Complex Renal Tumors Research Articles

Feasibility of a new L43K ultrasound probe attachment for intraoperative laparoscopic ultrasonography in robot-assisted partial nephrectomy

Abstract Background We assessed the feasibility of a new probe attachment (PA) developed to improve the ease of holding the drop-in-type L43K ultrasound probe during robot-assisted partial nephrectomy. Materials and methods We retrospectively analyzed the outcomes of 58 patients after robot-assisted partial nephrectomy using the conventional grip and 13 patients after surgery using the PA between September 2019 and February 2021. Propensity score matching (1:1) was performed to adjust for potential baseline confounders. The usability of the PA was evaluated regarding (1) total procedure time for intraoperative laparoscopic ultrasound; (2) proportion rate of intraoperative laparoscopic ultrasound in console time; (3) total number of probe fin grips; (4) total number of grip failures; (5) intraoperative laparoscopic ultrasound procedure time per grip; and (6) rate of successful gripping. Results After matching, 12 patients were allocated to each group, and the tumor site was significantly different between the groups. Usability was significantly better in the PA group: (1) conventional versus PA: 6.8 versus 7.6, p = 0.53; (2) 5.6% versus 6.1%, p = 0.61; (3) 8 versus 10, p = 0.32; (4) 3 versus 0, p = 0.014; and (5) 1.5% versus 0.7%, p = 0.021; (6) 66% versus 100%, p = 0.002. In patients with complex renal tumors, completely endophytic tumors, and renal hilum tumors, nearly identical improvements in usability were observed: (1) 9.8 versus 7.8 min, p = 0.21; (2) 9.9% versus 4.7%, p = 0.001; (3) 7 versus 6, p = 0.025; (4) 3 versus 0, p = 0.048, (5) 2.9 versus 1.6 min, p = 0.89, and (6) 60% versus 100%, p = 0.003. Conclusions Our proposed L43K PA can enhance the usability of the probe for intraoperative laparoscopic ultrasonography during robot-assisted partial nephrectomy and increase the accuracy of ultrasonography for complex renal tumors.

Robot-assisted partial nephrectomy in complex renal tumors using the Versius platform: An initial but promising experience

ABSTRACT Background and objectives The widespread utilization of robotic surgeries in urology encouraged several teams to explore the option of performing robot-assisted partial nephrectomy (RAPN), taking advantage of its magnified stereoscopic vision and the articulating instruments that facilitate tumor resection and the reconstructive steps of hemostasis and renorrhaphy. The implementation of the CMR Versius system in RAPN, especially in complex masses, has not been explored yet. Herein, we present our initial experience in performing RAPN in complex renal masses using this novel platform. Methods Between July 2022 and November 2023, thirty patients who had complex renal masses and were candidates for RAPN were enrolled in this study. Tumor complexity was assessed using the preoperative aspects of the dimension used for anatomic (PADUA) nephrometry scores. Perioperative data were prospectively collected and analyzed. ‘TRIFECTA’ was defined as free surgical margins, warm ischemia time (WIT)< 30 minutes, and no major complications (>Clavien-Dindo II). Results All cases were successfully completed with no conversion to radical, open, or laparoscopic surgery. The median PADUA score was 9.5 (8–11). The mean docking time, console time, and total operative time were 9.17 ± 0.91, 149 ± 14.27, and 177.17 ± 29.53 minutes, respectively. The mean WIT was 26.67 ± 3.66 minutes. Surgical margins were free in all cases. TRIFECTA was fulfilled in 25/30 patients (83.33%). Five patients (16.66%) did not fulfill TRIFECTA; two patients had prolonged WIT > 30 minutes, two had prolonged WIT with prolonged urine leakage necessitating DJ stent insertion, and the fifth patient had only prolonged urine leakage and DJ insertion. None of the patients developed tumor recurrence or acute kidney injury during follow-up. Conclusion Performing RAPN with the CMR Versius platform is a feasible option in complex renal masses with slightly increased but accepted WIT and total operative time. It should be wisely restricted to well-experienced teams.

