Robotic-assisted partial nephrectomy (RAPN) and standardization of outcome reporting: a prospective, observational study on reaching the “Trifecta and Pentafecta”

Abstract

Partial nephrectomy (PN) for small renal masses is common, but outcomes are not reported in a standard manner. Traditionally, parameters such as 90-day mortality, blood loss, transfusion rates, length of stay, nephrometry scoring and complications are published but their collective impact on warm ischemia time (WIT) and post-surgery GFR is rarely determined. Thus, our aim was to assess if “Trifecta” and “Pentafecta” outcomes could be used as useful surgical outcome markers. A prospective database of 252 Robotic-Assisted PN (RAPN) cases (2008–2019) was analysed. “Pentafecta” was defined as achievement of “Trifecta” (negative surgical margin, no postoperative complications and WIT of < 25 min) plus over 90% estimated GFR preservation and no CKD stage upgrading at 1 year. Binary logistic regression analysis was conducted to predict factors which may prevent achieving a Trifecta/Pentafecta. Median tumour size was 3 cm and mean WIT was 15 min. Positive surgical margins (PSM) occurred in 2 cases. Overall, the intra-operative complication rate was 7%. One recurrence conferred 5-year cancer-free survival of 97%. Trifecta outcome was achieved in 169 (67%) and Pentafecta in 141 (56%) of cases. At logistic regression analysis, intraoperative blood loss was the only factor to affect Trifecta achievement (p = 0.018). Advanced patient age negatively impacted Pentafecta achievement (p = 0.010). The Trifecta and Pentafecta outcomes are easily applicable to PN data, and offer an internationally comparable PN outcome, quality measure. We recommend applying this standardization to national data collection to improve the quality of reporting and ease of interpretation of surgeon/centres’ outcomes.

Robot-Assisted Partial Nephrectomy Mid-Term Oncologic Outcomes: A Systematic Review

“…After fulfilling all the inclusion criteria, 13 studies were identified [ 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ], and another 17 studies were excluded mainly because follow-up was too short [ 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 ]. All of the studies had an retrospective design except the ones from Furukawa et al [ 16 ] and Beauval et al [ 24 ].…”

External Validation of a Novel Comprehensive Trifecta System in Predicting Oncologic and Functional Outcomes of Partial Nephrectomy: Results of a Multicentric Series

“…Nonetheless, to regulate surgical training, introduce technical innovations and describe outcomes with a simple and univocal terminology, the ability to predict both oncologic and functional endpoints of PN by these clinical tools remains an unmet need in the urological practice [6][7][8][9]. In recent years, there have been many attempts to modify the original trifecta definition, but several improvements in its predictive ability were offset by being a combination of variables more difficult to incorporate in a single scoring system [10,11]. Brassetti et al have proposed a more comprehensive definition of the original trifecta version replacing the warm ischemia time (WIT) with perioperative estimated glomerular filtration rate (∆GFR) variations, to also include clamp-less procedures [12].…”

Trifecta and pentafecta outcomes following robot-assisted partial nephrectomy in a multi-institutional cohort of Indian patients

“…[ 4 16 20 22 ] Numerous studies have identified predictors of trifecta outcomes in relation to different surgical modalities and patient populations. Perioperative variables such as tumor size,[ 23 24 25 26 27 28 29 ] nephrometry scores (RNS,[ 27 30 31 ] PADUA score,[ 27 28 29 ] C-Index,[ 27 ] Simplified PADUA REnal [SPARE][ 32 ]), surgical approach,[ 23 33 ] pelvicalyceal system involvement,[ 23 ] hospital volume,[ 34 ] hilar location,[ 16 24 ] intraoperative blood loss,[ 24 28 35 ] and the American Society of Anesthesiologists grading[ 23 ] have been identified as independent predictors of the trifecta. However, apart from tumor complexity, none of the other factors have been consistently shown to predict these outcomes.…”