Robot-assisted partial nephrectomy during simultaneous extracorporeal membrane oxygenation and impella^® in a candidate for left ventricular assist device as a bridge for cardiac transplant: a case report

Introduction

Robot-assisted partial Nephrectomy (RAPN) has become a daily routine even in more advanced and morphologically complex cases, especially in referral centers,1–3 while long are the days that this approach is only employed for small renal masses in non-comorbid patients.4–6

The driving force behind these continuous improvements is not only ever-increasing surgical skill but also increasingly tailored supporting technology.2,7,8 However, complexities might stem not from the intrinsic characteristics of the tumor, but from severe comorbidities of the patient, particularly when the patient is simultaneously undergoing evaluation for advanced cardiac support or transplantation.9–11

In fact, perioperative management of urological malignancies in patients supported by venous-arterial ExtraCorporeal Membrane Oxygenation (VA ECMO), Impella®, or other mechanical assist devices remains poorly described in the literature. These patients are typically excluded from elective surgical pathways due to hemodynamic instability, coagulopathy, and elevated perioperative risk.11,12 Yet, the imperative for oncological control remains paramount in the context of solid-organ transplant candidacy, where active malignancy precludes listing and may derail definitive cardiac treatment.13 In such scenarios, the urologist assumes a central role not only in the oncological evaluation but also in the strategic timing and execution of safe surgical intervention under extraordinary systemic conditions.14,15

We hereby present a unique case where a renal mass was incidentally discovered during transplant workup in a patient with acute myocardial infarction complicated by cardiogenic shock who, after coronary percutaneous angioplasty and stent placement, was being stabilized with VA ECMO and Impella®.

Ethical review and approval were waived for this case report due to anonymity (D. Lgs. 196/2003, personal data protection code, as amended by D. Igs.101/2018 and general data protection regulation 679/2016). However, all procedures described in this case report involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The handwritten informed consent was obtained from the patient. Besides, this study was prepared according to the CARE case report guideline, and a CARE checklist was provided. Please see Supplementary Material S1 for more details.16

Case Report

Case presentation & surgical planning

A 51-year-old male with no prior cardiac or urological history was brought to the emergency room of our hospital, Fondazione IRCCS Policlinico San Matteo, a tertiary referral center for advanced critical care therapies, onco-urology and solid organ transplantation, due to severe chest pain. Electrocardiography demonstrated an extensive ST-Elevation Myocardial Infarction (STEMI), and coronary angiography confirmed thrombotic occlusions in both the left anterior descending and circumflex arteries. The patient underwent immediate percutaneous coronary angioplasty with medicated stent placement. Peri-procedurally, he suffered a cardiac arrest and, following initial resuscitation, was placed on Impella® and, for biventricular dysfunction a peripheral, femoro-femoral VA ECMO. He was initiated on Dual Antiplatelet Therapy (DAPT) with acetylsalicylic acid and Ticagrelor, while receiving continuous intravenous heparinization. However, his left ventricular ejection fraction was severely reduced (19%). An initial workup for potential cardiac transplantation was initiated. A contrast-enhanced abdominal CT scan revealed a 16 mm, partially exophytic, heterogeneously enhancing lesion with delayed washout in the upper pole of the left kidney, highly suspicious for renal cell carcinoma (RCC) upon review by a dedicated uro-radiologist (Figure 1). Recognizing that an untreated renal malignancy would preclude future transplant eligibility, a multidisciplinary team comprising cardiology, cardiac surgery, and urology determined that a definitive histopathological diagnosis was imperative. Given the lesion’s cT1a staging, favorable exophytic morphology, and optimal anatomical positioning for maximal parenchymal preservation, the decision was made to proceed with transperitoneal RAPN to achieve both diagnostic and therapeutic goals. The interventional radiology team was alerted to the higher-than-usual bleeding risk. RAPN was planned under continued intravenous heparinization and ongoing acetylsalicylic acid therapy and therapy with ticagrelor was shifted beforehand towards cangrelor, a short-acting antiplatelet agent, in order to momentarily interrupt the second only during the surgery. In fact, ticagrelor was interrupted 2 days after STEMI, and 24 h later, cangrelor was initiated at the 0.75 mg/kg/min dosage. Given that ECMO and Impella® (Abiomed, Danvers, MA, USA) offer only temporary circulatory support and are not suitable for long-term use, the cardiac team anticipated the need for a durable bridge-to-transplant strategy and planned implantation of an LVAD, thanks to the recovery of the global function of the right ventricle, in a subsequent stage after RAPN.

