexity groups, except for discharge-day creatinine levels, which were significantly higher in the moderate- and high-complexity groups. Table 3. Trifecta outcome and 6 months follow up outcomes. Total PADUA p value Low (n=10) Moderate (n=18/15*) High (n=22/20*) Trifecta achieved 39 (78%) 10 (100%) 16 (88.9%) 13 (59.1%) 0.006 180-day follow up* Tumor recurrence 1 (2.3%) 0 0 1 (5%) 1.000 eGFR (mL/min/1.73 m²) 82.7 (20) 81.8 (22) 82 (20) 87.5 (20.5) 0.897 Creatinine (mg/dL) 82.2 (17.7) 78.7 (20.3) 83.9 (17.7) 81.3 (20.3) 0.914 Results are presented as count (%), means ± standard deviation, or medians (25th – 75th percentile) depending on data type and distribution *For 180-day follow-up, data were available for 45 patients in total (5 missing: 3 in the moderate-complexity PADUA group, 2 in the high-complexity PADUA group). Trifecta outcomes were achieved in 78% of patients overall and in 61% of those with hilar tumor location. Trifecta outcome was significantly associated with PADUA score, with high-complexity tumors showing a statistically significantly lower outcome rate compared with low- and moderate-complexity tumors, combined as a single group (59.1% vs. 92.9%; OR 0.111, 95% CI 0.021–0.591). On univariable analysis, reduced Trifecta outcome was significantly associated with hilar tumor location (OR 0.224, 95% CI 0.055–0.922) and larger maximal tumor size (per cm increase) (OR 0.943, 95% CI 0.896–0.991), whereas higher BMI (per kg/m 2 increase) was paradoxically linked to improved outcomes (OR 4.455, 95% CI 1.085–18.294). In multivariable analysis adjusting for age, BMI, hilar location, and tumor size, hilar tumor location remained a strong predictor of reduced Trifecta outcome (OR 0.088, 95% CI 0.013–0.582; Table 4 ). Table 4 . Trifecta outcome modeling. Trifecta achieved Univariable Multivariable Yes (n=39) No (n=11) p value OR (95% CI) OR (95% CI) Sex Male 24 (75%) 8 (25%) 0.724 Female 15 (83.3%) 3 (16.7%) 1.667 (0.381; 7.288) Age 68.7±12.5 60.9±22.9 0.301 25 28 (87.5%) 4 (12.5%) 4.455 (1.085; 18.294)* 9.576 (1.336; 68.635)* Hilar Tumor No 28 (87.5%) 4 (12.5%) 0.041 Yes 11 (61.1%) 7 (38.9%) 0.224 (0.055; 0.922)* 0.088 (0.013; 0.582)* ASA 1 3 (60%) 2 (40%) 0.386 1.771 (0.524; 5.985) 2 26 (78.8%) 7 (21.2%) 3 10 (83.3%) 2 (16.7%) Max. Tu size (cm) 3.69±1.41 4.97±1.61 0.032 0.943 (0.896; 0.991)* 1.220 (0.208; 7.162) PAO** No 24 (75%) 8 (25%) 0.724 Yes 15 (83.3%) 3 (16.7%) 1.667 (0.381; 7.288) PADUA 9 (3) 10 (1) 0.002 Low 10 (100%) 0 0.006 0.146 (0.032; 0.673)* Moderate 16 (88.9%) 2 (11.1%) High 13 (59.1%) 9 (40.9%) PADUA Low/Mod 26 (92.9%) 2 (7.1%) 0.006 High 13 (59.1%) 9 (40.9%) 0.111 (0.021; 0.591)* Results are presented as count (%) or means ± SD; Continuous variables are expressed per unit increase: age per 1 year, BMI per 1 kg/m², and tumor size per 1 cm **PAO - Previous abdominal operations *p < 0.05 in model Regression analysis: Univariable analysis – each variable separately in model; Multivariable analysis – all significant predictors in univariable analysis together in model. Discussion When comparing the outcomes of our technique with previously published data, it is important to acknowledge differences in baseline tumor characteristics. Our cohort was dominated by high-complexity renal masses, with larger mean tumor size and a higher proportion of T1b tumors than reported in most RPN series [15, 20-22]. These characteristics underscore the technical difficulty of the cases included and suggest potential advantages of this technique when managing complex, dorsally located renal tumors. Since its introduction by Hung et al. [14], the Trifecta concept has become a widely accepted benchmark for comparing PN outcomes. Reported Trifecta achievement rates vary considerably across studies, ranging from 32% to 81% [23], reflecting differences in patient selection, tumor complexity, and surgical approach. A recent multicenter prospective study reported a Trifecta rate of 55% for centrally located tumors compared with 64.2% for non-hilar tumors, highlighting the increased technical demands of hilar tumors [15]. In our cohort, Trifecta outcomes were achieved in 78% of patients overall and in 61% of patients with hilar tumors. Hilar tumor location remained an independent predictor of reduced Trifecta achievement in multivariable analysis. This finding contrasts with some recent published data but is consistent with the known technical challenges associated with hilar tumor location [15, 24]. The PADUA score has been consistently identified as an independent predictor of Trifecta outcomes, with predictive performance comparable to other nephrometry systems such as RENAL [25]. In our study, the PADUA score remained an independent predictor of achieving Trifecta outcome, indicating that the proposed technique does not eliminate the impact of tumor complexity. Nevertheless, patients with high PADUA scores achieved Trifecta outcomes in 59.1% of cases, which is higher than reported in comparable cohorts with similar tumor complexity [26]. The influence of body mass index (BMI) on Trifecta achievement remains controversial. A recent retrospective study including 296 patients stratified by BMI (<25, 25–25 kg/m² and Trifecta outcomes. This finding may reflect residual confounding or sample size limitations. However, several studies have described an inverse association between obesity and adverse perioperative outcomes in kidney surgery, commonly referred to as the “obesity paradox.” Yoo et al. reported that obese patients tended to be younger and present with smaller tumors and lower T stage [28]. Subgroup analyses accounting for these potential confounders were not performed in the present study and represent a limitation. Dorsal renal tumors pose unique technical challenges, and both transperitoneal (TP) and retroperitoneal (RP) approaches have inherent advantages and disadvantages. While the TP approach offers a larger working space, familiar anatomy, and versatile access, multiple studies suggest inferior performance compared with the RP approach when treating posteriorly located tumors. The RP approach provides direct access to the dorsolateral kidney side and renal artery, which has been associated with shorter OT [29]. However, this advantage diminishes when managing anterior tumors [28]. Importantly, RPPN and TPPN have been shown to yield comparable postoperative, functional, and oncologic outcomes for posterolateral tumors [20,21,30,31]. The OT in our series (148.6 ± 29.3 minutes), including a console time of 69.7 ± 6.9 minutes, is comparable to published RPPN data and generally shorter than reported TPPN series [22, 32]. Mjaess et al. reported [22] mean OT of 123 minutes for RPPN and 171 minutes for TPPN, while Harke et al. [33] demonstrated mean OT of 119 minutes and 139 minutes, respectively, in a multicenter matched-pair analysis of 754 patients. Other RPPN series focusing on posterior tumors reported OT ranging from approximately 157 to 160 minutes [34,35]. WIT in our cohort was comparable to published data for complex renal masses treated with TPPN, typically ranging from 17 to 27 minutes [34,35]. Estimated blood loss was calculated using postoperative hemoglobin-based algorithms rather than intraoperative estimates, limiting direct comparison with other studies. No positive surgical margins were observed in our cohort, consistent with most TPPN series [32] and favorable compared with reported RPPN positive margin rates ranging from 2.8% to 16% [32]. The rate of major complications (Clavien–Dindo grade ≥3) was 6%, which aligns with contemporary robotic PN literature [32]. The absence of a contemporaneous control group undergoing standard RPPN or TPPN represents an additional limitation when interpreting perioperative outcomes. When compared with small laparoscopic [10] and robotic [11] PN case series describing 180° renal pedicle rotation, our results demonstrate shorter OT (148 minutes vs. 206 minutes for laparoscopic, and 242.6 minutes for robotic series) and comparable WIT. These comparisons should be interpreted cautiously due to the very small sample sizes in prior studies as well as advancements in robotic technology. It is also important to note that, compared to these two case series, our cohort employed a more radical approach to the implementation of 180° renal pedicle rotation, attempting to use it as a standard method for managing dorsal tumors at all locations, including hilar tumors. This differs from previous reports, which applied this rotation primarily to optimize access to upper pole dorsal tumors only [10, 11]. Concerns regarding 180° renal pedicle rotation include potential vascular injury and postoperative renal dysfunction. No vascular complications or pedicle-related injuries were observed in our series. Similar findings have been reported by Liang et al. and Song et al., who concluded that pedicle rotation is a safe maneuver to improve tumor exposure during retroperitoneal approach [36,37]. Postoperative renal functional outcomes further support the safety of our technique. The mean postoperative eGFR reduction of 23% is consistent with published PN data [38,39]. Long-term renal function has been shown to depend primarily on patient-related factors such as age, diabetes, and baseline renal function rather than tumor complexity [40]. In accordance with these findings, 180-day renal function in our cohort did not differ significantly across PADUA score groups. Tumor recurrence was observed in only one patient (2.3%) after a 180-day follow-up period. Similar recurrence-free survival rates have been reported in other RPN studies [2], but over much longer follow-up periods. Due to the limited follow-up in our study, no reliable conclusions can be drawn regarding recurrence-free or disease-specific survival. This study should be interpreted in light of its limitations, including its single-center design, relatively small sample size, and absence of a control group. These factors may limit generalizability and introduce residual confounding. Nevertheless, the consistent perioperative, oncologic, and functional outcomes observed in a cohort enriched with high-complexity dorsal renal tumors suggest that this technique is a safe and effective option. The “upside down” technique maintains advantages of TPPN, including the larger working space and a superior anatomical orientation, thus providing a framework to create single access to reach and successfully treat all types and locations of complex renal masses, avoiding suboptimal vision and reach leading to prolonged operating time, complications and the need for conversion. This study demonstrates the practical, visually reproducible workflow of the technique, providing a structured guide for centers managing complex dorsal renal tumors via a transperitoneal approach. Statements and Declarations 2.1 Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. 2.2 Competing Interests The authors have no relevant financial or non-financial interests to disclose. 2.3 Author Contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Amr Ahmed, Aleksa Zubelic and Ivan Soldatovic. The first draft of the manuscript was written by Amr Ahmed and Aleksa Zubelic and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. 2.3 Ethics approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of the Medical Association of Hesse (Landesärztekammer Hessen) , Frankfurt am Main, Germany (protocol code 2025-4314-evBO). 