An Analysis of Renal and Surgical Outcomes of Patients with and without Preoperative Ureteral Stenting before Nephron-Sparing Surgery for Renal Malignancies of Higher Complexity by Using a Propensity Score-Based Approach

Introduction: This study aims to evaluate the impact of preoperative ureteral stenting on post-operative outcomes, especially the incidence of urinoma, in patients with complex renal tumours undergoing nephron-sparing surgery (NSS). Methods: A retrospective analysis of 35 patients received preoperative ureteral stenting prior to NSS for complex tumours at the University Hospital of Würzburg between 2002 and 2021. A control group of 115 patients was established through 1:3 propensity score matching based on age, gender, T-stage, and RENAL score. Clinical parameters, surgical outcomes, and complications were assessed, and statistical comparisons were performed using the unpaired Student’s t test and chi-square test. Results: While both groups showed comparable tumour complexity (RENAL: 7 vs. 7, p = 0.58; PADUA: 9 vs. 8, p = 0.62), there were no significant differences in median hospital stay (12 vs. 11; p = 0.068), surgical time (183 vs. 190 min; p = 0.37), post-operative haemoglobin levels (11 g/dL vs. 11.1 day/dL; p = 0.9), and renal function (GFR 65 mL/min/m2 in both groups). Moreover complication severity during NSS, defined by Clavien-Dindo classification, was similar (none vs. grade I; p = 0.29). No significant difference in the rate of urinoma was observed (11% vs. 4%, p = 0.93). Conclusions: This study found no significant benefits of preoperative ipsilateral ureteral stenting on post-operative outcomes, particularly concerning the development of urinoma. Given these findings, preventive ureteral stenting is not recommended prior to partial kidney resection for complex renal tumours.

Comparison of robotic-assisted and laparoscopic partial nephrectomy based on the PADUA score and the predictive value of the PADUA score and the Mayo Adhesive Probability score for postoperative complications: a single-center retrospective study

PurposeThis study compared perioperative outcomes of robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) through the PADUA score as well as assessed the predictive value of the PADUA score and the Mayo Adhesive Probability (MAP) score for postoperative complications.MethodsTotally 196 patients suffering from RAPN or LPN for renal tumors were reviewed retrospectively. Patients were categorized by PADUA score (low-, moderate-, high-complexity) and MAP score (low-, intermediate-, high-grade). Evaluated outcomes included operative time (OT), warm ischemia time (WIT), estimated blood loss (EBL), drainage duration, postoperative length of stay, and absolute change in estimated glomerular filtration rate (eGFR) at three months post-surgery, along with intra- and postoperative complications.ResultsRAPN outperformed LPN in the low-complexity group by lowering WIT (P = 0.022) and absolute eGFR change (P = 0.011). For moderate-complexity group, RAPN reduced WIT (P = 0.021), absolute eGFR change (P = 0.027), and postoperative length of stay (P = 0.008). In the high-complexity group, RAPN reduced OT (P = 0.015), WIT (P = 0.023), EBL (P = 0.036), absolute eGFR change (P = 0.024), and postoperative length of stay (P = 0.019). Drainage duration showed no significant differences across groups (P = 0.442, P = 0.327, P = 0.260). RAPN incurred significantly higher total costs than LPN across groups (P < 0.001). ROC analysis suggested PADUA and MAP scores as reliable predictors of postoperative complications in RAPN (AUC = 0.880,0.828) and LPN (AUC = 0.757,0.702).ConclusionRAPN provides significant advantages over LPN in managing complex renal tumors (PADUA score ≥ 10), significantly in reducing OT, WIT, EBL, and absolute eGFR change at three months post-surgery, while minimizing postoperative stay. The PADUA and MAP scores are valuable in predicting postoperative complication.Trial registration number and date of registrationRetrospectively registered.

