'Zero ischaemia', sutureless laparoscopic partial nephrectomy for renal tumours with low nephrometry score.

Nephron-sparing surgery (NSS), using either an open or laparoscopic approach, has become a cornerstone in the management of small renal masses as its oncological safety has been widely proven [ 1 ] . Robotassisted NSS is widening its indications and is emerging as a viable approach for NSS, although to date only a few large singlecentre experiences have been described in the literature, while many reports have been limited by the evaluation of a relatively small number of patients [ 2,3 ] . Unfortunately, despite refi nements of surgical techniques, the introduction of haemostatic agents and improvements in intracorporeal suturing, the resection of renal masses in warm ischaemia, or even cold ischaemia, potentially jeopardizes long-term renal function and remains a drawback for partial nephrectomy [ 4 ] . Indeed, it remains of utmost importance to explore new ways to face this surgical step, in order to minimize or even eliminate the detrimental effect of renal ischaemia. Several techniques have been proposed, such as early unclamping, on-demand clamping, clampless NSS with controlled hypotension, superselective segmental arterial clamping and superselective arterial embolization. As suggested by Simone et al . in the present paper, a ‘ zero ischaemia ’ , sutureless laparoscopic partial nephrectomy for renal tumours with low nephrometry score is possible and can overcome the ischaemic obstacle. The authors state that this is a reasonable approach for small and peripheral tumours and that the technique has a low complication rate and provides excellent functional outcomes, without impairing oncological results. The inclusion criteria were tumours whose dimensions ranged between 1.5 and 4 cm and whose intraparenchymal growth ranged between 0.4 and 1.4 cm. Their results are rather impressive in terms of operating times, intra- and postoperative complications and renal function preservation, making this technique a further advance in the surgical treatment of small renal masses. In our unpublished data, a laparoscopic sutureless and clampless approach was performed in 32 cases, no intra- and postoperative complications occurred, estimated blood loss was negligible and serum creatinine variation was insignifi cant. In our series the tumour dimension cut-off was 2.5 cm, regardless of its spatial development, and this approach was adopted mainly for polar lesions. We believe that in cases of larger masses or parahilar neoplasms, hilar control and renal reconstruction should be preferred, since they allow a safer surgery, notably when combined with a tumour enucleation (TE), i.e. a tumorectomy performed using the natural cleavage plane existing between the tumour pseudocapsule and the normal renal parenchyma. Indeed, in cases of larger and parahilar tumours, the TE facilitates the plane identifi cation, speeding up the extirpative step of the procedure and helping the surgeon not to damage vascular and calyceal structures [ 9 ] . In our opinion therefore, in such circumstances, zeroischaemia, sutureless laparoscopic NSS should be left in the experienced hands of these authors and alternative valid techniques, such as TE with an early unclamping technique, the superselective embolization technique described by Simone et al . [ 8 ] or superselective clamping, as recently introduced by Gill [ 10 ] , should be considered to minimize renal parechymal damage during laparoscopic or robotassisted NSS‘