Which patients with clinical localized renal mass would achieve the trifecta after partial nephrectomy? The impact of surgical technique

BACKGROUND: To develop a clinical nomogram aimed to predict the achievement of trifecta in patients treated with open, laparoscopic and robotic partial nephrectomy (PN) for localized renal masses ( < cT2). METHODS: We retrospectively evaluated 482 consecutive patients who underwent PN with open (OPN: 243), laparoscopic (LPN: 156) and robotic (RAPN: 83) approach for T1 renal mass at single tertiary center. Trifecta was defined as follows: warm ischemia time (WIT) <20 min and no positive surgical margins (PSM) and no postoperative complications. First, we compared clinical, pathologic and perioperative outcomes within the three surgical approaches. Second, multivariable logistic regression was performed to identify the independent predictors of the trifecta's achievement. Finally, regression-based coefficients were used to develop a nomogram predicting the likelihood to achieve the trifecta and 200 bootstrap resamples were used for internal validation. RESULTS: The three cohorts were comparable in terms of demographics and clinical characteristics. Trifecta has been achieved in 49%, 50.6% and 69.9% of patients undergoing OPN, LPN and RAPN, respectively (p=0.003). At multivariable analyses, American Anesthesiologists Score (ASA) score 3-4 (Odd Ratio [OR]: 0.63; p=0.02), urinary collecting system (UCS) involvement (OR 0.56; p=0.02) and surgical approach (LPN and OPN vs. RAPN: OR: 0.39 and 0.38, respectively; p=0.001) were independent predictors of trifecta's achievement. A nomogram based on covariates included in the multivariable model demonstrated bootstrap-corrected predictive accuracy of 63%. CONCLUSIONS: ASA score, UCS involvement and the surgical technique were independent predictors of trifecta outcome. Our nomogram could facilitate the preoperative counselling and to choose the best surgical approach for PN.