Trifecta and Pentafecta rates after robotic partial nephrectomy: safety and feasibility in renal masses ≥ 4cm

Roberto Castellucci1, Giulia Primiceri2, Michele Marchioni2, Pietro Castellan1, Carlo D'Orta2, Luca Cindolo1, Luigi Schips1
  • 1 Ospedale "SS. Annunziata", U.O. Urologia (Chieti)
  • 2 Università "G. D'Annunzio" - Ospedale "SS. Annunziata", U.O. Urologia (Chieti)


Robotic Assisted Partial Nephrectomy (RAPN) is preferred to radical nephrectomy because it guarantees superior functional outcomes in patients with small renal masses (RMs). Only a few studies so far have evaluated the feasibility of RAPN for the treatment of RMs ≥ 4 cm (1).
The aim of this study is to evaluate the safety and feasibility of RAPN based on a comparison of trifecta and pentafecta rates for RMs ≥ 4 cm.

Materials and Methods

We retrospectively analyzed prospective collected data from an institutional database of patients undergoing RAPN from September 2013 to November 2016. Demographic and perioperative data were collected and statistically analyzed. Pentafecta is defined as achievement of trifecta (negative surgical margins, no postoperative complications and warm ischemia time ≤ 25 min) with the addition of two other variables, namely, over 90% estimated Glomerular Filtration Rate (eGFR) preservation and no chronic kidney disease stage progression 1 year after surgery.


Overall, 123 patients underwent RAPN. Of those,38 (30.9%) had RMs ≥4 cm. These patients were more frequently symptomatic at diagnosis (23.7 vs 8.2%, p=0.03) and had high PADUA scores (13.2 vs 3.5%, p=0.02). As expected, patients with RMs≥4 cm had longer OT (133.4 vs 105.9 minutes, p<0.01), higher EBL (287.4 vs 166.3 ml, p<0.01),and more frequently showed WIT >25 min(0% vs. 26.3 %, p<0.01). Mean pathologic tumor size was 2.4 cm in patients with RMs smaller than 4 cm and 4.8 in those with RMs larger than 4 cm. . In our study, no significant differences in post-operative complications were found between these two groups. Overall, trifecta and pentafecta were achieved in 64.2% and 19.5% of cases, respectively.. When patients were stratified according to tumor size, trifecta was achieved in 72.9% of those with RMs <4 cm and in 44.7 of those withRMs≥4 cm, whereas achievement rates for pentafecta were 23.5% and 10.5%, respectively. In logistic regression models, patients with RMs≥4 cm were less likely to achieve trifecta (p<0.01);however, RMs≥4 cm were not associated with lower pentafecta rates (p=0.08). On multivariable regression analysis, no significant predictive factors were found in connection with trifecta, whereas with regard to pentafecta the only significant predictor was age(OR: 0.91; 95%CI 0.85-0,98; p = 0.01).


We hypothesized that RAPN would be a safe and reliable procedure even in patients with RMs larger than 4 cm. We also hypothesized that achievement of trifecta and pentafecta, as surrogate markers of surgical success as well as of short- and long-term functional outcomes, would be similar for RMs smaller or larger than 4 cm treated with RAPN. Our data overlap favorably with data available in the literature. As regards perioperative complications after RAPN for larger RMs, data from the literature are controversial. Patel and Ficarra reported higher complications rates for tumors>4 cm, than for tumors<4 cm (26.6 vs 8.9% and 26.5 vs 9.4%, respectively (2-3). In a multicenter study, Petros et al. analized data of 445 patients, 83 of whom had RMs >4 cm, and found no increased risk of perioperative complications after RAPN (4). In our study, patients with RMs smaller or larger than 4 cm had similar perioperative complication rates, again with no significant differences(p=0.37). Likewise, no significant differences were recorded in connection with post-operative 90% eGFR preservation in RMs<4 or ≥4 cm (p=0.38). To the best of our knowledge, only Kim et al examined differences in trifecta and pentafecta rates in patients with pT1a and pT1b tumors. In their study,65.3% of pT1a patients and 43.3% of pT1b patients achieved trifecta, while pentafecta was achieved by38.3% of pT1a patients and by26.7% of pT1b patients (1). Our results corroborate data from the literature, with overall trifecta and pentafecta rates being achieved in 64.2% and 19.5% of cases, respectively.


RAPN is a feasible and safe procedure with good long-term renal outcomes even for patients with large renal masses (≥4cm). Trifecta and pentafecta are important tools for evaluating both short-and long-term perioperative and functional renal outcomes.


1) Kim DK, Kim LHC, Raheem AA, Shin TY, Alabdulaali I, Yoon YE, et al. Comparison of Trifecta and Pentafecta Outcomes between T1a and T1b Renal Masses following Robot-Assisted Partial Nephrectomy (RAPN) with Minimum One Year Follow Up: Can RAPN for T1b Renal Masses Be Feasible? PloS One. Mar 2016;11(3):e0151738.
2) Patel MN, Krane LS, Bhandari A, Laungani RG, Shrivastava A, Siddiqui SA, et al. Robotic partial nephrectomy for renal tumors larger than 4 cm. Eur Urol. Feb2010;57(2):310–6.
3) Ficarra V, Bhayani S, Porter J, Buffi N, Lee R, Cestari A, et al. Robot-assisted partial nephrectomy for renal tumors larger than 4 cm: results of a multicenter, international series. World J Urol. Oct 2012;30(5):665–70.
4) Petros F, Sukumar S, Haber G-P, Dulabon L, Bhayani S, Stifelman M, et al. Multi-institutional analysis of robot-assisted partial nephrectomy for renal tumors >4 cm versus ≤ 4 cm in 445 consecutive patients. J Endourol. Jun 2012;26(6):642–6.