Predictors of Pentafecta Failure Despite Trifecta Achievement in Robot-Assisted Partial Nephrectomy

Area of Science:

• Urology
• Oncology
• Surgical Innovation

Background:

• Robot-assisted partial nephrectomy (RAPN) offers functional and oncologic benefits for localized renal tumors.
• Achieving trifecta (negative margins, preserved renal function, and no major complications) is common, but pentafecta (adding trifecta plus no positive surgical margins and no genitourinary or gastrointestinal fistulas) remains challenging.
• Identifying factors influencing pentafecta achievement is crucial for optimizing patient selection and surgical strategy.

Purpose of the Study:

• To investigate the factors associated with achieving trifecta and pentafecta criteria after RAPN.
• To identify predictors of pentafecta failure in patients who have already met trifecta criteria.
• To inform surgical planning and postoperative management for improved outcomes.

Main Methods:

• Retrospective observational study of 103 patients undergoing RAPN for localized renal tumors (2019-2023).
• Analysis of clinical characteristics, surgical parameters, and postoperative renal function.
• Multivariate logistic regression to determine independent predictors of trifecta and pentafecta achievement and failure.

Main Results:

• Trifecta and pentafecta achievement rates were 88% and 27%, respectively.
• Predictors for trifecta included smaller tumor size (≤20mm) and less blood loss (≤50cc).
• Predictors for pentafecta included younger age (≤63 years) and higher tumor exophyticity (≥50%).
• Older age (>63 years) and lower tumor exophyticity (<50%) were independent predictors of pentafecta failure despite trifecta achievement, with a 95% failure rate in patients with both factors.

Conclusions:

• Older age and tumors with less exophytic growth (<50%) are significant predictors of pentafecta failure post-RAPN, even when trifecta is achieved.
• These findings highlight the importance of considering patient age and tumor characteristics in surgical planning.
• Refining surgical approaches and postoperative care based on these factors may enhance the likelihood of achieving pentafecta outcomes.