Laparoscopic Versus Open Partial Nephrectomy For Anatomically Complex Renal Tumors (Renal Score ≥ 7)

Purpose: The aim of this study was to compare the safety and efficiency of laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) for complex renal tumors with a RENAL nephrometry score of ≥7. Materials and Methods: We evaluated the data of 63 patients who had undergone LPN (n=32) or OPN (n=31) for renal tumors with a RENAL nephrometry score of ≥7 between 2016 and 2022, retrospectively. We compared the preoperative, functional and oncological outcomes among the groups. The warm ischemia time (WIT) of

The clinical application value of mixed reality in robotic laparoscopic partial nephrectomy.

Robot-assisted laparoscopic partial nephrectomy (RAPN) has become a key technology in the treatment of renal tumors. Effective preoperative planning and precise intraoperative navigation are critical to a successful surgical outcome. This study aimed to evaluate the clinical application value of mixed reality (MR) in robotic nephron-sparing partial nephrectomy for patients with renal tumors of different complexity based on the R.E.N.A.L. score. A retrospective analysis was conducted on 68 eligible patients with renal cancer who underwent RAPN at The Second Affiliated Hospital of Nanchang University from January 2021 to December 2023, with postoperative pathology confirmation. Patients were divided into two groups: the MR group, with 28 cases, and the traditional imaging (control) group, with 40 cases. All patients underwent mid-abdominal CT plain scans and enhancements. The MR group utilized three-dimensional reconstruction of CT data and employed 3D tablets and HoloLens glasses for preoperative discussions, surgical planning, and intraoperative guidance. Collect clinical data and metrics to assess surgical outcomes, as well as evaluate performance in areas such as preoperative discussions, doctor-patient communication, surgical planning, and intraoperative navigation. Compared to robot-assisted partial nephrectomy in the control group, the MR group experienced a reduction in operation time by approximately 30 min [(135.89 ± 23.494) min vs. (165.00 ± 34.320) min, P< 0.001)] and a decrease in ischemia time by around 2.5 min [(20.36 ± 3.956) min vs. (23.80± 6.889) min, P= 0.02)]. Within the subgroup with a R.E.N.A.L. score of less than 7 points, the MR group only showed a significant reduction in operation time [(134.55 ± 150.190) min vs. (150.19 ± 28.638) min, P = 0.045], with no notable differences in other parameters. For the subgroup with a R.E.N.A.L. score of 7 points or higher, the MR group exhibited shorter operation time [(140.83 ± 25.183) min vs. (195.77 ± 23.080) min, P< 0.001] and reduced warm ischemia time [(21.17 ± 2.714) min vs. (28.85 ± 7.570) min, P = 0.029]. Additionally, there was less estimated blood loss [(53.33 ± 5.164) min vs. (114.62 ± 80.376) min, P = 0.018]. All patients had negative resection margins, indicating equivalent therapeutic outcomes between the two groups. In comparison to traditional RAPN, MR technology demonstrates the ability to decrease operation time and warm ischemia time all the while maintaining equivalent curative outcomes. Additionally, it enhances preoperative discussions, doctor-patient interactions, preoperative strategizing, and intraoperative navigation, particularly excelling in complex renal tumor cases of RAPN, where its benefits are most pronounced.

Implementation of surgical rehearsal utilizing patient specific hydrogel kidney phantoms prior to complex renal cancer surgery: a pilot study.

