Partial nephrectomy for clinical T2b, T3a, and T3b renal mass: evaluating trifecta achievement and surgical outcomes

Purpose To evaluate the feasibility, and outcomes of partial nephrectomy (PN) for clinical T2b, T3a, and T3b renal mass in a high-volume tertiary care setting. Methods We retrospectively analyzed patients who underwent open or robotic-assisted PN between 2017 and 2024 at a single academic center. Patients had imperative indications for PN [solitary kidney, chronic kidney disease CKD, bilateral neoplasm]. Data on perioperative outcomes, renal function, oncologic endpoints, and Trifecta achievement [no major surgical complications according to Clavien-Dindo classification (CD ≥ 3), negative surgical margins, 80% of estimated new baseline estimated glomerular filtration rate (eGFR)] were collected. Multivariable Firth logistic regression (MLRA) assessed predictors of failure to achieve Trifecta. Results We analyzed 103 patients with (12 T2b/88 T3a/3 T3b) renal mass (median tumor size 6.0 cm/median R.E.N.A.L. score 10). Median ischemia time was 37.0 min (cold in 45.6%, warm in 44.7% and segmental/clampless in 9.7%). Median blood loss was 200 mL. Major post-operative complications occurred in 20.4% [urine leak (9.7%), fluid collection (6.7%), hematoma (2.9%)]. Intraoperative complication rate was 1.9% (2 enterotomies). Microscopic positive surgical margins were observed in 10.7%; mean ΔeGFR was − 14.6 ml/min/1.73m². At median 38-month follow-up, 3-year overall, cancerspecific and recurrence-free survival rates were 92%, 94% and 75%, respectively. Trifecta was achieved in 43.7% patients. On MLRA, receipt of neoadjuvant therapy was associated with higher odds of failure to achieve Trifecta (OR 3.25, 95%CI 1.15–9.20; p = 0.03). Conclusion PN for large and complex locally-advanced renal tumors is feasible with acceptable outcomes in carefully selected patients with imperative indication for nephron preservation. Further investigation is requisite to delineate role of PN in locally-advanced renal mass.