Factors influencing trifecta outcomes following robot-assisted partial nephrectomy for stage I renal cell carcinoma...

To evaluate trifecta achievement and identify predictors of successful outcomes in patients undergoing robot-assisted partial nephrectomy (RAPN) for stage I renal cell carcinoma (RCC) using the Medtronic Hugo™ robotic-assisted surgery (RAS) system, and to compare findings with contemporary literature using the da Vinci and other robotic platforms. This prospective observational study enrolled 77 patients with clinically staged T1 RCC undergoing RAPN using the Hugo™ RAS system at a single tertiary institution between August 2023 and March 2025. The primary endpoint was attainment of trifecta outcome. The trifecta outcome was defined as negative surgical margins, warm ischaemia time (WIT) ≤25 min, and absence of complications (Clavien-Dindo grade ≥ III) within 3 months. Patient demographics, tumour characteristics (including R.E.N.A.L. nephrometry score (RNS)), intraoperative variables, and perioperative outcomes were systematically recorded. Univariate and multivariate logistic regression analyses identified independent predictors of trifecta success using the new robotic system. Contemporary literature was reviewed for comparative analysis. Trifecta was achieved in 62 of 77 patients (80.5%; 95% CI: 69.9-88.1%). Mean patient age was 52.2 ± 13.5 years (81% male); mean tumor size was 3.6 ± 1.3 cm. The majority of tumors were T1a (67.5%) with intermediate complexity (50.6%). Median WIT was 22 (range 12-35) minutes; median R.E.N.A.L. nephrometry score (RNS) was 7 (4-10). All 36 patients with low RNS complexity achieved trifecta, whereas none of the 2 patients with high complexity did (p < 0.001). RNS was the only independent predictor of trifecta achievement on multivariate analysis (OR: 0.35; 95% CI: 0.18-0.68; p = 0.002). No positive surgical margins were identified. Two patients experienced Clavien-Dindo grade III complications (hematuria with clot retention), both managed endoscopically. No intraoperative conversions or perioperative deaths occurred. Postoperative creatinine changes were significantly lower in trifecta-achieved patients (0.12 ± 0.22 mg/dL, 14.1% increase) compared to non-trifecta patients (0.38 ± 0.39 mg/dL, 40.5% increase; p = 0.018), demonstrating enhanced renal functional preservation with successful trifecta achievement. The 80.5% trifecta rate with Hugo™ RAS compares favorably to published da Vinci RAPN series (60-70%) and approaches the 92.6% rate reported in the initial Hugo™ LPN vs. RAPN comparative study. RNS and complexity stratification emerged as the only significant independent predictor, consistent with findings from da Vinci series (Sharma et al.: 60.9%; Furukawa et al.: 62.1%; Kim et al.: 65% in T1a subset) but superior to some published cohorts. RAPN using the Hugo™ RAS system demonstrates high trifecta achievement rates (80.5%) in stage I RCC, with tumor complexity as assessed by R.E.N.A.L. nephrometry score emerging as the critical independent predictor of surgical success. These outcomes compare favorably with, or exceed, published da Vinci series and support the feasibility and safety of the Hugo™ RAS system in the Indian surgical setting. The consistency of RNS as a predictor across multiple robotic platforms suggests that preoperative anatomical assessment should guide patient selection and surgical planning. Multi-institutional studies with extended follow-up and direct head-to-head comparisons are warranted.