Robot-assisted Partial Nephrectomy for Complex (PADUA score >10) Renal Masses

Abstract

Objective: To evaluate the perioperative outcomes of robot-assisted partial nephrectomy (RAPN) in patients with complex renal masses, stratified by preoperative aspects and dimensions used for an anatomical (PADUA) score, and to assess the utility of the PADUA classification in surgical planning and risk prediction. Materials and Methods: We retrospectively analyzed 354 patients who underwent RAPN between April 2008 and February 2023 using Da Vinci Si and Xi systems. Tumors were classified as complex (PADUA >= 10) or non-complex (PADUA <10) based on preoperative imaging. Demographic data, perioperative outcomes, and renal function parameters were compared between groups. Complications were graded using the Clavien-Dindo system. Results: Of the 354 patients, 124 (35%) had PADUA scores >= 10 (group A), and 230 (65%) had scores <10 (group B). Group A patients were significantly younger (p=0.003) and had had larger tumors, had longer operative and warm ischemia times, had higher blood loss, and had longer hospital stays (all p<0.01). Despite increased complexity, positive surgical margin rates were similar between groups. Postoperative declines in hemoglobin, hematocrit, and estimated glomerular filtration rate, along with increased creatinine levels, were significant (p<0.001). High PADUA scores correlated with increased surgical difficulty and complication risk, supporting its role as a preoperative risk stratification tool. Despite technical challenges, RAPN provided effective oncologic control, with complication and margin rates consistent with those reported in prior studies. Conclusion: RAPN is a safe and effective treatment for complex renal tumors when guided by detailed preoperative assessment using the PADUA score. A multidisciplinary approach and experienced surgical technique are critical for optimizing outcomes in high-complexity cases.