2.4 Consent to participate The study was conducted using fully anonymized data. The Ethics Committee did not require informed consent for individual cases; therefore, it was waived. No identifying patient information is presented. All visual materials are anonymized, contain no patient-identifiable features, and all metadata, names, dates, and other identifiers have been removed. References Wang L, Deng JY, Liang C, Zhu PY (2023) Perioperative, functional, and oncological outcomes of robotic vs laparoscopic partial nephrectomy for complex renal tumors (RENAL score ≥ 7): an evidence-based analysis. Front Oncol 13:1195910. https://doi.org/10.3389/fonc.2023.1195910 Lee S, Ryu H, Lee JW (2021) Open partial nephrectomy vs robot-assisted partial nephrectomy for a renal tumor larger than 4 cm: a propensity score matching analysis. J Korean Med Sci 36:e120. https://doi.org/10.3346/jkms.2021.36.e120 Liu S, Zhang B, Weng B, Liu X, Hou S (2024) Comparison of robotic-assisted and laparoscopic partial nephrectomy based on the PADUA score and the predictive value of the PADUA and Mayo Adhesive Probability scores for postoperative complications: a single-center retrospective study. J Cancer Res Clin Oncol 151:1. https://doi.org/10.1007/s00432-024-05771-1 Mahmud H, Haitovic B, Zilberman DE, Rosenzweig B, Laufer M, Portnoy O, Fridman E, Dotan ZA (2024) Robotic partial nephrectomy is associated with a significantly decreased rate of postoperative pseudoaneurysm compared to open and laparoscopic partial nephrectomy. J Robot Surg 18:241. https://doi.org/10.1007/s11701-024-01999-3 Zhu D, Shao X, Guo G, Zhang N, Shi T, Wang Y, Gu L (2021) Comparison of outcomes between transperitoneal and retroperitoneal robotic partial nephrectomy: a meta-analysis based on comparative studies. Front Oncol 10:592193. https://doi.org/10.3389/fonc.2020.592193 Rong RZ, Zhang P, Zhao M, He CE (2025) Transperitoneal vs retroperitoneal robotic partial nephrectomy: a meta-analysis and systematic review of propensity-matched studies. J Robot Surg 19:56. https://doi.org/10.1007/s11701-025-02003-4 Zhou J, Liu ZH, Cao DH, Peng ZF, Song P, Yang L, Liu LR, Wei Q, Dong Q (2021) Retroperitoneal or transperitoneal approach in robot-assisted partial nephrectomy: which one is better? Cancer Med 10:3299–3308. https://doi.org/10.1002/cam4.3895 Harris KT, Ball MW, Gorin MA, Curtiss KM, Pierorazio PM, Allaf ME (2014) Transperitoneal robot-assisted partial nephrectomy: a comparison of posterior and anterior renal masses. J Endourol 28:655–659. https://doi.org/10.1089/end.2013.0608 Timsit MO, Terrier N, Toinet T, Dariane C, Debedde E, Panthier F, Thiounn N, Audenet F, Méjean A (2022) Posterior transperitoneal robot-assisted partial nephrectomy in the treatment of renal tumors: feasibility of a hybrid approach. Prog Urol 32:217–225. https://doi.org/10.1016/j.purol.2022.01.002 Kaplan JR, Chang P, Percy AG, Wagner AA (2013) Renal transposition during minimally invasive partial nephrectomy: a safe technique for excision of upper pole tumors. J Endourol 27:1096–1100. https://doi.org/10.1089/end.2013.0225 Nouralizadeh A, Ziaee SA, Basiri A, Simforoosh N, Abdi H, Mahmoudnejad N, Kashi AH (2009) Transperitoneal laparoscopic partial nephrectomy using a new technique. Urol J 6:176–181 Hua M, Liu W, Wang C, Xiao C, Shi H, Yang Y, Wu H, Pang Q, Zhang W, Yang Q (2023) Trans-retroperitoneal laparoscopic partial nephrectomy for posterior hilar tumor: technical feasibility and preliminary results. Transl Androl Urol 12:1638. https://doi.org/10.21037/tau-23-646 Yin X, Jiang S, Shao Z, Lu Y, Guo J, Xiao Y, Zhu X, Yu H, Ma H, Yang Y, Gao J (2020) Kidney ventral rotation technique in retroperitoneal robot-assisted partial nephrectomy for posterior hilar tumor. World J Surg Oncol 18:148. https://doi.org/10.1186/s12957-020-01928-2 Hung AJ, Cai J, Simmons MN, Gill IS (2013) Trifecta in partial nephrectomy. J Urol 189:36–42. https://doi.org/10.1016/j.juro.2012.09.042 Sarkis J, Champy CM, Doumerc N et al (2024) Robot-assisted partial nephrectomy for hilar and nonhilar renal masses: results from a multicentre prospective cohort (NEPRAH Study, UroCCR 175). Eur Urol Oncol 7:1487–1496. https://doi.org/10.1016/j.euo.2024.06.003 Ficarra V, Novara G, Secco S et al (2009) Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours. Eur Urol 56:786–793. https://doi.org/10.1016/j.eururo.2009.07.040 Levey AS, Stevens LA, Schmid CH et al (2009) A new equation to estimate glomerular filtration rate. Ann Intern Med 150:604–612. https://doi.org/10.7326/0003-4819-150-9-200905050-00006 McCullough TC, Roth JV, Ginsberg PC, Harkaway RC (2004) Estimated blood loss underestimates calculated blood loss during radical retropubic prostatectomy. Urol Int 72:13–16. https://doi.org/10.1159/000075264 Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications. Ann Surg 240:205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae Kälble S, Engelmann SU, Schrutz H et al (2025) Randomised controlled feasibility trial of retroperitoneal vs transperitoneal robot-assisted partial nephrectomy: the ROPARN study. BJU Int 135:977–986. https://doi.org/10.1111/bju.16342 Ge S, Chen L, Tai S (2021) Comparison of therapeutic effects among different surgical approaches in robot-assisted partial nephrectomy: a systematic review and meta-analysis. J Endourol 35:623–632. https://doi.org/10.1089/end.2020.0876 Mjaess G, Bernhard JC, Khene ZE, Doumerc N, Vaessen C, Henon F, Bruyere F, Brenier M, Parier B, Albisinni S, Ingels A (2023) Retroperitoneal vs transperitoneal robotic partial nephrectomy: a multicenter propensity-score matching analysis (PADORA Study-UroCCR 68). Minerva Urol Nephrol 75:434–442. https://doi.org/10.23736/S2724-6051.23.05119-6 Sri D, Thakkar R, Patel HR, Lazarus J, Berger F, McArthur R, Lavigueur-Blouin H, Afshar M, Fraser-Taylor C, Le Roux P, Liban J (2021) Robotic-assisted partial nephrectomy and standardization of outcome reporting: a prospective observational study on reaching the trifecta and pentafecta. J Robot Surg 15:571–577. https://doi.org/10.1007/s11701-020-01169-1 Miyake H, Hinata N, Imai S, Furukawa J, Tanaka K, Fujisawa M (2015) Partial nephrectomy for hilar tumors: comparison of conventional open and robot-assisted approaches. Int J Clin Oncol 20:808–813. https://doi.org/10.1007/s10147-014-0789-0 Egen L, Kowalewski KF, Riffel P, Honeck P, Kriegmair MC (2021) Nephrometry scores: can preoperative assessment of sectional imaging really mirror intraoperative renal tumor anatomy? Urol Int 105:108–117. https://doi.org/10.1159/000510684 Karamık K, Aktaş Y, Erdemir AG, İslamoğlu E, Ölçücü MT, Özsoy Ç, Savaş M, Ateş M (2021) Predicting strict trifecta outcomes after robot-assisted partial nephrectomy: comparison of RENAL, PADUA, and C-index scores. J Kidney Cancer VHL 8:1–12. https://doi.org/10.15586/jkcvhl.v8i4.183 Ohsugi H, Ikeda J, Takayasu K, Takizawa N, Taniguchi H, Yanishi M, Kinoshita H (2024) Trifecta outcomes of robotic partial nephrectomy in obese patients. Int J Urol 31:1108–1113. https://doi.org/10.1111/iju.15529 Yoo HJ, Kim SI, Kim SJ, Won I, Cho DS (2023) Prognostic significance of body mass index in patients undergoing nephrectomy for nonmetastatic renal cell carcinoma. J Urol Oncol 21:88–94. https://doi.org/10.22465/juo.224400480024 Socarrás MR, Elbers JR, Rivas JG, Autran AM, Esperto F, Tortolero L, Carrion DM, Sancha FG (2021) Retroperitoneal robot-assisted partial nephrectomy: surgical technique and review. Curr Urol Rep 22:33. https://doi.org/10.1007/s11934-021-01042-0 Carbonara U, Eun D, Derweesh I, Capitanio U, Celia A, Fiori C, Checcucci E, Amparore D, Lee J, Larcher A, Patel D (2021) Retroperitoneal versus transperitoneal robot-assisted partial nephrectomy for posterolateral renal masses: an international multicenter analysis. World J Urol 39:4175–4182. https://doi.org/10.1007/s00345-021-03672-0 Tao M, Cheng K, Xu W, Qian Z, Pan P (2024) Comparison of the effects of transperitoneal and retroperitoneal robot-assisted partial nephrectomy. Pak J Med Sci 40:2202. https://doi.org/10.12669/pjms.40.10.9286 Hinata N, Murakami S, Nakano Y, Hara I, Kondo T, Hamamoto S, Shiroki R, Nagayama J, Kawakita M, Eto M, Ukimura O (2024) Efficacy of robot-assisted partial nephrectomy compared with laparoscopic partial nephrectomy for completely endophytic renal tumors. Int J Clin Oncol 29:1548–1556. https://doi.org/10.1007/s10147-024-02427-4 Harke NN, Darr C, Radtke JP, von Ostau N, Schiefelbein F, Eraky A, Hamann C, Szarvas T, Hadaschik BA, Tropmann-Frick M, Juenemann KP (2021) Retroperitoneal versus transperitoneal robotic partial nephrectomy: a multicenter matched-pair analysis. Eur Urol Focus 7:1363–1370. https://doi.org/10.1016/j.euf.2020.05.007 Boga MS, Ates M (2021) Retroperitoneal robot-assisted laparoscopic partial nephrectomy for posterior renal tumors: technique and early outcomes. Int J Clin Pract 75:e13851. https://doi.org/10.1111/ijcp.13851 Okhawere KE, Rich JM, Ucpinar B, Beksac AT, Saini I, Deluxe A, Zuluaga L, Eun DD, Bhandari A, Hemal AK, Porter J (2023) Comparison of outcomes between transperitoneal and retroperitoneal robotic-assisted partial nephrectomy in patients with completely endophytic kidney tumors. Urol Oncol 41:111e1–111e8. https://doi.org/10.1016/j.urolonc.2022.11.011 Liang YH, Zu XB, Cheng X, Liu LF (2017) Retroperitoneal laparoscopic partial nephrectomy with renal pedicle rotation for ventral renal tumors. J Peking Univ Health Sci 49:608–612 Song S, Zhang H, Ma L, Huang Y, Zhao L, Wang G, Lu J, Zhang S (2015) Application of renal pedicle rotation in retroperitoneal laparoscopic partial nephrectomy for ventral renal tumors. J Endourol 29:1038–1043. https://doi.org/10.1089/end.2015.0064 Shin TY, Han H, Min HS, Cho H, Kim S, Park SY, Kim HJ, Kim JH, Lee YS (2023) Prediction of postoperative creatinine levels by artificial intelligence after partial nephrectomy. Medicina 59:1402. https://doi.org/10.3390/medicina59081402 Wang Z, Liu C, Chen R, Liu S, Feng C, Yu K, Zeng X (2018) Renal function outcomes following laparoscopic partial nephrectomy: impact of baseline eGFR, warm ischemia time, and RENAL nephrometry score. Urol Oncol 36:498e15–498e21. https://doi.org/10.1016/j.urolonc.2018.07.005 Roussel E, Laenen A, Bhindi B, De Dobbeleer A, Stichele AV, Verbeke L, Van Cleynenbreugel B, Sprangers B, Beuselinck B, Van Poppel H, Joniau S, Albersen M (2023) Predicting short- and long-term renal function following partial and radical nephrectomy. Urol Oncol 41:110e1–11110. https://doi.org/10.1016/j.urolonc.2022.10.006 Additional Declarations No competing interests reported. Supplementary Files STROBECheckliste.doc Cite Share Download PDF Status: Published Journal Publication published 14 Mar, 2026 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 06 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviews received at journal 05 Feb, 2026 Reviews received at journal 05 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers invited by journal 04 Feb, 2026 Editor assigned by journal 04 Feb, 2026 Submission checks completed at journal 04 Feb, 2026 First submitted to journal 03 Feb, 2026 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8778464","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587253755,"identity":"0ad56d03-c797-479e-9557-3c9e61c7409a","order_by":0,"name":"Amr Ahmed","email":"","orcid":"","institution":"Varisano Kliniken Frankfurt-Main-Taunus","correspondingAuthor":false,"prefix":"","firstName":"Amr","middleName":"","lastName":"Ahmed","suffix":""},{"id":587253756,"identity":"71853cf2-70eb-4526-afb8-d26a7343d20f","order_by":1,"name":"Aleksa Zubelic","email":"data:image/png;base64,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","orcid":"","institution":"Varisano Kliniken Frankfurt-Main-Taunus","correspondingAuthor":true,"prefix":"","firstName":"Aleksa","middleName":"","lastName":"Zubelic","suffix":""},{"id":587253757,"identity":"b6a076bb-a1c1-4ba7-96d4-a21bfa0e8d90","order_by":2,"name":"Steffen Lebentrau","email":"","orcid":"","institution":"GLG Werner Forssmann Klinikum Eberswalde","correspondingAuthor":false,"prefix":"","firstName":"Steffen","middleName":"","lastName":"Lebentrau","suffix":""},{"id":587253761,"identity":"54e06b8c-5592-4135-98b7-e834baf48259","order_by":3,"name":"Ivan Soldatovic","email":"","orcid":"","institution":"School of Medicine, University of Belgrade","correspondingAuthor":false,"prefix":"","firstName":"Ivan","middleName":"","lastName":"Soldatovic","suffix":""},{"id":587253763,"identity":"4212808b-acb1-4840-bc03-ed15ed361c83","order_by":4,"name":"Matthias May","email":"","orcid":"","institution":"St. Elisabeth Klinikum Straubing","correspondingAuthor":false,"prefix":"","firstName":"Matthias","middleName":"","lastName":"May","suffix":""}],"badges":[],"createdAt":"2026-02-03 16:38:59","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8778464/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8778464/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11701-026-03266-z","type":"published","date":"2026-03-14T15:58:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":102212914,"identity":"ded360b8-9e5d-459a-9414-7461d1ad3f77","added_by":"auto","created_at":"2026-02-09 12:37:20","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":873479,"visible":true,"origin":"","legend":"\u003cp\u003eAfter all key anatomical landmarks have been identified and marked, the kidney was completely dissected and prepared for a 180-degree \u003cem\u003e“upside-down”\u003c/em\u003e pedicle rotation.