FIGURE 1. Pre-operative contrast-enhanced CT scan showing a 16 mm, partially exophytic, heterogeneously enhancing lesion with delayed washout in the upper pole of the left kidney, highly suspicious for renal cell carcinoma (RCC): A) non-enhanced phase; B) arterial phase; C) nephrographic phase; D) excretory phase

Surgical technique

One hour before surgery, on the fifth day after its start, the cangrelor infusion was discontinued. On the other end, anticoagulation was maintained with a continuous infusion of unfractionated heparin at a medium dosage of 1000 IU/h, titrated to keep the ACT around 160–180 s, with concomitant monitoring of aPTT.

In a supine position, Trans-Esophageal Echocardiographic (TEE) monitoring was placed, and it was then maintained during the whole procedure in order to monitor the maintenance of the Impella®’s correct position alongside cardiac function.

With all the team already present in the operating room, which comprised urologists, anesthesiologists, anesthesia nurses, scrub nurses and ECMO and Impella® technicians, the patient was positioned in a 60° right lateral decubitus position, ensuring that both devices’ access sites remained stable throughout (Figure 2), while monitoring the intracardiac device during positioning with TEE was continued by the dedicated cardiologist. VA ECMO flow rate was set at 3.5 L/min and was stable after lateral decubitus positioning. However, flexion of the operating table at the flank was immediately stopped due to a sudden decrease of VA ECMO flow rate to nearly 2.5 L/min, probably due to the reduction of blood drainage by the venous cannula. Therefore, it was immediately reduced under 10° with prompt restoration of the flow rate to 3.5 L/min, which was then observed to be stable throughout the whole procedure. After disinfection and surgical draping, three in-line robotic ports were placed alongside a 12 mm Airseal® (CONMED, Utica, NY, USA) and one additional 5 mm assistant port. A 10 mmHg pneumoperitoneum was induced and then maintained at this pressure for the whole procedure. After docking the DaVinci Xi (Intuitive Surgical, Sunnyvale, CA, USA) cart, the standard robotic surgical instruments for RAPN in our center were inserted a 0°-degree endoscope in the middle arm, monopolar surgical scissors in the right one and a fenestrated forced bipolar in the left one. Thereafter, the descending colon was mobilized; Gerota’s fascia was incised and the renal hilum, with its artery and vein, was isolated. After careful dissection, the partially exophytic renal mass was identified on the medial aspect of the anterior surface of the kidney (Figure 3A). The renal artery was clamped using a bulldog clamp, and an enucleoresection was performed. A cold-cut technique was opted for the careful dissection of the neoplasm from the resection bed. A slightly wider surgical margin was intentionally chosen to minimize the risk of compromising future cardiac transplant eligibility in the event of positive margins (Figure 3B): therefore an enucleoresective technique was employed Hemostasis was achieved with a continuous 4-0 Monosyn® (B. Braun Aesculap, Tuttlingen, Germany) suture placed in the renal medulla and secured with Hem-o-Lok® (Teleflex, Morrisville, NC, USA) clips. Following placement of Floseal® hemostatic matrix (Baxter Healthcare, Deerfield, IL, USA) on the resection bed, the renal artery was declamped. Warm-ischemia time was 9 min. Cortical renorrhaphy was performed using two continuous 3-0 Vicryl™ (Ethicon, Somerville, NJ, USA) sutures, which were secured with Hem-o-Lok® clips employing a sliding clip technique. Floseal® was applied over the renorrhaphy site, followed by placement of TachoSil® fibrin sealant patch (Takeda Austria GmbH, Linz, Austria) to reinforce hemostasis. The Gerota’s fascia was closed with a continuous 3-0 suture. Estimated blood loss was 150 mL. From a cardiovascular standpoint, the surgery was uneventful with no hemodynamic instability event during the procedure. Upon macroscopic review of the surgical specimen, a Surface-Intermedia-Base (SIB) score of 3 was assigned (base 1, intermediate 1, surface 1), indicating a pure enucleoresection.17