With the advancement of surgical technology, the opportunity to integrate novel surgical preparation is imperative to improve patient outcomes and enhance safety. Patient specific perfused kidney phantoms including the tumor, parenchyma, artery, vein, and calyx were fabricated using 3D-printing and hydrogel injection molding from scans of 25 patients scheduled for robotic partial-nephrectomy (RAPN). Models are validated for anatomical accuracy, mechanical, functional properties and surrounded by the other models of relevant anatomy in a body cast for a simulated surgical rehearsal. We investigated the impact of these preoperative rehearsals preceding complex RAPN by analyzing changes in surgeons' decisions following review of both axial-imaging and following rehearsal simulation. Predictive ability of these rehearsal platforms was compared to live surgery outcomes and trifecta of cases as an outcome was calculated. 25 patients with complex renal tumors, average 9.8 nephrometry score and 4.9cm mean tumor diameter were consented. Mean blood loss and WIT were 193.2ml and 19.8min. Two Clavien 2 complications were reported at 30-day postoperative. Trifecta was achieved in 17 (68%) of surgical cases. Surgeons' confidence in their ability to complete a partial nephrectomy and ability to predict WIT significantly increased from initial viewing the axial imaging to after the rehearsal. The correlation coefficient between the procedural clinical data collected during the rehearsals and live surgery were calculated. The application of this versatile method for creating authentic perfused kidney phantoms can result in increased confidence in surgical plan and thus improved surgical performance and outcomes.

Application for Tridimensional Renal Visualization and Operative Planning

Background: Partial nephrectomy is the preferred surgical approach for renal neoplasms smaller than 7 cm, without compromising disease-free or cancer-specific survival. It is increasingly being performed in patients with complex renal tumors. Three-dimensional models of preoperative computed tomography (CT) or magnetic resonance imaging (MRI) scans are the future for accurately identifying the tumor's location and planning the surgical strategy. Objectives: This study aims to develop an application for use by medical professionals, designed to view three-dimensional (3D) renal images with radius, extension, nearness, anterior/posterior, and lines scores from preoperative CT or MRI exams. Methods: This descriptive study focuses on developing a mobile application, which was entirely created by a urologist on a no-code platform without using programming languages. The renal 3D images were generated from the patient's specific CT or MRI scans. A dedicated database was also utilized for the application. Results: The development of the NeoRenal application resulted in ten complexly designed screens created within a no-code platform, each serving a specific purpose in a coherent sequence to ensure an optimal user experience. The uniform flow and design of these screens aim to provide intuitive and comprehensive user acceptance, facilitating registration, data entry, visualization, and editing functionalities. Conclusions: The application was successfully developed and is ready to be published on various operating systems.

The application of mixed reality navigation system in laparoscopic partial nephrectomy for highly complex renal tumors (RENAL score ≥ 10): a retrospective cohort study.

The application of mixed reality navigation system in laparoscopic partial nephrectomy for highly complex renal tumors (RENAL score ≥ 10): a retrospective cohort study.

Robotic nephron-sparing surgery for a high-complexity renal carcinoma in an obese patient with chronic kidney disease Stage 4

ABSTRACT The approach to managing renal masses has significantly changed over time. Traditionally, nephrectomy was the standard treatment for both large and small tumors, but modern practices are more nuanced. Today, treatment strategies are tailored to each patient’s overall health, personal preferences, and specific tumor characteristics. In recent years, partial nephrectomy has become the standard of care whenever possible. However, this approach is not always feasible in complex renal tumors. Radical nephrectomy continues to be the preferred method for larger, complex tumors and those with aggressive growth patterns. The rise of minimally invasive procedures has empowered the surgeon to perform nephron-sparing partial nephrectomy in complex tumors too. We report the case of a 70-year-old obese patient with a complex left renal tumor and chronic kidney disease. The patient underwent robotic partial nephrectomy with clear margins and no deterioration of renal function which was of paramount importance in preventing progression to overt renal failure requiring dialysis.