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8778464/v1/34d01bc871678d0202648ab0.jpeg"},{"id":102212915,"identity":"bde2c939-37cb-472a-9955-e7643fe9160b","added_by":"auto","created_at":"2026-02-09 12:37:20","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":853752,"visible":true,"origin":"","legend":"\u003cp\u003eAn \u003cem\u003e“upside-down”\u003c/em\u003erotation is performed, revealing a dorsally positioned endophytic renal tumor that is now in an optimal ventral position for resection and suturing.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8778464/v1/bc904e02ad617abc9ccb3356.jpeg"},{"id":104740247,"identity":"9c3ea2bf-de28-4c7a-aa70-8c0bc1a2bcda","added_by":"auto","created_at":"2026-03-16 16:16:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2712301,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8778464/v1/c635df75-d383-4287-b70f-d02e0cd0c574.pdf"},{"id":102212913,"identity":"f39790b8-f1a3-448e-b3fc-697638b53b67","added_by":"auto","created_at":"2026-02-09 12:37:20","extension":"doc","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":90624,"visible":true,"origin":"","legend":"","description":"","filename":"STROBECheckliste.doc","url":"https://assets-eu.researchsquare.com/files/rs-8778464/v1/5e0f4d669aa49d52953eb453.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"The ‘Upside-Down’ Technique in Transperitoneal Robotic Partial Nephrectomy: Visual Standardization and Clinical Outcomes in 50 Consecutive Dorsally Located Renal Masses","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe ideal partial nephrectomy (PN) should ensure satisfactory perioperative, functional, and oncological outcomes across all anatomical tumor locations [1]. Robotic partial nephrectomy (RPN), facilitated by advanced robotic surgical platforms, has become the preferred minimally invasive modality. This preference is largely attributed to its enhanced surgical capabilities, lower complication rates, especially in highly complex cases, improved visualization of the operative field, superior ergonomics, and a more favorable learning curve compared with laparoscopic partial nephrectomy (LPN) [2-4]. The transperitoneal approach to renal masses (TPPN) is traditionally used in RPN and offers advantages such as easy trocar placement, a larger working space, and reduces instrument collisions. However, transperitoneal access to dorsally located tumors can be challenging [5]. The retroperitoneal approach (RPPN) is a feasible alternative for accessing dorsal tumors, and studies have shown that, in selected patients, it provides similar or even superior perioperative, functional, and oncological outcomes compared with TPPN [6]. Nevertheless, due to the larger working space and superior anatomical orientation, available data indicate that TPPN is still more commonly applied in patients with larger and more complex tumors [7].\u003c/p\u003e\n\u003cp\u003eAchieving an optimal field of vision and proper kidney positioning for tumor resection and subsequent suturing of the tumor bed are key factors for successful TPPN in complex, dorsally positioned renal masses, particularly those located in the hilar region. With this objective in mind, several surgical techniques have been proposed to facilitate access to dorsally positioned renal tumors. After posterolateral dissection of the perinephric space and opening of Gerota\u0026rsquo;s fascia, Harris et al. proposed anteromedial rotation of the kidney [8]. Alternatively, placement of additional robotic ports in the lumbar region before tumor resection, as suggested by Timsit et al. in their hybrid approach to RPN, may facilitate access to dorsal renal masses [9]. Experimenting with more extensive renal mobilization, Nouralizadeh et al. and Kaplan et al. independently evaluated, in small LPN and RPN case series, a technique involving 180-degree rotation of the kidney around its vascular pedicle to access dorsal upper pole tumors, repositioning them anteriorly and inferiorly to facilitate resection during TPPN [10,11]. At the same time, ventral renal pedicle rotation has been shown to be a safe and feasible approach for treating ventrally located renal masses using RPPN [12,13]. Building on and optimizing this experience, we propose and demonstrate a broader implementation of the 180-degree pedicle rotation technique for the robotic-assisted management of dorsally positioned renal masses in all locations, including hilar tumors, using a transperitoneal approach. Drawing inspiration from kidney transplantation surgery, we have termed this variant of the technique the \u003cem\u003e\u0026ldquo;upside-down\u0026rdquo;\u003c/em\u003e PN.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost commonly used term to describe the primary goals of PN is called\u0026nbsp;Trifecta\u0026nbsp;[14]. A recent multicenter prospective study provided a comprehensive analysis of Trifecta outcomes in 3,449 patients undergoing robotic-assisted partial nephrectomy (RAPN) across various anatomical tumor locations [15]. The overall Trifecta rate, defined as warm ischemia time under 25 minutes, negative surgical margins, and absence of major complications, was 62.4% (2,153 out of 3,449 patients). Notably, the study demonstrated a significantly lower Trifecta rate for hilar tumors (55.0%) compared to non-hilar tumors (64.2%, p \u0026lt; 0.01), highlighting the technical challenges associated with centrally located renal masses.\u003c/p\u003e\n\u003cp\u003eWe hypothesized that the \u003cem\u003e\u0026ldquo;upside-down\u0026rdquo;\u003c/em\u003e technique enables safe and effective resection of dorsally positioned renal tumors in all locations, including hilar masses, using a transperitoneal robotic approach, even during the early phase of its clinical adoption. This study presents a consecutive series of the 50 patients treated with this technique by a single surgeon with longstanding experience in RPN. We anticipated that Trifecta outcomes would be comparable to those reported in recent prospective multicenter trials. Specifically, we expected an overall Trifecta rate in at least two out of three patients, with rates of 60% or higher in hilar tumors and above 70% in non-hilar tumors, reflecting the feasibility and safety of this novel strategy in expert hands.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003eThis single-center retrospective cohort study analyzed data from 50 patients with dorsally located renal masses who underwent robotic-assisted partial nephrectomy via a transperitoneal approach using our \u003cem\u003e\u0026ldquo;upside-down\u0026rdquo;\u003c/em\u003e technique between June 2021 and July 2024. The study was approved by the local ethics committee. All surgeries were performed by a single surgeon with extensive prior experience in robotic partial nephrectomy (RPN).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1 Participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were selected consecutively over a three-year period. Since the introduction of the \u003cem\u003e\u0026ldquo;upside-down\u0026rdquo;\u003c/em\u003e technique in June 2021 in our center (the surgeon was previously experienced in using 180-degree pedicle rotation), all patients with dorsally located renal tumors were assigned to this technique group based on preoperative imaging with contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI). In exceptional cases, the decision to use the \u003cem\u003e\u0026ldquo;upside-down\u0026rdquo;\u003c/em\u003e technique was made intraoperatively if deviations from preoperative imaging were observed. Apart from tumor location, no additional inclusion or exclusion criteria were applied. No control group was included in this study. Short-term follow-up was performed during the hospital stay, \u003cstrong\u003ea 30-day follow-up\u003c/strong\u003e(to collect information on potential complications required to define trifecta outcomes)\u003cstrong\u003e\u0026nbsp;\u003cstrong\u003eas well as a 180-day follow-up were\u0026nbsp;\u003c/strong\u003e\u003c/strong\u003econducted through direct communication with patients or their urologists to obtain relevant clinical information. 180-day follow-up data could not be obtained for five patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2. Study endpoints\u003c/strong\u003e\u003cbr\u003eThe primary endpoint was achievement of the Trifecta outcome using the \u003cem\u003e\u0026ldquo;upside-down\u0026rdquo;\u003c/em\u003e technique. Trifecta outcome was defined as negative surgical margins (R0), no major complications within 30 days postoperatively (Clavien-Dindo classification \u0026ge; 3) and warm ischemia time (WIT) \u0026lt; 25 minutes. Negative surgical margins (R0) were also defined for benign pathology. R0 resection was defined by the pathologist as a complete excision without entry into tumor (no residual lesion). Therefore, the Trifecta outcome could be calculated for the entire cohort.\u003c/p\u003e\n\u003cp\u003eWe also tested the hypothesis that, when using the \u003cem\u003e\u0026ldquo;upside-down\u0026rdquo;\u003c/em\u003e technique, Trifecta outcomes are independent of the PADUA score. Secondary endpoints included: R0 resection rate, WIT, postoperative and 180-day renal function, actual blood loss, Clavien-Dindo complication rates, operative time (OT), and console time. Additional documented variables included: ASA Score, length of hospital stay, hemoglobin levels (pre- and postoperative) and postoperative histology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3. Data collection\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData on patient demographics, clinical characteristics, operative details, and postoperative outcomes were collected from medical records. Preoperative imaging with contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) was performed for all patients. Dorsal tumor location was defined according to the PADUA nephrometry score [16] by reviewing axial CT or MRI slices, with the entire tumor or the bulk of an endophytic mass positioned posterior to the kidney\u0026rsquo;s midline on axial imaging (defined as posterior according to the PADUA nephrometry score). The PADUA nephrometry score, tumor size in centimeters, and tumor location (hilar vs. non-hilar) were assigned by a single experienced radiologist to ensure consistency. Patients were then classified into low-complexity (PADUA 6\u0026ndash;7), moderate-complexity (PADUA 8\u0026ndash;9), and high-complexity (PADUA \u0026ge;10) groups [3,16]. Postoperative and long-term renal function was assessed using serum creatinine values, and estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI formula [17]. Intraoperative blood loss was calculated using the actual blood loss (ABL) method described by McCullough et al. [18] to improve accuracy compared with estimated blood loss (EBL). Postoperative complications were graded using the Clavien-Dindo classification system [19].\u0026nbsp;Data collection was completed after enrollment of 50 consecutive patients in July 2024. This number was considered sufficient to allow statistical analysis of the study endpoints while maintaining the feasibility of complete data collection and follow-up of up to 180 days. The \u003cem\u003e\u0026ldquo;upside-down\u0026rdquo;\u0026nbsp;\u003c/em\u003etechnique continues to be routinely used in clinical practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4. Upside-Down Surgical Technique\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures were performed using the \u003cstrong\u003eda Vinci Xi robotic system\u003c/strong\u003e (Intuitive Surgical Inc., Sunnyvale, CA, USA) with pneumoperitoneum maintained at 15\u0026ndash;20 mmHg. Patients were positioned in the flank position utilizing table flexion to optimize port placement. A 12 mm assistant port was placed near the umbilicus (or lateral to the rectus in obese patients), followed by four 8 mm robotic ports along the midclavicular line below the costal margin. After standard bowel mobilization, the ureter and gonadal vein were identified and traced to the renal hilum. The renal vein and artery were dissected and marked, and 20 mg of intravenous furosemide was administered prior to arterial dissection to prevent spasm. The kidney was then completely mobilized (\u003cstrong\u003eFigure 1\u003c/strong\u003e), and rotated \u003cstrong\u003e180 degrees around the renal pedicle\u003c/strong\u003e to optimize exposure of dorsally located tumors (\u003cstrong\u003eFigure 2\u003c/strong\u003e), a maneuver feasible in all patients with up to three hilar arteries. Intraoperative ultrasonography was used to localize the tumor and define resection margins, which were marked with cautery. The renal artery was clamped with a laparoscopic bulldog clamp through the 12 mm assistant port, leaving the vein open. Correct clamp placement and perfusion were verified using\u003cstrong\u003e\u0026nbsp;\u003cstrong\u003eindocyanine green (ICG)\u003c/strong\u003e,\u003c/strong\u003e ensuring no accessory arteries were missed. Tumor excision was performed using robotic scissors with negative parenchymal margins. Renorrhaphy was completed using 4-0 PDS for deep layers, followed by capsulorrhaphy with 3-0 Vicryl interrupted sutures, secured with Hem-o-lok clips to optimize hemostasis. Absorbable hemostatic gauze (oxidized regenerated cellulose, Tabotamp, Johnson \u0026amp; Johnson) was applied over the defect. The kidney was then rotated back to its normal position, the clamp removed, and perfusion reconfirmed with ICG. Finally, the kidney was retroperitonealized, the specimen retrieved in an entrapment bag, and hemostasis confirmed before placement of a Foley drain.