FIGURE 2. Patient positioning and OR set-up: the patient was placed in a right lateral decubitus position, ensuring that both the ECMO and Impella® access sites remained stable throughout, with both ECMO & Impella® control columns kept caudally in respect to the patient; the ultrasound machine for intraoperative trans-esophageal echocardiographic monitoring was kept cranially and to the right side in respect to the patients, next to the ventilator; DaVinci Xi HD patient cart was kept and then docked on the from the left side, as in standard transperitoneal RAPN configuration

FIGURE 3. Intraoperative details: A) Intraoperative aspect of the partially endophytic neoplasm, with its location confirmed on the medial rim of the upper pole; B) Intraoperative appearance of the resection bed

Post-operative course

At the end of the procedure, the patient was transferred to the ICU, where he remained sedated and continued on both VA ECMO and Impella® support. Immediately post-operatively, hemoglobin was 8.4 mg/dL in comparison to the preoperative one of 8.2 mg/dL, while eGFR (estimated with BSA-adjusted CKD-EPI formula18) was 87 mL/min compared the preoperative level of 94 mL/min; therefore, the cangrelor infusion was resumed. Hemoglobin was stable until postoperative day (POD) 4, when the abdominal drain suddenly became productive with hematic material, and a drop of 2.4 mg/dL was observed, with hemoglobin reaching 6.0 mg/dL. As a result, a contrast-enhanced abdominal CT scan was performed. The scan revealed active late arterial bleeding from the resection bed, associated with a perirenal hematoma. The patient was promptly transferred to the angiography suite, where bleeding from two subsegmental arterial branches was identified and successfully embolized using sclerosing agents. Post-embolization renal function remained stable, with an eGFR of 89 mL/min. On postoperative day (POD) 6, a follow-up contrast-enhanced CT scan confirmed the absence of residual bleeding. From a urological standpoint, the remainder of the postoperative course was uneventful. On POD 7, due to foreseen persistent left ventricular dysfunction, the patient underwent implantation of a LVAD as a bridge to cardiac transplantation. The abdominal drain was removed on POD 11. During the remainder of the hospital stay, cangrelor was shifted again to ticagrelor and unfractionated heparin was bridged to coumadin.

The patient was discharged to a cardiovascular rehabilitation facility on POD 28, where he remained for nearly two months, during which time no late complication arose. Final histopathological analysis confirmed a pT1a, G2, R0 clear cell renal cell carcinoma (RCC).

At 6 months follow-up, contrast-enhanced thoraco-abdominal CT found no sign of recurrence, nor the patient incurred any major cardiovascular complication, alongside normal eGFR (91 mL/min). Therefore, he was awaiting completion of the required three-year cancer-free period to become eligible for cardiac transplant listing.

Discussion

This case portrays a rare situation in which a renal malignancy might impact the listing or cardiac transplantation. As of today, active malignancy remains a contraindication to heart transplant listing; however, contemporary guidance emphasizes individualized, multidisciplinary assessment of recurrence risk rather than rigid time-based rules.13,19–21 Historically, a 2–5 years cancer-free interval was advised for many tumors, but recent consensus statements and the 2024 ISHLT candidate guidelines support tailoring the waiting period to tumor biology, stage, and response to curative therapy, with documented shared decision-making with oncology.13,19–21 Notably, for low-grade RCC completely excised and ≤3 cm, several transplant guidance documents indicate that no observation period may be required.19–21 However, in Italy, eligibility for heart transplantation is coordinated within the Centro Nazionale Trapianti (CNT) network: local program policies list active malignancy or cancer within the previous 3 years as an absolute contraindication for cardiac transplant, with the risk of recurrence assessed case-by-case in consultation with oncology.22

