Three-dimensional Virtual Models’ Assistance During Minimally Invasive Partial Nephrectomy Minimizes the Impairment of Kidney Function

Identification of Recurrent Anatomical Clusters Using Three-dimensional Virtual Models for Complex Renal Tumors with an Imperative Indication for Nephron-sparing Surgery: New Technological Tools for Driving Decision-making

“…In this context, it has been shown that both printed and virtual 3D models for preoperative planning and intraoperative navigation for NSS have a positive impact on postoperative outcomes [19] , [20] , [21] , [22] . Therefore, 3DVMs are increasingly being used for planning complex surgeries in routine practice [8] , [21] and pioneering studies have demonstrated the feasibility of 3D-AR guidance during RAPN to tailor tumor resection and renal reconstruction with the aim of achieving “precision RAPN” and maximizing postoperative functional recovery [10] , [12] .…”

“…Contrast-enhanced CT images in digital DICOM format were processed by MEDICS Srl ( www.medics3d.com ) using dedicated software for hyperaccuracy 3D (HA3D) virtual reconstruction of the case, as previously reported [9] , [10] , [11] , [12] . In brief, the reconstruction was focused on the kidney vasculature and collecting system, the kidney parenchyma, and the renal mass.…”

“…Hyperaccuracy three-dimensional virtual models (3DVMs) of the kidney and tumor anatomy, which are based on preoperative computed tomography (CT) images, have been introduced to improve surgical planning and intraoperative navigation assistance and use different supports that range from holograms to intraoperative superimposition with augmented reality (AR) technology [8] , [9] , [10] . It has been shown that these tools can improve perioperative and functional outcomes in cases involving highly complex renal tumors by optimizing many surgical steps of the procedure [11] , [12] .…”

Editorial Comment to Randomized trials to determine the ideal management of the renal artery during partial nephrectomy: Life's under no obligation to give us what we expect

“…The controversial results of available RCTs stem from the fact that renal ischemia is just one of the several and partly unknown drivers of functional outcomes after RAPN. Recent well‐designed studies have robustly shown that the quality of the kidney, the baseline patient characteristics, resection techniques (enucleation vs enucleoresection vs resection 2 ), reconstruction techniques 3 (the technical finesse in renal renorrhaphy after tumor excision 4 ) and, importantly, surgeon experience and skills, 5 do have a tremendous impact on functional recovery after RAPN. As such, predicting estimated glomerular filtration rate trajectories after RAPN is still highly nuanced in individual patients, making the kidney reaction to RAPN still a “black box” difficult to decode.…”

“… 1 These caveats highlight the inherent complexity of this topic, which resembles the Heisenberg's indetermination principle: assessing the impact of a single factor on postoperative renal function after RAPN might be simply not possible, even with RCTs (too many factors to randomize – patients, tumors, surgeons, hospitals and techniques – and/or to control for in statistical analyses). Furthermore, the evolving indications for RAPN coupled with the increasing use of cutting‐edge technology to improve pre‐ and intraoperative surgical planning, 4 ultimately make the question, “to clamp or not to clamp the renal hilum”, old fashioned.…”