\u003c/p\u003e\n\u003cp\u003eResults are presented as counts (%), means \u0026plusmn; standard deviation, or medians (25\u003csup\u003eth\u003c/sup\u003e\u0026ndash;75\u003csup\u003eth\u0026nbsp;\u003c/sup\u003epercentile), depending on data type and distribution. Groups were compared using parametric tests (t-test, ANOVA) and nonparametric tests (Chi-square test, Fisher\u0026rsquo;s exact test, Fisher\u0026ndash;Freeman\u0026ndash;Halton test, Mantel\u0026ndash;Haenszel test for trend, Mann\u0026ndash;Whitney U test, and Kruskal\u0026ndash;Wallis test), as appropriate for data type and distribution. Data distribution was assessed using descriptive statistics, graphical methods (histograms, boxplots, and Q\u0026ndash;Q plots), and tests (Shapiro\u0026ndash;Wilk) methods. Continuous variables (age and BMI) were dichotomized using predefined cutoffs (BMI 25 kg/m\u0026sup2;) or the median value (age) to improve interpretability of the modeling predictors. Logistic regression analyses were performed to evaluate the association between the dependent variable (trifecta outcome) and independent variables, which were predefined based on clinical experience or selected using a p-value \u0026lt; 0.2. Modeling was conducted in two steps: univariable analysis (one predictor per model) and multivariable analysis (all relevant predictors included simultaneously). The total sample size was 50, with 39 subjects achieving trifecta, which limited the number of predictors included in the multivariable model. Therefore, the multivariable model included four predictors, following the rule of 10 events per predictor. All p-values \u0026lt; 0.05 were considered statistically significant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven the limited number of events, the multivariable model should be interpreted as exploratory and is primarily intended for hypothesis generation.\u003c/p\u003e\n\u003cp\u003eAt the 180-day follow-up, data were available for 45 patients (5 missing). Analyses of 180-day outcomes, including tumor recurrence and renal function parameters, were performed only in patients with available data.\u003c/p\u003e\n\u003cp\u003eAll analyses were performed using SPSS 31.0 (IBM Corp. Released 2023. IBM SPSS Statistics for Windows, Version 29.0. Armonk, NY: IBM Corp.) and R 4.5.0. (R Core Team (2017). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/.).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.6. STROBE Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is reported in accordance with the \u003cstrong\u003eSTROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines\u003c/strong\u003e for cohort studies. The design, participant selection, data collection, study variables, endpoints, and statistical methods were structured to ensure transparency, reproducibility, and completeness of reporting.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 50 patients successfully underwent transperitoneal robotic-assisted partial nephrectomy using the \u0026nbsp;\u003cem\u003e\u0026ldquo;upside-down\u0026rdquo;\u003c/em\u003e technique, without the need for conversion or additional port placement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on the PADUA score, patients were classified as low (20%), moderate (36%), or high complexity (44%), with high-complexity tumors predominating. No statistically significant differences were observed among PADUA groups in preoperative characteristics, including sex, age, BMI, ASA score, prior abdominal surgery, tumor laterality, preoperative creatinine levels, or maximal tumor size (mean 4.0 \u0026plusmn; 1.5 cm). Malignant histology was identified in 68% of cases, most commonly clear cell renal cell carcinoma. Among malignant tumors, the predominant postoperative stage was pT1a, although pT1b disease was present in 35.3% of patients (\u003cstrong\u003eTable 1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e General characteristics of participants.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 104px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003ePADUA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eLow (n=10)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003eModerate (n=18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003eHigh (n=22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003eSex\u0026nbsp;(male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e32 (64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e6 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e9 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e17 (77.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.194\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e67\u0026plusmn;15.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e69\u0026plusmn;11.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e70.78\u0026plusmn;13.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e63\u0026plusmn;17.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.258\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003eBMI\u0026nbsp;(kg/m2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e29.1\u0026plusmn;6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e28.7\u0026plusmn;7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e29.7\u0026plusmn;7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e28.8\u0026plusmn;6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.896\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003eASA score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e5 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e2 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e3 (13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.879\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e33 (66%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e8 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e11 (61.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e14 (63.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e12 (24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e5 (27.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e5 (22.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003eHilar tumor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e18 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e5 (27.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e13 (59.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.004\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003ePAO*\u0026nbsp;(yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e18 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e6 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e9 (40.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.800\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003eTumor side\u0026nbsp;(right)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e26 (52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e5 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e9 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e12 (54.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.950\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003eMax. tumor size\u0026nbsp;(cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e4\u0026plusmn;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e3.8\u0026plusmn;1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e3.4\u0026plusmn;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e4.6\u0026plusmn;1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.053\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003eTumor histopathology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Clear cell RCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e26 (52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e3 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e12 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e11 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Papillary RCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e4 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e2 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e2 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Chromophobe RCC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e4 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e1 (5.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e3 (13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Oncocytoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e4 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e2 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e1 (5.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e1 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Angiomyolipoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e3 (13.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Renal sarcoma**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e1 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Nephritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Renal cyst\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e7 (14%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e4 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e2 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e1 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 239px;\"\u003e\n \u003cp\u003epT stage\u0026nbsp;(among malignant tumors)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; pT1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e21 (61.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e3 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e11 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e7 (43.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e0.25\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; pT1b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e12 (35.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e4 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e8 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; pT2b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (2.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e1 (6.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eResults are presented as count (%), means \u0026plusmn; standard deviation, or medians (25th\u0026ndash;75th\u0026nbsp;percentile) depending on data type and distribution\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e*PAO \u0026ndash; Previous abdominal operation\u003c/p\u003e\n\u003cp\u003e**For this patient, the pT stage was not provided postoperatively by the pathologist; only the R0 resection status was reported.\u003c/p\u003e\n\u003cp\u003eThe mean OT (skin incision to closure) was 148.6 \u0026plusmn; 29.3 minutes, with a console time of 69.7 \u0026plusmn; 6.9 minutes, without significant differences among PADUA complexity groups. The mean warm ischemia time was 23.1 \u0026plusmn; 6.0 minutes and was significantly longer in the high-complexity group (\u003cstrong\u003eTable 2\u003c/strong\u003e). The average ABL was 158 mL.