Robotic Partial Nephrectomy: Different Surgical Approaches for Different Locations

BACKGROUND: The adoption of robotic partial nephrectomy has grown significantly over the past decade, prompting a debate on the merits of transperitoneal versus retroperitoneal surgical access. This study evaluated the association between surgical route (transperitoneal, TRPN; retroperitoneal, RRPN) and pentafecta achievement using a detailed location classification. METHODS: We retrospectively analyzed 368 patients who underwent RPN. Tumor location was classified into four main categories (anteromedial, AM; anterolateral, AL; posteromedial, PM; posterolateral, PL). Inverse probability of treatment weighting (IPTW) with covariate balancing propensity score (CBPS) balanced baseline covariates. Weighted logistic regression assessed the interaction between surgical approach and location on pentafecta achievement. Statistical methods employed included the binomial test, chi-square test, and Mann-Whitney U test. RESULTS: After IPTW, all covariates were balanced (SMD < 0.1). Compared with RRPN, TRPN significantly reduced pentafecta odds for PL (OR = 0.03, 95% CI 0.005-0.13, p < 0.001) and PM tumors (OR = 0.08, 95% CI 0.015-0.39, p = 0.002), but significantly increased odds for AL tumors (OR = 10.45, 95% CI 2.91-37.48, p < 0.001). No significant difference was found for AM tumors (OR = 0.13, p = 0.053). Low R.E.N.A.L. complexity independently predicted higher pentafecta odds (OR = 3.67, p = 0.034). CONCLUSIONS: A location-guided strategy is supported: TRPN is superior for AL tumors, while RRPN achieves better pentafecta rates for PL and PM tumors. Individualized approach selection based on detailed tumor anatomy is essential. Prospective multicenter studies are warranted to validate these findings.