Management of renal sinus angiomyolipoma: modified robotic nephron-sparing surgery in a single center

BackgroundRenal sinus angiomyolipoma (RSAML) is a rare and typically complex renal tumor. The objective is to present our single-center experience with a modified technique of robotic nephron-sparing surgery (NSS) for treating RSAML.MethodsWe retrospectively evaluated 15 patients with RSAMLs who were treated with robotic NSS at the Department of Urology of Tongji hospital, ranging from November 2018 to September 2022. Renal vessels and ureter were dissected. The outer part of RSAML was resected. The rest of tumor was removed by bluntly grasp, curettage and suction. Absorbable gelatin sponges were filled in the renal sinus. The preoperative parameters, operative measures and postoperative outcomes were all collected. Follow-up was performed by ultrasonography and estimated glomerular filtration rate (eGFR).ResultsRobotic NSS was successfully performed in all the patients, without any conversion to open surgery or nephrectomy. The mean operation time was 134.13 ± 40.56 min. The mean warm ischemia time was 25.73 ± 3.28 min. The median estimated blood loss was 100 [50, 270] ml and 1 patient required blood transfusion. The mean drainage duration was 5.77 ± 1.98 days. The median postoperative hospital stay was 6.90 [5.80, 8.70] days. Two patients experienced postoperative urinary tract infection (Clavien-Dindo Grade II). During the median follow-up of 25.53 ± 15.28 months, patients received 91.18% renal function preservation. No local recurrence occurred in all the patients.ConclusionsRobotic NSS for RSAML is a complicated procedure that demands technical expertise and a well-designed strategy is critical in the operation. Treating RSAML with modified robotic NSS is safe, effective and feasible.

ASO Author Reflections: Perioperative and Oncologic Outcomes of Partial Versus Radical Nephrectomy for Complex Renal Tumors (RENAL Score ≥ 7): Systematic Review and Meta-Analysis.

ASO Author Reflections: Perioperative and Oncologic Outcomes of Partial Versus Radical Nephrectomy for Complex Renal Tumors (RENAL Score ≥ 7): Systematic Review and Meta-Analysis.

Nephrectomy with Autotransplantation-A Key Treasure.

Background: Nephrectomy with autotransplantation (NAT) has been performed as an alternative treatment for complex renovascular lesions, intricate ureteral strictures and nephron-sparing surgery in complex renal tumors. Methods: A retrospective observational study was conducted including patients who underwent a NAT from January 2010 to September 2023. Data collected included surgery indications, surgical technique, complications according to Clavien-Dindo classification and mean hospital stay. Descriptive and inferential statistical analysis was performed using IBM® SPSS® Statistics version 28.0.1.0. Results: A total of 34 consecutive patients underwent 38 NATs at our institution. Surgery indications were complex renovascular conditions in 35 cases (92.1%), of which 24 had renal artery aneurysms, and ureteral injuries in 3 cases (7.9%). Thirty-four kidneys (89.5%) were retrieved through a laparoscopic approach. No significant difference was observed between post- and pre-operative creatinine levels (0.81 vs. 0.72, p = 0.303). Early high-grade complications developed in 12 procedures (31.6%). Median cold ischemia time was significantly longer in patients who developed complications (163.0 vs. 115.0, p = 0.010). The median hospital stay was 10 days (8-13). The median follow-up was 51.5 months. Conclusions: NAT emerges as a successful therapeutic strategy for a highly select group of patients dealing with intricate ureteral lesions and kidney vascular abnormalities, demonstrating positive outcomes that endure in the long term.

Scrutinizing VTE risk factors in complex renal tumor patients: a comprehensive look at the VTE-RT-IVCTT study.

Scrutinizing VTE risk factors in complex renal tumor patients: a comprehensive look at the VTE-RT-IVCTT study.

Outcomes and Techniques of Robotic-Assisted Partial Nephrectomy (RAPN) for Renal Hilar Masses: A Comprehensive Systematic Review.