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Laboratory findings, intraoperative data and postoperative course.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ePADUA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eLow (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eModerate (n=18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eHigh (n=22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eLaboratory\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Creatinine Preop. (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e71.6 (29.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e56.6 (24.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0.88 (0.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e77.8 (47.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.155\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Creatinine Postop. 1D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e102.5 (39.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e84.9 (21.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e114.0 (62.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e113.0 (30.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.052\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Creatinine Postop. 5D*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e91.9 (33.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e80.4 (8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e104.3 (53.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e99.8 (55.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.007\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;% of change (5D-Preop.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e+42.1 (47.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e+40.7 (53.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e+33.8 (36.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e+50.1 (80.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.136\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; eGFR Preop. (mL/min/1.73 m\u0026sup2;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e90 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e90 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e82.6 (46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e90 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.027\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; eGFR Postop. 1D\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e58.75 (26.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e69.25 (31.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e46.8 (33.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e59.25 (19.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.119\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; eGFR Postop. 5D*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e64.8 (37.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e82.5 (25.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e56.4 (43.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e65.65 (37.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.060\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;% of change (5D-Preop.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e-23.0 (26.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-4.1 (26.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e-17.7 (25.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e-26.9 (28.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.056 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Hb Preop. (g/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e140.2\u0026plusmn;17.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e139.3\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e140.3\u0026plusmn;17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e140.4\u0026plusmn;18.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.985\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Hb Postop. 1D\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e125.3\u0026plusmn;17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e127.7\u0026plusmn;16.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e124.1\u0026plusmn;19.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e125.3\u0026plusmn;17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.875\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;% of change (1D-Preop.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e-10.6\u0026plusmn;5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-8.3\u0026plusmn;3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e-11.8\u0026plusmn;6.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e-10.7\u0026plusmn;5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.292\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003ePostop. Complications**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Infection\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e3 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1 (5.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.788\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Urinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e3 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1 (5.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.000\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Transfusion\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e3 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1 (5.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.000\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Clavien-Dindo grade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e42 (84%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e9 (90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e14 (77.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e19 (86.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.671\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e5 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e1 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e3 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e3 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e1 (5.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2 (9.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eConsole time\u0026nbsp;(min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e69.7\u0026plusmn;6.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e66.3\u0026plusmn;6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e69.1\u0026plusmn;4.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e71.7\u0026plusmn;8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.111\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eWIT\u0026nbsp;(min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003e23.1\u0026plusmn;5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp\u003e20\u0026plusmn;4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003e21.8\u0026plusmn;3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e25.5\u0026plusmn;7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e0.032\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eOperation time\u0026nbsp;(min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e148.6\u0026plusmn;29.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e130.1\u0026plusmn;26.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e149.8\u0026plusmn;31.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e156.1\u0026plusmn;26.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.064\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eHospital stay\u0026nbsp;(days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e6.4\u0026plusmn;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e5.9\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e6.4\u0026plusmn;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e6.5\u0026plusmn;2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.726\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eResults are presented as count (%), means \u0026plusmn; standard deviation, or medians (25th\u0026ndash;75th\u0026nbsp;percentile) depending on data type and distribution\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e*\u003cem\u003e5D \u0026ndash; fifth postoperative day, or the day of discharge for patients discharged before the fifth hospital day.\u003c/em\u003e\u003c/em\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e**Complications observed in the postoperative period up to 30 days after surgery (as part of the trifecta criteria).\u003c/p\u003e\n\u003cp\u003eNegative surgical margins (R0) were achieved in all cases. Major postoperative complications (Clavien\u0026ndash;Dindo grade \u0026ge; 3) occurred in three patients, all of whom developed urinomas within the 30-day follow-up period. These were successfully managed with double-J stent placement, with stent removal 12 weeks after resolution. No additional complications related to the operation were identified between the 30- and 180-day follow-up periods.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo intraoperative hilar vessel injury or postoperative, 30- or 180-day adverse events, including infarction or vessel thrombosis, occurred as a result of the 180\u0026deg; pedicle rotation. Postoperative and 180-day follow-up of renal function (\u003cstrong\u003eTable 3\u003c/strong\u003e) demonstrated successful preservation of kidney function, with no statistically significant differences in measured parameters (eGFR and creatinine) across PADUA complexity groups, except for discharge-day creatinine levels, which were significantly higher in the moderate- and high-complexity groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e Trifecta outcome and 6 months follow up outcomes.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 84px;\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003ePADUA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eLow (n=10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003eModerate (n=18/15*)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003eHigh (n=22/20*)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eTrifecta achieved\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e39 (78%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e10 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e16 (88.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e13 (59.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.006\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e180-day follow up*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 103px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Tumor recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1 (2.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e1.000\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eeGFR (mL/min/1.73 m\u0026sup2;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e82.7 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e81.8 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e82 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e87.5 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.897\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 189px;\"\u003e\n \u003cp\u003eCreatinine (mg/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 84px;\"\u003e\n \u003cp\u003e82.2 (17.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 87px;\"\u003e\n \u003cp\u003e78.7 (20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 103px;\"\u003e\n \u003cp\u003e83.9 (17.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 94px;\"\u003e\n \u003cp\u003e81.3 (20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.914\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eResults are presented as count (%), means \u0026plusmn; standard deviation, or medians (25th\u0026nbsp;\u0026ndash; 75th\u0026nbsp;percentile) depending on data type and distribution\u003c/p\u003e\n\u003cp\u003e*For 180-day follow-up, data were available for 45 patients in total (5 missing: 3 in the moderate-complexity PADUA group, 2 in the high-complexity PADUA group).\u003c/p\u003e\n\u003cp\u003eTrifecta outcomes were achieved in 78% of patients overall and in 61% of those with hilar tumor location. Trifecta outcome was significantly associated with PADUA score, with high-complexity tumors showing a \u003cstrong\u003estatistically significantly lower outcome rate\u003c/strong\u003e compared with low- and moderate-complexity tumors, combined as a single group (59.1% vs. 92.9%; OR 0.111, 95% CI 0.021\u0026ndash;0.591).