Surgical quality, cancer control and functional preservation: introducing a novel trifecta for robot-assisted partial nephrectomy

Aldo Brassetti, Umberto Anceschi, Riccardo Bertolo, Mariaconsiglia Ferriero, Gabriele Tuderti, Umberto Capitanio, Alessandro Larcher, Juan Garisto, Alessandro Antonelli, Alexander Mottire, Andrea Minervini, Paolo Dell'oglio, Alessandro Veccia, Daniele Amparore, Rocco S Flammia, Andrea Mari, Francesco Porpiglia, Francesco Montorsi, Jihad Kaouk, Riccardo AutorinoMarco Carini, Michele Gallucci, Giuseppe Simone

Research output: Contribution to journalArticlepeer-review


BACKGROUND: In order to improve standard reporting of outcomes after partial nephrectomy, different "trifecta" systems have been conceived. The subjective assessment of the included parameters and the unreliability for off-clamp procedures limited their reproducibility; their role in predicting functional and oncologic outcomes has never been assessed. We propose a new trifecta, based on standardized parameters, that summarizes PN outcomes regardless the clamping technique used and predicts main clinical outcomes.

METHODS: A retrospective analysis of a multicenter, multi-national dataset of patients with non-metastatic cT1-2 renal masses undergoing Robot-assisted partial nephrectomy was performed. Baseline demographic, clinical, pathologic and perioperative data were collected. Trifecta was defined as the coexistence of negative margins, no Clavien-Dindo ≥3 complications and ≤30% postoperative estimated glomerular filtration rate reduction. Univariable and multivariable regression analyses identified predictors of trifecta achievement. Kaplan-Meier method assessed differences in oncological outcomes between patients achieving trifecta or not. Univariable and multivariable Cox regression analysis identified predictors of newly onset chronic kidney disease stage ≥IIIa, recurrence-free and overall survival.

RESULTS: Overall, 1492 patients achieved trifecta. This cohort displayed significantly lower incidence of newly onset IIIa-V chronic kidney disease stages (all P<0.001), higher recurrence-free (P=0.009) and overall (P=0.014) survival probabilities. Patients achieving trifecta had a 65% reduced risk of developing newly onset stage IIIb-V Chronic Kidney Disease and a 55% reduced risk of overall mortality. Heterogeneity of surgical technique is a limitation.

CONCLUSIONS: This novel reproducible trifecta is based on standardized parameters and is an independent predictor of severe chronic kidney disease development and mortality.

Original languageEnglish
Pages (from-to)82-90
Number of pages9
JournalMinerva urologica e nefrologica = The Italian journal of urology and nephrology
Issue number1
Publication statusPublished - Feb 2020


  • Adult
  • Aged
  • Constriction
  • Databases, Factual
  • Female
  • Glomerular Filtration Rate
  • Humans
  • Kidney Neoplasms/surgery
  • Male
  • Margins of Excision
  • Middle Aged
  • Nephrectomy/methods
  • Postoperative Complications/epidemiology
  • Recovery of Function
  • Renal Insufficiency, Chronic/etiology
  • Retrospective Studies
  • Robotic Surgical Procedures/methods
  • Survival Analysis
  • Treatment Outcome


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