Open, laparoscopic, and robotic techniques for partial nephrectomy for renal cell carcinoma: a comparison of outcomes based on "trifecta" and "pentafecta" criteria

Introduction. There is a dearth of literature comparing the three modalities of partial nephrectomy – open, laparoscopic, and robotic – based on two contemporary criteria, “trifecta” and “pentafecta”. This scarcity justifies the significance of this study.

Objective. To conduct a comparative evaluation of the outcomes of the three methods of partial nephrectomy, assessed against the criteria of “trifecta” and “pentafecta”.

Materials & Methods. The prospective study included 600 patients with renal cell cancer from 2018 to 2022. partial nephrectomy was performed using open (200 patients), laparoscopic (200 patients) and robotic (200 patients) techniques. Outcomes were assessed by “trifecta” (negative surgical margin; warm ischemia time ≤ 25 minutes or without ischemia; no ≥ Clavien-Dindo III grade postoperative complications within 3 months after surgery) and “pentafecta” (“trifecta”, ≥ 90% estimated glomerular filtration rate preservation and no chronic kidney disease stage upgrading 12 months after surgery).

Results. The “trifecta” outcome was achieved in 82%, 89%, and 84% of cases, respectively, using open, laparoscopic, and robotic approaches. No significant differences in outcomes were found between these methods (p > 0.05), according to this criterion. The “pentafecta” outcome was achieved in 53%, 64%, and 66% of cases using the same three approaches, respectively. Significant differences in outcomes between the open approach and the minimally invasive techniques were observed (p < 0.05) based on this criterion. For tumors that were considered easier to resect (R.E.N.A.L. 4 – 6 score), the highest “pentafecta” rates were observed with laparoscopic and robotic procedures. For tumors with moderate complexity (R.E.N.A.L. 7 – 9 score), open surgery resulted in the poorest outcomes, which were significantly different from those of robotic partial nephrectomy (p < 0.05). The laparoscopic approach yielded the poorest results for the most complex tumors (R.E.N.A.L. 10 – 12 score).

Conclusions. In general, all three methods of partial nephrectomy produce the same outcome according to the “trifecta”, but according to the “pentafecta” better results may be achieved using minimally invasive techniques (laparoscopic and robotic procedures). Robotic partial nephrectomy should be considered as the method of choice for high-scored R.E.N.A.L. and cT1 – cT2 tumours.

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