\u003c/p\u003e\n\u003cp\u003eOn univariable analysis, reduced Trifecta outcome was significantly associated with hilar tumor location (OR 0.224, 95% CI 0.055\u0026ndash;0.922) and larger maximal tumor size (per cm increase) (OR 0.943, 95% CI 0.896\u0026ndash;0.991), whereas higher BMI (per kg/m\u003csup\u003e2\u0026nbsp;\u003c/sup\u003eincrease) was paradoxically linked to improved outcomes (OR 4.455, 95% CI 1.085\u0026ndash;18.294). In multivariable analysis adjusting for age, BMI, hilar location, and tumor size, hilar tumor location remained a strong predictor of reduced Trifecta outcome (OR 0.088, 95% CI 0.013\u0026ndash;0.582; \u003cstrong\u003eTable 4\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e. Trifecta outcome modeling.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"612\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Trifecta achieved\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eUnivariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eMultivariable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003eYes (n=39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003eNo (n=11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eOR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eOR (95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e24 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e8 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.724\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e15 (83.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e3 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1.667 (0.381; 7.288)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e68.7\u0026plusmn;12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e60.9\u0026plusmn;22.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.301\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026lt;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e19 (73.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e7 (26.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.382\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ge;70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e20 (83.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e4 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1.842 (0.464; 7.320)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e3.458 (0.609; 19.639)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eBMI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e29.4\u0026plusmn;6.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e27.9\u0026plusmn;8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.599\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026le;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e11 (61.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e7 (38.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.041\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026gt;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e28 (87.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e4 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e4.455 (1.085; 18.294)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e9.576 (1.336; 68.635)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eHilar Tumor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e28 (87.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e4 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.041\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e11 (61.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e7 (38.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.224 (0.055; 0.922)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e0.088 (0.013; 0.582)*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eASA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e3 (60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e2 (40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.386\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1.771 (0.524; 5.985)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e26 (78.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e7 (21.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e10 (83.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e2 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eMax. Tu size (cm)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e3.69\u0026plusmn;1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e4.97\u0026plusmn;1.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.032\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.943 (0.896; 0.991)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1.220 (0.208; 7.162)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003ePAO**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e24 (75%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e8 (25%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.724\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e15 (83.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e3 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e1.667 (0.381; 7.288)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003ePADUA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e9 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e10 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.002\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Low\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e10 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.006\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.146 (0.032; 0.673)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Moderate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e16 (88.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e2 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;High\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e13 (59.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e9 (40.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003ePADUA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Low/Mod\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e26 (92.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e2 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.006\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;High\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e13 (59.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 78px;\"\u003e\n \u003cp\u003e9 (40.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003e0.111 (0.021; 0.591)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eResults are presented as count (%) or means \u0026plusmn; SD; Continuous variables are expressed per unit increase: age per 1 year, BMI per 1 kg/m\u0026sup2;, and tumor size per 1 cm\u003c/p\u003e\n\u003cp\u003e**PAO - Previous abdominal operations\u003c/p\u003e\n\u003cp\u003e*p \u0026lt; 0.05 in model\u003c/p\u003e\n\u003cp\u003eRegression analysis: Univariable analysis \u0026ndash; each variable separately in model; Multivariable analysis \u0026ndash; all significant predictors in univariable analysis together in model.\u003c/p\u003e"},{"header":"Discussion ","content":"\u003cp\u003eWhen comparing the outcomes of our technique with previously published data, it is important to acknowledge differences in baseline tumor characteristics. Our cohort was dominated by high-complexity renal masses, with larger mean tumor size and a higher proportion of T1b tumors than reported in most RPN series [15, 20-22]. These characteristics underscore the technical difficulty of the cases included and suggest potential advantages of this technique when managing complex, dorsally located renal tumors.\u003c/p\u003e\n\u003cp\u003eSince its introduction by Hung et al. [14], the Trifecta concept has become a widely accepted benchmark for comparing PN outcomes. Reported Trifecta achievement rates vary considerably across studies, ranging from 32% to 81% [23], reflecting differences in patient selection, tumor complexity, and surgical approach. A recent multicenter prospective study reported a Trifecta rate of 55% for centrally located tumors compared with 64.2% for non-hilar tumors, highlighting the increased technical demands of hilar tumors [15]. In our cohort, Trifecta outcomes were achieved in 78% of patients overall and in 61% of patients with hilar tumors. Hilar tumor location remained an independent predictor of reduced Trifecta achievement in multivariable analysis. This finding contrasts with some recent published data but is consistent with the known technical challenges associated with hilar tumor location [15, 24]. The PADUA score has been consistently identified as an independent predictor of Trifecta outcomes, with predictive performance comparable to other nephrometry systems such as RENAL [25]. In our study, the PADUA score remained an independent predictor of achieving Trifecta outcome, indicating that the proposed technique does not eliminate the impact of tumor complexity. Nevertheless, patients with high PADUA scores achieved Trifecta outcomes in 59.1% of cases, which is higher than reported in comparable cohorts with similar tumor complexity [26]. The influence of body mass index (BMI) on Trifecta achievement remains controversial. A recent retrospective study including 296 patients stratified by BMI (\u0026lt;25, 25–\u0026lt;30, and ≥30 kg/m²) found no significant association between BMI and Trifecta outcomes [27]. In contrast, our multivariable analysis demonstrated a positive association between BMI \u0026gt;25 kg/m² and Trifecta outcomes. This finding may reflect residual confounding or sample size limitations. However, several studies have described an inverse association between obesity and adverse perioperative outcomes in kidney surgery, commonly referred to as the “obesity paradox.” Yoo et al. reported that obese patients tended to be younger and present with smaller tumors and lower T stage [28]. Subgroup analyses accounting for these potential confounders were not performed in the present study and represent a limitation.\u003c/p\u003e\n\u003cp\u003eDorsal renal tumors pose unique technical challenges, and both transperitoneal (TP) and retroperitoneal (RP) approaches have inherent advantages and disadvantages. While the TP approach offers a larger working space, familiar anatomy, and versatile access, multiple studies suggest inferior performance compared with the RP approach when treating posteriorly located tumors. The RP approach provides direct access to the dorsolateral kidney side and renal artery, which has been associated with shorter OT [29]. However, this advantage diminishes when managing anterior tumors [28]. Importantly, RPPN and TPPN have been shown to yield comparable postoperative, functional, and oncologic outcomes for posterolateral tumors [20,21,30,31]. The OT in our series (148.6 ± 29.3 minutes), including a console time of 69.7 ± 6.9 minutes, is comparable to published RPPN data and generally shorter than reported TPPN series [22, 32]. Mjaess et al. reported [22] mean OT of 123 minutes for RPPN and 171 minutes for TPPN, while Harke et al. [33] demonstrated mean OT of 119 minutes and 139 minutes, respectively, in a multicenter matched-pair analysis of 754 patients. Other RPPN series focusing on posterior tumors reported OT ranging from approximately 157 to 160 minutes [34,35]. WIT in our cohort was comparable to published data for complex renal masses treated with TPPN, typically ranging from 17 to 27 minutes [34,35]. Estimated blood loss was calculated using postoperative hemoglobin-based algorithms rather than intraoperative estimates, limiting direct comparison with other studies. No positive surgical margins were observed in our cohort, consistent with most TPPN series [32] and favorable compared with reported RPPN positive margin rates ranging from 2.8% to 16% [32]. The rate of major complications (Clavien–Dindo grade ≥3) was 6%, which aligns with contemporary robotic PN literature [32]. The absence of a contemporaneous control group undergoing standard RPPN or TPPN represents an additional limitation when interpreting perioperative outcomes.\u003c/p\u003e\n\u003cp\u003eWhen compared with small laparoscopic [10] and robotic [11] PN case series describing 180° renal pedicle rotation, our results demonstrate shorter OT (148 minutes \u003cem\u003evs.