Tips and tricks for retroperitoneal Single Port Robot Assisted Partial Nephrectomy

• Retroperitoneal Single Port Robot Assisted Partial Nephrectomy is safe and effective also in the surgical management of large or anterior renal masses. • The preoperative planning of the enucleative phase plays a pivotal role in enhancing both functional and oncological outcomes. • A proper troubleshooting is mandatory particularly when it deals with complex cases. To provide a comprehensive step by step description of the retroperitoneal Single Port Robot Assisted Partial Nephrectomy (SP RAPN) focusing on the troubleshooting and on the tips and tricks to successfully achieve optimal oncological and functional outcomes. All patients with preoperative imaging-based evidence of renal mass amenable to partial nephrectomy were treated with retroperitoneal SP-RAPN, regardless of the tumor location. In case of infiltrative tumor growth pattern, the nephron sparing surgical management was excluded. The main surgical steps during RAPN were: (1) perform supine retroperitoneal access (Low Anterior Access) (2) identification of the Quadratus Lomborum and of the Psoas muscle (supine retroperitoneal landmarks) (3) dissection of the renal pedicle and identification of the tumor location (4) perform an anatomic pure enucleative strategy reaching the tumor pseudocapsule (5) perform anatomical renorraphy. The troubleshooting analyzed the most common intraoperative issues potentially occurring during retroperitoneal SP RAPN. Particularly we sought to analyze (1) management of peritoneal breach (2) limited working space due to the presence of abundant perinephric fat (3) management of large renal masses (4) intraoperative bleeding. The retroperitoneal approach for Single Port Robot Assisted Partial Nephrectomy is safe and potentially provides several perioperative benefits, also when it deals with large renal masses or anterior tumors. In this setting, a proper troubleshooting can expand its feasibility through the current surgical practice.