In fact, prior literature describing abdominal or urologic surgery under temporary mechanical circulatory support is sparse. Isolated reports include radical nephrectomy performed with pre-operative ECMO support in RCC with venous tumor thrombus,23 and non-urologic abdominal cancer (colorectal) surgery conducted under Impella® support to maintain hemodynamic stability.24 Notably, there is only one single reported instance of RAPN in a patient undergoing Impella® due to cardiogenic shock: the authors report that the procedure was well tolerated with minimal blood loss.25 Notably, Impella® provides percutaneous left-ventricular unloading and requires a heparinized purge solution, and many patients also need systemic anticoagulation, which compounds perioperative bleeding risk—especially when dual antiplatelet therapy is concurrently indicated,26 like in the case of our patients who had just undergone percutaneous coronary angioplasty and stent placement.27 While venous-arterial ECMO can stabilize end-organ perfusion in advanced heart failure, it is also strongly suggested systemic anticoagulation; this creates a narrow therapeutic window: non-cardiac procedures carry heightened risks of hemorrhage, transfusion, and circuit thrombosis. Notably, however, the need for anticoagulation was due to the recent PTCA and the presence of the Impella®, rather than the VA-ECMO.28–30 Indeed, with newer fully biocoated (heparin-coated) ECMO circuits, it is possible to perform surgery for hours without any systemic anticoagulation.31–33 Therefore, bleeding complications around ECMO are common and multifactorial, so perioperative plans should pre-identify rescue strategies (e.g., percutaneous angiographic embolization) and coordinate heparin titration, monitoring, and reversal protocols with the ECMO team. In fact, to the best of our knowledge, this report is the first recording of performing RAPN in a patient both on ECMO and Impella®.

In our setting, the decision to avoid a percutaneous biopsy was due to both the mixed diagnostic yield of the procedure and the high likelihood of RCC upon review of the CT scan by the dedicated radiologist. Notably, renal mass biopsy offers high positive predictive value but has a clinically relevant nondiagnostic rate and limited negative predictive value, partly due to intratumoral heterogeneity; meta-analyses report nondiagnostic results in ~10%–15% of biopsies, with many nondiagnostic lesions ultimately proving malignant at surgery.34,35

Moreover, bleeding is the most frequent complication after image-guided renal biopsy. In contemporary series of renal mass biopsy, acute complications occur in ~3%–4% of procedures and the majority are bleeding-related (peri-renal hematoma or hematuria), while severe events are uncommon.36 This risk rises critically with concomitant anticoagulation or antiplatelet therapy.36 Notably, the Society of Interventional Radiology (SIR) guidance classifies deep organ biopsies (e.g., kidney) as higher-bleeding-risk procedures and recommends withholding P2Y12 inhibitors for several days pre-procedure and ensuring correction of therapeutic anticoagulation when feasible.37 Data on acetylsalicylic acid are mixed: older studies show minimal effect, while newer cohorts show higher major hemorrhage rates when it is continued.38,39 However, DAPT and therapeutic heparinization amplify peri-procedural bleeding risk and often necessitate deferral, bridging strategies, or multidisciplinary planning.40 In our patient on VA ECMO & Impella®, requiring systemic anticoagulation and DAPT, the cumulative hemostatic burden further strengthened the argument to avoid biopsy unless results have changed the therapeutic pathway (Figure 4). In fact, in case of confirmed malignancy at biopsy, it would still have been necessary to radically treat the kidney’s neoplasm in order to list the patient for cardiac transplant in the future.13 All these issues drove the choice toward an upfront RAPN pathway instead of a biopsy-first one.

FIGURE 4. Timeline showing both cardiovascular (upper portion) and urological (lower portion) interventions and procedures, alongside the antiplatelet and anticoagulant drugs management (ASA, acetylsalicylic acid; UHF, unfractionated heparin)

However, instead of choosing a nephron-sparing treatment, one might argue that radical nephrectomy was warranted to avoid any risk of positive margins. The choice between radical nephrectomy (RN) and partial nephrectomy (PN) was informed by both the very extensive literature supporting the oncological safety of PN, especially in cT1a small renal masses, and by the very well-described renal function impairment and increased cardiovascular risk of RN.11,41–43 Therefore, these facts were accounted for in the pre-operative MDT discussion, where it was argued that both renal impairment and cardiovascular risk would have been even more increased in a compromised cardiovascular status like that of the reported patient. We acknowledged that avoiding RN-associated nephron loss, and its association with chronic kidney disease and cardiovascular events, was a priority in a patient who was progressing towards bridge LVAD and cardiac transplant down the line.11,42,43 Alongside this, we did indeed assume the existence of the trade-off of higher hemorrhagic risk under VA-ECMO/Impella anticoagulation.40,44 The late arterial bleed on POD 4, promptly resolved by selective embolization with sclerosing agents, exemplifies this calculated trade-off: renal function and hemodynamics were preserved, LVAD implantation proceeded as planned. Overall, we inferred that PN balanced oncologic adequacy, renal preservation, and maintenance of the transplant trajectory more favorably than RN in this context. In addition, a robot-assisted approach was chosen instead of a laparotomic one for the need to reduce as much as possible the invasiveness of the procedure due to the concomitant DAPT and anticoagulation, knowing that the robotic approach has been employed almost routinely in a wide array of technically challenging PN in referral centers.1,2,7