\u003c/em\u003e 206 minutes for laparoscopic, and 242.6 minutes for robotic series) and comparable WIT. These comparisons should be interpreted cautiously due to the very small sample sizes in prior studies as well as advancements in robotic technology. It is also important to note that, compared to these two case series, our cohort employed a more radical approach to the implementation of 180° renal pedicle rotation, attempting to use it as a standard method for managing dorsal tumors at all locations, including hilar tumors. This differs from previous reports, which applied this rotation primarily to optimize access to upper pole dorsal tumors only [10, 11].\u003c/p\u003e\n\u003cp\u003eConcerns regarding 180° renal pedicle rotation include potential vascular injury and postoperative renal dysfunction. No vascular complications or pedicle-related injuries were observed in our series. Similar findings have been reported by Liang et al. and Song et al., who concluded that pedicle rotation is a safe maneuver to improve tumor exposure during retroperitoneal approach [36,37]. Postoperative renal functional outcomes further support the safety of our technique. The mean postoperative eGFR reduction of 23% is consistent with published PN data [38,39]. Long-term renal function has been shown to depend primarily on patient-related factors such as age, diabetes, and baseline renal function rather than tumor complexity [40]. In accordance with these findings, 180-day renal function in our cohort did not differ significantly across PADUA score groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTumor recurrence was observed in only one patient (2.3%) after a 180-day follow-up period. Similar recurrence-free survival rates have been reported in other RPN studies [2], but over much longer follow-up periods. Due to the limited follow-up in our study, no reliable conclusions can be drawn regarding recurrence-free or disease-specific survival.\u003c/p\u003e\n\u003cp\u003eThis study should be interpreted in light of its limitations, including its single-center design, relatively small sample size, and absence of a control group. These factors may limit generalizability and introduce residual confounding. Nevertheless, the consistent perioperative, oncologic, and functional outcomes observed in a cohort enriched with high-complexity dorsal renal tumors suggest that this technique is a safe and effective option. The \u003cem\u003e“upside down”\u003c/em\u003e technique maintains advantages of TPPN, including the larger working space and a superior anatomical orientation, thus providing a framework to create single access to reach and successfully treat all types and locations of complex renal masses, avoiding suboptimal vision and reach leading to prolonged operating time, complications and the need for conversion. This study demonstrates the practical, visually reproducible workflow of the technique, providing a structured guide for centers managing complex dorsal renal tumors via a transperitoneal approach.\u003c/p\u003e"},{"header":"Statements and Declarations","content":"\u003cp\u003e\u003cstrong\u003e2.1 Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Author Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Amr Ahmed, Aleksa Zubelic and Ivan Soldatovic. The first draft of the manuscript was written by Amr Ahmed and Aleksa Zubelic and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Ethics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the\u0026nbsp;\u003c/em\u003e\u003cstrong\u003eEthics Committee of the Medical Association of Hesse (Landesärztekammer Hessen)\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e Frankfurt am Main, Germany (protocol code 2025-4314-evBO). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4 Consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted using fully anonymized data. The Ethics Committee did not require informed consent for individual cases; therefore, it was waived. No identifying patient information is presented. All visual materials are anonymized, contain no patient-identifiable features, and all metadata, names, dates, and other identifiers have been removed.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWang L, Deng JY, Liang C, Zhu PY (2023) Perioperative, functional, and oncological outcomes of robotic vs laparoscopic partial nephrectomy for complex renal tumors (RENAL score\u0026thinsp;\u0026ge;\u0026thinsp;7): an evidence-based analysis. Front Oncol 13:1195910. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fonc.2023.1195910\u003c/span\u003e\u003cspan address=\"10.3389/fonc.2023.1195910\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee S, Ryu H, Lee JW (2021) Open partial nephrectomy vs robot-assisted partial nephrectomy for a renal tumor larger than 4 cm: a propensity score matching analysis. J Korean Med Sci 36:e120. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3346/jkms.2021.36.e120\u003c/span\u003e\u003cspan address=\"10.3346/jkms.2021.36.e120\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu S, Zhang B, Weng B, Liu X, Hou S (2024) Comparison of robotic-assisted and laparoscopic partial nephrectomy based on the PADUA score and the predictive value of the PADUA and Mayo Adhesive Probability scores for postoperative complications: a single-center retrospective study. J Cancer Res Clin Oncol 151:1. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00432-024-05771-1\u003c/span\u003e\u003cspan address=\"10.1007/s00432-024-05771-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahmud H, Haitovic B, Zilberman DE, Rosenzweig B, Laufer M, Portnoy O, Fridman E, Dotan ZA (2024) Robotic partial nephrectomy is associated with a significantly decreased rate of postoperative pseudoaneurysm compared to open and laparoscopic partial nephrectomy. J Robot Surg 18:241. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11701-024-01999-3\u003c/span\u003e\u003cspan address=\"10.1007/s11701-024-01999-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu D, Shao X, Guo G, Zhang N, Shi T, Wang Y, Gu L (2021) Comparison of outcomes between transperitoneal and retroperitoneal robotic partial nephrectomy: a meta-analysis based on comparative studies. Front Oncol 10:592193. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fonc.2020.592193\u003c/span\u003e\u003cspan address=\"10.3389/fonc.2020.592193\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRong RZ, Zhang P, Zhao M, He CE (2025) Transperitoneal vs retroperitoneal robotic partial nephrectomy: a meta-analysis and systematic review of propensity-matched studies. J Robot Surg 19:56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11701-025-02003-4\u003c/span\u003e\u003cspan address=\"10.1007/s11701-025-02003-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou J, Liu ZH, Cao DH, Peng ZF, Song P, Yang L, Liu LR, Wei Q, Dong Q (2021) Retroperitoneal or transperitoneal approach in robot-assisted partial nephrectomy: which one is better? Cancer Med 10:3299\u0026ndash;3308. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/cam4.3895\u003c/span\u003e\u003cspan address=\"10.1002/cam4.3895\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarris KT, Ball MW, Gorin MA, Curtiss KM, Pierorazio PM, Allaf ME (2014) Transperitoneal robot-assisted partial nephrectomy: a comparison of posterior and anterior renal masses. J Endourol 28:655\u0026ndash;659. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/end.2013.0608\u003c/span\u003e\u003cspan address=\"10.1089/end.2013.0608\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTimsit MO, Terrier N, Toinet T, Dariane C, Debedde E, Panthier F, Thiounn N, Audenet F, M\u0026eacute;jean A (2022) Posterior transperitoneal robot-assisted partial nephrectomy in the treatment of renal tumors: feasibility of a hybrid approach. Prog Urol 32:217\u0026ndash;225. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.purol.2022.01.002\u003c/span\u003e\u003cspan address=\"10.1016/j.purol.2022.01.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaplan JR, Chang P, Percy AG, Wagner AA (2013) Renal transposition during minimally invasive partial nephrectomy: a safe technique for excision of upper pole tumors. J Endourol 27:1096\u0026ndash;1100. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/end.2013.0225\u003c/span\u003e\u003cspan address=\"10.1089/end.2013.0225\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNouralizadeh A, Ziaee SA, Basiri A, Simforoosh N, Abdi H, Mahmoudnejad N, Kashi AH (2009) Transperitoneal laparoscopic partial nephrectomy using a new technique. Urol J 6:176\u0026ndash;181\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHua M, Liu W, Wang C, Xiao C, Shi H, Yang Y, Wu H, Pang Q, Zhang W, Yang Q (2023) Trans-retroperitoneal laparoscopic partial nephrectomy for posterior hilar tumor: technical feasibility and preliminary results. Transl Androl Urol 12:1638. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21037/tau-23-646\u003c/span\u003e\u003cspan address=\"10.21037/tau-23-646\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYin X, Jiang S, Shao Z, Lu Y, Guo J, Xiao Y, Zhu X, Yu H, Ma H, Yang Y, Gao J (2020) Kidney ventral rotation technique in retroperitoneal robot-assisted partial nephrectomy for posterior hilar tumor. World J Surg Oncol 18:148. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12957-020-01928-2\u003c/span\u003e\u003cspan address=\"10.1186/s12957-020-01928-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHung AJ, Cai J, Simmons MN, Gill IS (2013) Trifecta in partial nephrectomy. J Urol 189:36\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.juro.2012.09.042\u003c/span\u003e\u003cspan address=\"10.1016/j.juro.2012.09.042\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarkis J, Champy CM, Doumerc N et al (2024) Robot-assisted partial nephrectomy for hilar and nonhilar renal masses: results from a multicentre prospective cohort (NEPRAH Study, UroCCR 175). Eur Urol Oncol 7:1487\u0026ndash;1496. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.euo.2024.06.003\u003c/span\u003e\u003cspan address=\"10.1016/j.euo.2024.06.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFicarra V, Novara G, Secco S et al (2009) Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours. Eur Urol 56:786\u0026ndash;793. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.eururo.2009.07.040\u003c/span\u003e\u003cspan address=\"10.1016/j.eururo.2009.07.040\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevey AS, Stevens LA, Schmid CH et al (2009) A new equation to estimate glomerular filtration rate. Ann Intern Med 150:604\u0026ndash;612. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7326/0003-4819-150-9-200905050-00006\u003c/span\u003e\u003cspan address=\"10.7326/0003-4819-150-9-200905050-00006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCullough TC, Roth JV, Ginsberg PC, Harkaway RC (2004) Estimated blood loss underestimates calculated blood loss during radical retropubic prostatectomy. Urol Int 72:13\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1159/000075264\u003c/span\u003e\u003cspan address=\"10.1159/000075264\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDindo D, Demartines N, Clavien PA (2004) Classification of surgical complications. Ann Surg 240:205\u0026ndash;213. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.sla.0000133083.54934.ae\u003c/span\u003e\u003cspan address=\"10.1097/01.sla.0000133083.54934.ae\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eK\u0026auml;lble S, Engelmann SU, Schrutz H et al (2025) Randomised controlled feasibility trial of retroperitoneal vs transperitoneal robot-assisted partial nephrectomy: the ROPARN study. BJU Int 135:977\u0026ndash;986. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/bju.16342\u003c/span\u003e\u003cspan address=\"10.1111/bju.16342\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGe S, Chen L, Tai S (2021) Comparison of therapeutic effects among different surgical approaches in robot-assisted partial nephrectomy: a systematic review and meta-analysis. J Endourol 35:623\u0026ndash;632. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/end.2020.0876\u003c/span\u003e\u003cspan address=\"10.1089/end.2020.0876\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMjaess G, Bernhard JC, Khene ZE, Doumerc N, Vaessen C, Henon F, Bruyere F, Brenier M, Parier B, Albisinni S, Ingels A (2023) Retroperitoneal vs transperitoneal robotic partial nephrectomy: a multicenter propensity-score matching analysis (PADORA Study-UroCCR 68). Minerva Urol Nephrol 75:434\u0026ndash;442. