Differential therapeutic efficacy of robotic versus open partial nephrectomy in tumor resection: a meta-analysis with stratified multidimensional meta-regression

Abstract

Abstract Background Differential tumor resection efficacy between robotic and open partial nephrectomy (RPN/RAPN vs. OPN) has been extensively explored. This study comparatively evaluates these nephron-sparing approaches, focusing on the Trifecta outcome and its individual components as composite metrics of surgical quality. Methods A systematic literature review (August 2022–June 2025) identified 56 eligible studies. The primary outcome was Trifecta attainment. Secondary endpoints included major and minor postoperative complications (Clavien–Dindo grade ≥ 3 and ≤ 2, respectively), positive surgical margin (PSM) rates, ischemia time (IT), and postoperative changes in estimated glomerular filtration rate (ΔeGFR) and serum creatinine (ΔCr). Random-effects meta-analysis was performed, supplemented by subgroup and meta-regression analyses stratified by publication period, methodological quality, tumor size, and anatomical complexity. Subgroup analyses also accounted for the two major clusters of Trifecta definitions (eGFR- & IT-based). Sensitivity analyses included studies with higher statistical precision and those without baseline imbalances. Results RPN/RAPN showed a consistent trend toward higher Trifecta achievement (OR: 1.3–1.8), reaching statistical significance in studies employing “ΔeGFR % < 10%” as part of the Trifecta definition. This benefit gradually diminished in tumors > T1a and with increasing complexity. In sensitivity analyses restricted to balanced populations, the advantage persisted only as a directional trend, suggesting potential selection bias in current clinical practice. Major and minor complications were significantly reduced with RPN/RAPN (by 35–45% and 45–50%, respectively), with the benefit for minor complications remaining stable or increasing over time, tumor size, and complexity. RPN/RAPN preserved an additional 2–3 ml/min/1.73 m 2 in postoperative eGFR. While this difference was below clinical significance thresholds in the general population, it proved critical for patients with preoperative CKD stage II–IIIa, in whom robotic access may be the preferred approach. No significant differences were observed in PSM or IT. ΔCr comparisons remained inconclusive. Conclusion RPN/RAPN confers a clear clinical benefit in reducing perioperative morbidity, which likely underpins the observed advantage in Trifecta attainment–particularly in studies incorporating ΔeGFR % in its definition. Although renal function preservation was modest overall, its clinical relevance increases in high-risk patients. The superiority of RPN/RAPN appears largely context-dependent, reflecting current patterns of selective application in favorable surgical candidates.