Background: Robot-assisted partial nephrectomy (RAPN) is increasingly being employed in the management of renal cell carcinoma (RCC) and it is expanding in the field of complex renal tumors. The aim of this systematic review was to consolidate and assess the results of RAPN when dealing with entirely central hilar masses and to examine the various methods used to address the surgical difficulties associated with them. Methods: A thorough literature search in September 2023 across various databases focused on RAPN for renal hilar masses, adhering to PRISMA guidelines. The primary goal was to evaluate RAPN's surgical and functional outcomes, with a secondary aim of examining different surgical techniques. Out of 1250 records, 13 full-text manuscripts were reviewed. Results: Evidence is growing in favor of RAPN for renal hilar masses. Despite a predominance of retrospective studies and a lack of long-term data, RAPN shows positive surgical outcomes and preserves renal function without compromising cancer treatment effectiveness. Innovative suturing and clamping methods are emerging in surgical management. Conclusions: RAPN is a promising technique for managing renal hilar masses in RCC, offering effective surgical outcomes and renal function preservation. The study highlights the need for more long-term data and prospective studies to further validate these findings.

HoloLens® platform for healthcare professionals simulation training, teaching, and its urological applications: an up-to-date review.

The advancements of technological devices and software are putting mixed reality in the frontline of teaching medical personnel. The Microsoft® HoloLens 2® offers a unique 3D visualization of a hologram in a physical, real environment and allows the urologists to interact with it. This review provides a state-of-the-art analysis of the applications of the HoloLens® in a medical and healthcare context of teaching through simulation designed for medical students, nurses, residents especially in urology. Our objective has been to perform a comprehensively analysis of the studies in PubMed/Medline database from January 2016 to April 2023. The identified articles that researched Microsoft HoloLens, having description of feasibility and teaching outcomes in medicine with an emphasize in urological healthcare, have been included. The qualitative analysis performed identifies an increasing use of HoloLens in a teaching setting that covers a great area of expertise in medical sciences (anatomy, anatomic pathology, biochemistry, pharmacogenomics, clinical skills, emergency medicine and nurse education, imaging), and above these urology applications (urological procedures and technique, skill improvement, perception of complex renal tumors, accuracy of calyx puncture guidance in percutaneous nephrolithotomy and targeted biopsy of the prostate) can mostly benefit from it. The future potential of HoloLens technology in teaching is immense. So far, studies have focused on feasibility, applicability, perception, comparisons with traditional methods, and limitations. Moving forward, research should also prioritize the development of applications specifically for urology. This will require validation of needs and the creation of adequate protocols to standardize future research efforts.

Current Application of Navigation Systems in Robotic-Assisted and Laparoscopic Partial Nephrectomy: Focus on the Improvement of Surgical Performance and Outcomes.

Kidney cancer represents the third most prevalent malignancy among all types of genitourinary cancer worldwide. Currently, there is a growing trend of employing partial nephrectomy for the management of large and complex tumors. Surgical outcomes are associated with some amendable surgical factors, including warm ischemic time, pedicle clamping, preserved volume of renal parenchyma, appropriate surgical strategy, and precise resection of the tumor. Improving surgical performance is pivotal for achieving favorable surgical outcomes. Due to advancements in imaging visualization technology and the shift of the medical paradigm toward precision medicine, an increasing number of navigation systems have been implemented in partial nephrectomy procedures. The navigation system can assist surgeons in formulating optimal surgical strategies and enhance the safety, precision, and feasibility of resecting complex renal tumors. In this review, we provide an overview of currently available navigation systems and their feasible applications, with a focus on how they contribute to the improvement of surgical performance and outcomes during robotic-assisted and laparoscopic partial nephrectomy.

Clinical experience of bench surgery combined with autotransplantation after three-dimensional laparoscopic nephrectomy for the treatment of highly complex renal tumor

