Predictors of Pentafecta Failure Despite Trifecta Achievement in Robot-Assisted Partial Nephrectomy.

INTRODUCTION: The present study examined factors preventing the achievement of pentafecta in patients who have already met trifecta criteria following robot-assisted partial nephrectomy (RAPN). METHODS: A retrospective observational study was conducted on 103 patients who underwent RAPN for localized renal tumors at Keio University Hospital between 2019 and 2023. Clinical characteristics, surgical parameters, and postoperative renal function were analyzed. Multivariate logistic regression analyses were performed to identify independent predictors of trifecta and pentafecta achievement. RESULTS: The achievement rates for trifecta and pentafecta were 88% and 27%, respectively. Independent predictors of trifecta achievement were tumor size ≤ 20 mm (OR = 5.496, p = 0.039) and estimated blood loss ≤ 50 cc (OR = 7.983, p = 0.011). Significant predictors of pentafecta achievement were age ≤ 63 years (OR = 3.753, p = 0.026) and tumor exophyticity ≥ 50% (OR = 4.054, p = 0.018). Independent predictors of pentafecta failure despite trifecta achievement were age > 63 years (OR = 0.223, 95% CI: 1.347-14.904, p = 0.014) and tumor exophyticity < 50% (OR = 0.205, 95% CI: 1.474-16.159, p = 0.009). The pentafecta failure rate was 95% in patients who achieved trifecta but had both risk factors, namely, older age and embedded tumors. CONCLUSION: Older age and tumor exophyticity < 50% are significant predictors of pentafecta failure despite achieving trifecta. The consideration of these factors may help refine surgical planning and postoperative management.