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.23736/S2724-6051.23.05119-6\u003c/span\u003e\u003cspan address=\"10.23736/S2724-6051.23.05119-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSri D, Thakkar R, Patel HR, Lazarus J, Berger F, McArthur R, Lavigueur-Blouin H, Afshar M, Fraser-Taylor C, Le Roux P, Liban J (2021) Robotic-assisted partial nephrectomy and standardization of outcome reporting: a prospective observational study on reaching the trifecta and pentafecta. J Robot Surg 15:571\u0026ndash;577. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11701-020-01169-1\u003c/span\u003e\u003cspan address=\"10.1007/s11701-020-01169-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiyake H, Hinata N, Imai S, Furukawa J, Tanaka K, Fujisawa M (2015) Partial nephrectomy for hilar tumors: comparison of conventional open and robot-assisted approaches. Int J Clin Oncol 20:808\u0026ndash;813. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10147-014-0789-0\u003c/span\u003e\u003cspan address=\"10.1007/s10147-014-0789-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEgen L, Kowalewski KF, Riffel P, Honeck P, Kriegmair MC (2021) Nephrometry scores: can preoperative assessment of sectional imaging really mirror intraoperative renal tumor anatomy? Urol Int 105:108\u0026ndash;117. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1159/000510684\u003c/span\u003e\u003cspan address=\"10.1159/000510684\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaramık K, Aktaş Y, Erdemir AG, İslamoğlu E, \u0026Ouml;l\u0026ccedil;\u0026uuml;c\u0026uuml; MT, \u0026Ouml;zsoy \u0026Ccedil;, Savaş M, Ateş M (2021) Predicting strict trifecta outcomes after robot-assisted partial nephrectomy: comparison of RENAL, PADUA, and C-index scores. J Kidney Cancer VHL 8:1\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.15586/jkcvhl.v8i4.183\u003c/span\u003e\u003cspan address=\"10.15586/jkcvhl.v8i4.183\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOhsugi H, Ikeda J, Takayasu K, Takizawa N, Taniguchi H, Yanishi M, Kinoshita H (2024) Trifecta outcomes of robotic partial nephrectomy in obese patients. Int J Urol 31:1108\u0026ndash;1113. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/iju.15529\u003c/span\u003e\u003cspan address=\"10.1111/iju.15529\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoo HJ, Kim SI, Kim SJ, Won I, Cho DS (2023) Prognostic significance of body mass index in patients undergoing nephrectomy for nonmetastatic renal cell carcinoma. J Urol Oncol 21:88\u0026ndash;94. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.22465/juo.224400480024\u003c/span\u003e\u003cspan address=\"10.22465/juo.224400480024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSocarr\u0026aacute;s MR, Elbers JR, Rivas JG, Autran AM, Esperto F, Tortolero L, Carrion DM, Sancha FG (2021) Retroperitoneal robot-assisted partial nephrectomy: surgical technique and review. Curr Urol Rep 22:33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11934-021-01042-0\u003c/span\u003e\u003cspan address=\"10.1007/s11934-021-01042-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarbonara U, Eun D, Derweesh I, Capitanio U, Celia A, Fiori C, Checcucci E, Amparore D, Lee J, Larcher A, Patel D (2021) Retroperitoneal versus transperitoneal robot-assisted partial nephrectomy for posterolateral renal masses: an international multicenter analysis. World J Urol 39:4175\u0026ndash;4182. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00345-021-03672-0\u003c/span\u003e\u003cspan address=\"10.1007/s00345-021-03672-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTao M, Cheng K, Xu W, Qian Z, Pan P (2024) Comparison of the effects of transperitoneal and retroperitoneal robot-assisted partial nephrectomy. Pak J Med Sci 40:2202. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.12669/pjms.40.10.9286\u003c/span\u003e\u003cspan address=\"10.12669/pjms.40.10.9286\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHinata N, Murakami S, Nakano Y, Hara I, Kondo T, Hamamoto S, Shiroki R, Nagayama J, Kawakita M, Eto M, Ukimura O (2024) Efficacy of robot-assisted partial nephrectomy compared with laparoscopic partial nephrectomy for completely endophytic renal tumors. Int J Clin Oncol 29:1548\u0026ndash;1556. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10147-024-02427-4\u003c/span\u003e\u003cspan address=\"10.1007/s10147-024-02427-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarke NN, Darr C, Radtke JP, von Ostau N, Schiefelbein F, Eraky A, Hamann C, Szarvas T, Hadaschik BA, Tropmann-Frick M, Juenemann KP (2021) Retroperitoneal versus transperitoneal robotic partial nephrectomy: a multicenter matched-pair analysis. Eur Urol Focus 7:1363\u0026ndash;1370. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.euf.2020.05.007\u003c/span\u003e\u003cspan address=\"10.1016/j.euf.2020.05.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoga MS, Ates M (2021) Retroperitoneal robot-assisted laparoscopic partial nephrectomy for posterior renal tumors: technique and early outcomes. Int J Clin Pract 75:e13851. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/ijcp.13851\u003c/span\u003e\u003cspan address=\"10.1111/ijcp.13851\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkhawere KE, Rich JM, Ucpinar B, Beksac AT, Saini I, Deluxe A, Zuluaga L, Eun DD, Bhandari A, Hemal AK, Porter J (2023) Comparison of outcomes between transperitoneal and retroperitoneal robotic-assisted partial nephrectomy in patients with completely endophytic kidney tumors. Urol Oncol 41:111e1\u0026ndash;111e8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.urolonc.2022.11.011\u003c/span\u003e\u003cspan address=\"10.1016/j.urolonc.2022.11.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiang YH, Zu XB, Cheng X, Liu LF (2017) Retroperitoneal laparoscopic partial nephrectomy with renal pedicle rotation for ventral renal tumors. J Peking Univ Health Sci 49:608\u0026ndash;612\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSong S, Zhang H, Ma L, Huang Y, Zhao L, Wang G, Lu J, Zhang S (2015) Application of renal pedicle rotation in retroperitoneal laparoscopic partial nephrectomy for ventral renal tumors. J Endourol 29:1038\u0026ndash;1043. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1089/end.2015.0064\u003c/span\u003e\u003cspan address=\"10.1089/end.2015.0064\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShin TY, Han H, Min HS, Cho H, Kim S, Park SY, Kim HJ, Kim JH, Lee YS (2023) Prediction of postoperative creatinine levels by artificial intelligence after partial nephrectomy. Medicina 59:1402. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/medicina59081402\u003c/span\u003e\u003cspan address=\"10.3390/medicina59081402\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang Z, Liu C, Chen R, Liu S, Feng C, Yu K, Zeng X (2018) Renal function outcomes following laparoscopic partial nephrectomy: impact of baseline eGFR, warm ischemia time, and RENAL nephrometry score. Urol Oncol 36:498e15\u0026ndash;498e21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.urolonc.2018.07.005\u003c/span\u003e\u003cspan address=\"10.1016/j.urolonc.2018.07.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoussel E, Laenen A, Bhindi B, De Dobbeleer A, Stichele AV, Verbeke L, Van Cleynenbreugel B, Sprangers B, Beuselinck B, Van Poppel H, Joniau S, Albersen M (2023) Predicting short- and long-term renal function following partial and radical nephrectomy. Urol Oncol 41:110e1\u0026ndash;11110. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.urolonc.2022.10.006\u003c/span\u003e\u003cspan address=\"10.1016/j.urolonc.2022.10.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"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":"partial nephrectomy, upside-down, dorsal kidney tumors, robotic-assisted","lastPublishedDoi":"10.21203/rs.3.rs-8778464/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8778464/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAn ideal partial nephrectomy (PN) should achieve optimal perioperative, functional, and oncological outcomes. We adapted a robotic-assisted transperitoneal technique for the management of dorsally positioned renal masses across all tumor locations. Drawing inspiration from kidney transplantation surgery, we have termed this technique the “\u003cem\u003eupside-down\u003c/em\u003e” PN.\u003c/p\u003e\n\u003cp\u003eThis single-center retrospective cohort study included 50 consecutive patients with dorsally located renal tumors who underwent robotic-assisted PN using the “\u003cem\u003eupside-down\u003c/em\u003e” transperitoneal approach. Tumor complexity was assessed using the PADUA score. Trifecta outcomes were evaluated and compared across tumor complexity and tumor locations.\u003c/p\u003e\n\u003cp\u003eThe cohort was dominated by high-complexity tumors, with 44% exhibiting a PADUA score ≥10, and 35.3% of malignant tumors classified as pT1b grade postoperative. Mean operative time was 148.6 ± 29.3 minutes, with a mean console time of 69.7 ± 6.9 minutes, without significant differences among PADUA complexity groups. Negative surgical margins (R0) were achieved in all cases (100%). Overall, Trifecta outcomes were achieved in 78% of patients and in 61% of those with a hilar tumor. A PADUA score ≥ 10 was significantly associated with reduced Trifecta outcome, although Trifecta was still achieved in 59.1% of cases. Hilar tumors and larger tumor size were significantly associated with lower Trifecta rates.\u003c/p\u003e\n\u003cp\u003eThe “\u003cem\u003eupside-down\u003c/em\u003e” transperitoneal technique for robotic-assisted PN provides satisfactory perioperative, functional, and oncological outcomes for dorsally positioned renal masses, including complex and hilar tumors. Despite limitations related to its single-center design and sample size, this study offers a visually reproducible workflow of the technique, providing a structured guide for centers managing complex dorsal renal tumors via a transperitoneal approach.\u003c/p\u003e","manuscriptTitle":"The ‘Upside-Down’ Technique in Transperitoneal Robotic Partial Nephrectomy: Visual Standardization and Clinical Outcomes in 50 Consecutive Dorsally Located Renal Masses","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-09 12:37:15","doi":"10.21203/rs.3.rs-8778464/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-07T01:23:58+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"230255294178551767169181505328744280938","date":"2026-02-05T23:32:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"148676185650878600216986309093765481148","date":"2026-02-05T16:15:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T13:29:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T11:19:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"121962815251651764788435359279269742322","date":"2026-02-05T08:46:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124808147102370726000604021946103329522","date":"2026-02-05T08:07:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138838019608062137069422129835226573580","date":"2026-02-05T07:28:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309228758329937784614218577404413120406","date":"2026-02-05T06:19:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-05T03:05:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-05T02:54:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-04T12:17:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2026-02-03T16:15:17+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":"647e225a-a686-4487-a873-eedcbcd2397b","owner":[],"postedDate":"February 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:06:47+00:00","versionOfRecord":{"articleIdentity":"rs-8778464","link":"https://doi.org/10.1007/s11701-026-03266-z","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2026-03-14 15:58:15","publishedOnDateReadable":"March 14th, 2026"},"versionCreatedAt":"2026-02-09 12:37:15","video":"","vorDoi":"10.1007/s11701-026-03266-z","vorDoiUrl":"https://doi.org/10.1007/s11701-026-03266-z","workflowStages":[]},"version":"v1","identity":"rs-8778464","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8778464","identity":"rs-8778464","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}