Association of PADUA and RENAL scores with early perioperative outcomes in large renal tumors managed with robot-assisted partial nephrectomy

Introduction Tumor complexity scoring supports preoperative planning for robot-assisted partial nephrectomy (RAPN), but evidence in larger tumors is limited. We evaluated whether PADUA and RENAL nephrometry scores are associated with early perioperative outcomes in a stage-focused cohort of pathological pT1b or higher renal tumors treated with multiport RAPN. Methods We retrospectively reviewed a prospectively maintained single-center database of multiport RAPN cases (2011–2025). Patients with pathological pT1b–pT2a disease were included. The primary endpoint was a 30-day composite adverse outcome: major complications (Clavien–Dindo ≥3) and/or perioperative transfusion. Secondary endpoints were any complication (Clavien 1–5), transfusion, warm ischemia time (WIT; continuous and >25 min), operative time, length of stay, and trifecta achievement. Associations were tested using logistic regression (penalized models for sparse outcomes), linear regression, and AUC; β represents the adjusted change in the outcome per 1-point increase in score. Results In total, 109 patients were included (PADUA available in 108; RENAL in 83). Neither PADUA nor RENAL was independently associated with the composite adverse outcome, and discrimination was limited (PADUA AUC 0.583, 95% CI 0.411–0.733; RENAL AUC 0.563, 95% CI 0.347–0.775; p = 0.738). Both scores were associated with intraoperative metrics. Each 1-point increase in PADUA correlated with longer WIT (β 1.13 min; 95% CI 0.20–2.07; p = 0.019) and operative time (β 4.55 min; 95% CI 0.20–8.90; p = 0.043). Each 1-point increase in RENAL correlated with longer WIT ( β 1.33 min; 95% CI 0.25–2.40; p = 0.018) and operative time (β 5.01 min; 95% CI 1.62–8.40; p = 0.005). Trifecta achievement was not significantly associated with either score. Conclusion In patients with pathological pT1b or higher renal tumors treated with multiport RAPN, PADUA and RENAL scores were not associated with a 30-day composite adverse outcome and had limited discrimination for major morbidity and/or transfusion, but both correlated with WIT and operative time. Larger externally validated cohorts incorporating longitudinal renal function and broader patient-level risk factors are needed to refine preoperative risk assessment in larger renal tumors.