However, a wide array of technical precautions was employed during the procedure to mitigate as much as possible the enhanced and wider-than-usual array of possible complications. In fact, we adopted a 60° right lateral decubitus with minimal table flexion to protect cannula geometry and maintain device performance. During flexion of the operating table at the bed, the ECMO blood flows fell from 3.5 to 2.5 L/min, promptly normalizing when flexion was limited to <10°, so the flank break was kept minimal; continuous TEE was used throughout to confirm Impella® position while Impella® lines and VA ECMO cannulae were placed to avoid mispositioning. While this strategy reflects standard transperitoneal RAPN ergonomics, all these adjustments were necessary to account for the presence of VA ECMO and Impella® and their correct functioning.45,46 Notably, patient and cannulae positioning was preoperatively decided in a multidisciplinary meeting with all operating room personnel, including scrub nurses, nurse anesthetists, circulating nurses, VA ECMO and Impella® technicians, anesthesiologists and surgeons. In the same setting, an exact draft of all equipment placement in the operating room was established, alongside the exact procedure for patient positioning (starting with the transfer of the patient from the bed to the operating table and ending with lateral decubitus with flank flexion), with preassigned roles for every single step.

Furthermore, we maintained a 10 mmHg pneumoperitoneum to limit CO2 absorption and the consequent sweep-gas/ventilatory demand on VA ECMO and, primary, to avoid the compression of the inferior vena cava and the subsequent difficult blood drainage by the peripheral inserted venous cannula, accepting a slightly tighter workspace in exchange for physiologic stability: low-pressure pneumoperitoneum (around 8–10 mmHg) has documented anesthetic and physiologic advantages and reduces CO2-related burden compared with the 12–15 mmHg commonly used.46–48 Pneumoperitoneum target pressure was established during one of the pre-operative multidisciplinary meetings based on available reported data and our experience. Analyzing the literature, one could conclude the non-difference in terms of CO2 burden between using an average of 8 mmHg compared to 10 mmHg. On the other hand, by using an average of 10 mmHg, a larger intrabdominal space for robotic arm movement could be achieved. However, it was also decided that in case of any hemodynamic issues using 10 mmHg pressure, we would easily proceed to reduce the pressure to 8 mmHg target or lower if needed.46–48 In addition, an on-clamp enucleoresection provided a nearly bloodless field, enhancing visualization of the surgical plane to avoid macroscopic surgical margins (as compared to the pure enucleation and hybrid enucleation techniques usually employed in our center17) and medullary layer suturing; thereafter, we continued with early declamping and only then completed cortical closure with sliding-clip sutures. This sequence shortens warm ischemia while preserving resection bed hemostasis and has been reported as safe, with similar blood loss and complication rates vs. full-ischemia closure.49,50 In our case, it contributed to a 9-min warm ischemia time with stable intraoperative hemodynamics. In fact, evidence shows that when tumors are appropriately selected, on- and off-clamp RAPN yield broadly comparable functional outcomes;51 however, on-clamp often confers superior visibility and hemostasis for deeper or endophytic components, as in our case, thereby facilitating margin control.52–54 Moreover, we decided to perform a cold-scissor enucleoresection for the same aim of maintaining maximal gross margin control, even though comparative histologic data indicate that energy-based instruments (bipolar/ultrasonic) generally do not preclude reliable margin assessment; cold cutting, however, is associated with less tissue fragmentation and shallower artifact than energy based dissection, thereby sharpening the dissection plane and aiding pathologic evaluation.55 However, due to the need for anticoagulation and DAPT during the perioperative period, the risk of post-operative bleeding was steeply increased. In fact, this was foreseen, and the interventional radiology team was pre-emptively alerted. However, it was not expected for the patient to experience a late bleeding from the resection bed on POD 4, since most bleeding events in urological cancer surgery occur in the first 24 to 48 h.44 However, this event did not significantly impact the planned second surgery of LVAD implantation and the subsequent post-operative course.

