title: Evolution from laparoscopic to robotic nephron sparing surgery: a high-volume laparoscopic center experience on achieving 'trifecta' outcomes.
abstract: OBJECTIVE
  To evaluate the transition from laparoscopic (LPN) to robotic partial nephrectomy (RPN) in our institution using 'trifecta' outcomes as surrogate marker of efficacy.
  
  
  METHODS
  We identified 347 patients (LPN = 303, RPN = 44) in our prospectively maintained PN database between 2000 and 2014. The patients were chronologically divided into G1-first 151 LPN cases, G2-subsequent 152 LPN cases and G3-all RPN patients. Trifecta outcomes were defined as warm ischemia time (WIT) ≤25 min, no positive surgical margin (PSM) and complications ≤Clavien 2. Multivariable logistic model was used to analyze the predictors of the trifecta outcomes.
  
  
  RESULTS
  The tumor complexity significantly increased from G1 to G3. We achieved lower WIT and less high-grade complication (Clavien ≥ 3) from G1 to G2, and the trend continued even with transition to RPN. PSM was consistently low throughout the transition. Renal functional outcomes always showed a significant positive trend, and with RPN, we achieved improved recovery of renal function (44 vs 57 vs 82 %, p < 0.05). The overall 'trifecta' rates increased significantly from G1 to G2 and reached 81.8 % in RPN (48 vs 75.6 vs 81 %, p < 0.01). Multivariate analysis has shown that the use of robot has significant effect on achieving overall trifecta. The limitations of the study are being retrospective and non-randomized, and the trifecta definitions were not externally validated.
  
  
  CONCLUSIONS
  Our transition to RPN was essentially a continuation of our previous LPN experience as we continue to achieve higher 'trifecta' rates inspite of increasing tumor complexity.
authors: Department of Urology, Institute Mutualiste Montsouris, 42, Boulevard Jourdan, 75674, Paris Cedex 14, France.
authors: Arie
authors: A
authors: Carneiro
authors: Department of Urology, Institute Mutualiste Montsouris, 42, Boulevard Jourdan, 75674, Paris Cedex 14, France.
authors: Arjun
authors: A
authors: Sivaraman
authors: Department of Urology, Institute Mutualiste Montsouris, 42, Boulevard Jourdan, 75674, Paris Cedex 14, France. rafaelsanchezsalas.imm@gmail.com.
authors: Rafael
authors: R
authors: Sanchez-Salas
authors: Department of Urology, Institute Mutualiste Montsouris, 42, Boulevard Jourdan, 75674, Paris Cedex 14, France.
authors: Ettore
authors: E
authors: Di Trapani
authors: Department of Urology, Institute Mutualiste Montsouris, 42, Boulevard Jourdan, 75674, Paris Cedex 14, France.
authors: Eric
authors: E
authors: Barret
authors: Department of Urology, Institute Mutualiste Montsouris, 42, Boulevard Jourdan, 75674, Paris Cedex 14, France.
authors: Francois
authors: F
authors: Rozet
authors: Department of Urology, Institute Mutualiste Montsouris, 42, Boulevard Jourdan, 75674, Paris Cedex 14, France.
authors: Marc
authors: M
authors: Galiano
authors: Department of Urology, Institute Mutualiste Montsouris, 42, Boulevard Jourdan, 75674, Paris Cedex 14, France.
authors: Facundo Uriburu
authors: FU
authors: Pizzaro
authors: Department of Urology, Institute Mutualiste Montsouris, 42, Boulevard Jourdan, 75674, Paris Cedex 14, France.
authors: Steeve
authors: S
authors: Doizi
authors: Department of Urology, Institute Mutualiste Montsouris, 42, Boulevard Jourdan, 75674, Paris Cedex 14, France.
authors: Nathalie
authors: N
authors: Cathala
authors: Department of Urology, Institute Mutualiste Montsouris, 42, Boulevard Jourdan, 75674, Paris Cedex 14, France.
authors: Annick
authors: A
authors: Mombet
authors: Department of Urology, Institute Mutualiste Montsouris, 42, Boulevard Jourdan, 75674, Paris Cedex 14, France.
authors: Dominique
authors: D
authors: Prapotnich
authors: Department of Urology, Institute Mutualiste Montsouris, 42, Boulevard Jourdan, 75674, Paris Cedex 14, France.
authors: Xavier
authors: X
authors: Cathelineau
mesh_terms: D000368:Aged; D015331:Cohort Studies; D005260:Female; D061847:Hospitals, High-Volume; D006801:Humans; D007674:Kidney Diseases / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy; D009399:Nephrons; D065287:Robotic Surgical Procedures; D016896:Treatment Outcome
keywords: Kidney neoplasm; Nephron sparing surgery; Partial nephrectomy; Robotic surgery; Trifecta