title: Trifecta and optimal perioperative outcomes of robotic and laparoscopic partial nephrectomy in surgical treatment of small renal masses: a multi-institutional study.
abstract: OBJECTIVE
  To compare the perioperative outcomes of robotic partial nephrectomy (RPN) with laparoscopic PN (LPN) performed for small renal masses (SRMs), in a large multi-institutional series and to define a new composite outcome measure, termed 'optimal outcome' for the RPN group.
  
  
  METHODS
  Retrospective review of 2392 consecutive cases of RPN and LPN performed in five high-volume centres from 2004 to mid-2013. We limited our study to SRMs and cases performed by surgeons with significant expertise with the technique. The Trifecta was defined as negative surgical margin, zero perioperative complications and a warm ischaemia time of ≤25 min. The 'optimal outcome' was defined as achievement of Trifecta with addition of 90% estimated glomerular filtration rate preservation and no chronic kidney disease stage upgrading. Univariable and multivariable analysis were used to identify factors predicting Trifecta and 'optimal outcome' achievement.
  
  
  RESULTS
  In all, 1185 RPN and 646 LPN met our inclusion criteria. Patients in the RPN group were older and had a higher median Charlson comorbidity index and higher R.E.N.A.L. nephrometry score. The RPN group had lower warm ischaemia time (18 vs 26 min), overall complication rate (16.2% vs 25.9%), and positive surgical margin rate (3.2% vs. 9.7%). There was a significantly higher Trifecta rate for RPN (70% vs 33%) and the rate of achievement of 'optimal outcome' for the RPN group was 38.5%.
  
  
  CONCLUSIONS
  In this large multi-institutional series RPN was superior to LPN for perioperative surgical outcomes measured by Trifecta. Patients in the RPN group had better outcomes for all three components of Trifecta compared with their LPN counterparts. Our more strict definition for 'optimal outcome' might be a better tool for assessing perioperative and functional outcomes after minimally invasive PN. This tool needs to be externally validated.
authors.affiliation: Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH, USA.
authors.forename: Homayoun
authors.identifier: http://orcid.org/0000-0001-8424-1087
authors.initials: H
authors.lastname: Zargar
authors.affiliation: The Johns Hopkins Medical Institutions, James Buchanan Brady Urological Institute, Baltimore, MD, USA.
authors.forename: Mohamad E
authors.initials: ME
authors.lastname: Allaf
authors.affiliation: Dept. of Urology, Washington University School of Medicine, St. Louis, MO, USA.
authors.forename: Sam
authors.initials: S
authors.lastname: Bhayani
authors.affiliation: Dept. of Urology, New York University School of Medicine, New York, NY, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Stifelman
authors.affiliation: Henry Ford Health System, Vattikuti Urology Institute, Detroit, MI, USA.
authors.forename: Craig
authors.initials: C
authors.lastname: Rogers
authors.affiliation: The Johns Hopkins Medical Institutions, James Buchanan Brady Urological Institute, Baltimore, MD, USA.
authors.forename: Mark W
authors.initials: MW
authors.lastname: Ball
authors.affiliation: Dept. of Urology, Washington University School of Medicine, St. Louis, MO, USA.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Larson
authors.affiliation: Dept. of Urology, New York University School of Medicine, New York, NY, USA.
authors.forename: Susan
authors.initials: S
authors.lastname: Marshall
authors.affiliation: Henry Ford Health System, Vattikuti Urology Institute, Detroit, MI, USA.
authors.forename: Ramesh
authors.initials: R
authors.lastname: Kumar
authors.affiliation: Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH, USA.
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
mesh_terms: D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007680:Kidney Neoplasms / Q000453:epidemiology* / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods / Q000706:statistics & numerical data*; D059351:Organ Sparing Treatments / Q000379:methods / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000379:methods / Q000706:statistics & numerical data*; D016896:Treatment Outcome
keywords: Trifecta; favourable outcome; laparoscopic partial nephrectomy; nephron-sparing surgery; perioperative outcomes; robotic partial nephrectomy