ObjectiveTo assess the feasibility and safety of three-dimensional (3D) laparoscopic nephrectomy in combination with bench surgery and autotransplantation for treating highly complex renal tumors.Materials and methodsThe clinical data of six patients with highly complex renal cell carcinoma were collected. All patients underwent 3D laparoscopic nephrectomy in combination with bench surgery and autotransplantation by the same surgeons, two of them had previously undergone laparoscopic partial nephrectomy for contralateral renal cancer.ResultsThe total operative time was 366 ± 65 min, the warm ischemia time (WIT) was 1.3 ± 0.4 min, and the cold ischemia time was 121 ± 26 min. While one patient received a diluted autologous blood transfusion, the intraoperative blood loss was 217 ± 194 ml. No increase in the serum creatinine (SCr) level was observed at postoperative day 30 compared with the preoperative time, and none of the patients received dialysis either during the hospital stay or to date. Although one patient underwent nephrectomy due to tumor recurrence in the transplanted kidney, the others reported no tumor recurrence or distant metastases on imaging to date.Conclusion3D laparoscopic nephrectomy, when combined with bench surgery and autotransplantation, can become a feasible option for treating highly complex renal cell carcinoma cases when expecting to preserve renal function maximally.

Nephrometry scores to predict oncological outcomes following partial nephrectomy (UroCCR Study 70).

Partial nephrectomy (PN) for large or complex renal tumors can be difficult and associated with a higher risk of recurrence than radical nephrectomy. We aim to evaluate the clinical useful of nephrometry scores for predicting oncological outcomes in a large cohort of patients who underwent PN for renal cell carcinomas. Our analysis included patients who underwent PN for renal cell carcinoma in 21 French academic centers (2010-2020). RENAL, PADUA, and SPARE scores were calculated based on preoperative imaging. Uni- and multivariate cox models were performed to identify predictors of recurrence-free survival and overall survival. The area under the curve (AUC) was used to identify models with the highest discrimination. Decision curve analyses (DCAs) determined the net benefit associated with their use. A total of 1927 patients were analyzed with a median follow-up of 32months (14-45). RENAL score (p = 0.01), age (p = 0.002), histological type (p = 0.001), high nuclear grade (p = 0.001), necrotic component (p < 0.001), and positive margins (p = 0.005) were significantly related to recurrence in multivariate analyses. The discriminative performance of the 3 radiological scores was modest (65, 63, and 63%, respectively). All 3 scores showed good calibration, which, however, deteriorated with time. Decision curve analysis of the three models for the prediction of overall and recurrence-free survival was similar for all three scores and of limited clinical relevance. The association between nephrometry scores and oncological outcomes after NP is very weak. The use of these scores for predicting oncological outcomes in routine practice is therefore of limited clinical value.

Predictive factors for pentafecta achievement in robot-assisted partial nephrectomy for intermediate highly complex RENAL tumors (RENAL score ≥ 7).

To investigate the predictive factors for pentafecta achievement of robot-assisted partial nephrectomy (RAPN) for intermediate highly complex renal tumors (RENAL score ≥ 7). We retrospectively analyzed the data of 247 patients with renal tumors with a RENAL score ≥ 7 who underwent RAPN. Baseline characteristics and perioperative outcomes were compared between the pentafecta achieved group and the unachieved group. A multivariable logistic regression model was used to identify the predictive factors for pentafecta achievement for cT1 renal tumors with a RENAL score ≥ 7. Of the 247 patients, 75 (30.3%) patients were in the achieved group and 172 (69.7%) patients were in the unachieved group. The median warm ischemia time and total operation time were 18 min versus 23 min (p < 0.001) and 179 min versus 201 min (p < 0.001) in the achieved and unachieved groups, respectively. In the unachieved group, six patients (3.4%) had major perioperative complications (Clavien-Dindo classification system ≥3). The median preservation rates of estimated GFR at the 1-year postoperative period were 96.5% versus 83.0% (p < 0.001) in the achieved and unachieved groups. Multivariable logistic regression models revealed that age and tumor size were independent predictive factors for pentafecta achievement for cT1 renal tumors with a RENAL score ≥ 7. There were no significant differences in cancer-free survival between the two groups (p = 0.456). Age and tumor size were independent predictive factors for pentafecta achievement, although there was no difference in oncological outcomes between the pentafecta achieved group and the unachieved group in RAPN for cT1 renal tumors with a RENAL score ≥ 7.