Notably, we elected not to perform pre-operative selective renal embolization before RAPN in order to preserve the diagnostic integrity of the specimen, paramount because transplant candidacy hinges on a definitive pathology: presurgical devascularization produces treatment-effect necrosis that cannot be reliably distinguished from tumor-type necrosis, thereby compromising a key prognostic parameter in RCC reporting.56 In addition, current evidence on preoperative selective embolization remains limited and shows only reduced estimated blood loss, but no clear benefit in terms of major complications or oncologic outcomes.57 Furthermore, from this procedure can arise non-trivial risks, including post-embolization syndrome and rare non-target embolization.58 Notably, this case shows that RAPN can be prioritized over biopsy in selected transplant candidates to obtain definitive pathology, minimize renal function loss in comparison to RN, thereby mitigating cardiovascular risk, and keeping a plausible path toward future listing in alignment with modern transplant-oncology guidance. It also highlights practical perioperative strategies for surgery under temporary mechanical cardiovascular support—anticipatory interventional radiology backup, predefined anticoagulation targets with dynamic lab-based monitoring, and device-team co-management—that may generalize to other high-risk oncologic surgeries in patients bridged to advanced heart failure therapies.

Furthermore, our report underscores that complex management of localized renal masses, ranging from partial and radical nephrectomy to ablation or active surveillance, should be centralized in high-volume, multidisciplinary centers, where guideline-concordant selection and perioperative rescue resources are routine.59,60 Contemporary guidelines endorse individualized choice among surgery, thermal ablation, and surveillance, all of which are operator- and program-dependent for safety and oncologic quality, while higher hospital/surgeon volume is consistently linked to fewer complications and better perioperative outcomes for RAPN.59,60 Nonetheless, an intertwined scenario like this one demands a wide multidisciplinary team to balance oncologic control, hemodynamics, and transplant eligibility.13,61 From our experience, we posit that core multidisciplinary team membership in such a scenario should include urologic oncology, diagnostic and interventional radiology, pathology, anesthesiology, integrated with heart-failure/transplant cardiology and cardiothoracic surgery.

Lastly, beyond its clinical relevance, this scenario underscores the value of integrated multidisciplinary planning and offers insight into operative strategy, risk mitigation, and renal preservation in highly complex surgical environments.

Conclusion

The case illustrates the feasibility of robot-assisted partial nephrectomy in the presence of combined advanced circulatory support and highlights the critical role of a multi-disciplinary collaborative evaluation, in a high-volume tertiary care setting, in maintaining transplant eligibility through timely and anatomically tailored oncological intervention.

Acknowledgement

Multidisciplinary team (MDT) for urological cancers (Lucia Aretano; Valentina Bobbi; Edda Buffa; Silvia Chiellino; Anna Gallotti; Giulia Manfrinato; Benedetta Montagna; Andrea Lancia; Salvatore La Mattina); Operating room staff (Colombo Costanza Natalia Julia, Massimiliano Cornaghi, Valentina Cutrona, Federica Maria Russo, Guido Tavazzi).

Funding Statement

The authors received no specific funding for this study.

Author Contributions

The authors confirm contribution to the paper as follows: data collection: Francesco Cianflone, Mohammad Eisa Ali, Alessio Villano; draft manuscript preparation: Francesco Cianflone, Giuseppe Ottone Cirulli, Richard Naspro, Germana Bichisao, Carlo Marchetti; manuscript revision: Richard Naspro; Andrea Ringressi, Mirko Belliato, Roberto Veronesi, Simona Secondino, Paolo Pedrazzoli, Stefano Pelenghi, Carlo Pellegrini; supervision: Mirko Belliato, Richard Naspro, Paolo Pedrazzoli, Stefano Pelenghi. All authors reviewed the results and approved the final version of the manuscript.

Availability of Data and Materials

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.

Ethics Approval

Ethical review and approval were waived for this case report due to anonymity (D. Lgs. 196/2003, personal data protection code, as amended by D. Igs.101/2018 and general data protection regulation 679/2016). However, all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

- Registry and the Registration No. of the study/trial: N/A

- Animal Studies: N/A

Informed Consent

Obtained from all patients.

Conflicts of Interest

The authors declare no conflicts of interest to report regarding the present study.

Supplementary Materials

The supplementary material is available online at https://www.techscience.com/doi/10.32604/cju.2025.073002/s1.

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