title: "Trifecta" in partial nephrectomy.
abstract: OBJECTIVE
  We introduce the concept of trifecta outcomes during robotic/laparoscopic partial nephrectomy, in which the 3 key outcomes of negative cancer margin, minimal renal functional decrease and no urological complications are simultaneously realized. We report serial trifecta outcomes in patients treated with robotic/laparoscopic partial nephrectomy for tumor in a 12-year period.
  
  
  METHODS
  A total of 534 patients had complete data available and were retrospectively divided into 4 chronologic eras, including the discovery era--139 from September 1999 to December 2003, conventional hilar clamping era--213 from January 2004 to December 2006, early unclamping era--104 from January 2007 to November 2008 and anatomical zero ischemia era--78 from March 2010 to October 2011. Renal functional decrease was defined as a greater than 10% reduction in the actual vs volume predicted postoperative estimated glomerular filtration rate.
  
  
  RESULTS
  Across the 4 eras tumors trended toward larger size (2.9, 2.8, 3.1 and 3.3 cm, p = 0.08) and yet the estimated percent of kidney preserved was similar (89%, 90%, 90% and 88%, respectively, p = 0.3). Recent eras had increasingly complex tumors that were more often 4 cm or greater (p = 0.03), centrally located (p <0.009) or hilar (p <0.0001). Nevertheless, with significant technical refinement warm ischemia time decreased serially (36, 32, 15 and 0 minutes, respectively, p <0.0001). Renal functional outcomes were superior in recent eras with fewer patients experiencing a decrease (p <0.0001). Uniquely, actual estimated glomerular filtration rate outcomes exceeded volume predicted estimated glomerular filtration rate outcomes only in the zero ischemia cohort in regard to other eras (-9.5%, -11%, -0.9% and 4.2%, respectively, p <0.001). Positive cancer margins were uniformly low at less than 1%. Urological complications trended lower in recent eras (p = 0.01). Trifecta outcomes occurred more commonly in recent eras (45%, 44%, 62% and 68%, respectively, p = 0.0002).
  
  
  CONCLUSIONS
  Trifecta should be a routine goal during partial nephrectomy. Despite increasing tumor complexity, trifecta outcomes of robotic/laparoscopic partial nephrectomy improved significantly in the last decade.
authors.affiliation: Hillard and Roclyn Herzog Center for Robotic Surgery, University of Southern California Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California 90089, USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Hung
authors.forename: Jie
authors.initials: J
authors.lastname: Cai
authors.forename: Matthew N
authors.initials: MN
authors.lastname: Simmons
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
mesh_terms: D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery*; D010535:Laparoscopy; D009392:Nephrectomy / Q000379:methods*; D012189:Retrospective Studies; D012371:Robotics; D016896:Treatment Outcome; D052096:Warm Ischemia