Tumor anatomy predictors of mic and trifecta achievement in robot-assisted partial nephrectomy: a multicenter analysis stratified by PADUA score.

To assess the impact of individual anatomical components of the PADUA score on achieving composite surgical success metrics such as MIC and Trifecta in patients undergoing RAPN, and to identify subcomponents with independent predictive value for perioperative results. Data from 3,248 consecutive patients who underwent robotic nephron-sparing surgery at nine tertiary centers between 2010 and 2023 were retrospectively analyzed. Tumors were stratified into low/intermediate (PADUA 6-9) and high complexity (PADUA ≥ 10). Primary endpoints were MIC (negative margins, warm ischemia time < 20 min, and absence of severe postoperative complications (Clavien-Dindo grade ≥ III) and Trifecta (negative margins, ischemia time not exceeding 25 min, and an uncomplicated postoperative course). Associations between individual PADUA components and outcomes were assessed using uni- and multivariable logistic regression analyses. Among the 3,248 RAPN cases, low/intermediate-complexity tumors accounted for 72.3% (n = 2,348) and high-complexity tumors for 27.7% (n = 900). MIC was achieved in 92.2% vs. 86.3% and Trifecta in 83.5% vs. 77.0% of patients with low/intermediate versus high complexity (both p < 0.001). In multivariable analysis, tumor diameter remained the sole independent anatomical predictor of MIC (OR 0.98, 95% CI 0.97-0.99; p = 0.012). For Trifecta, tumor size (OR 0.98, 95% CI 0.98-0.99; p = 0.011) and collecting system involvement (OR 0.75, 95% CI 0.61-0.94; p = 0.014) were independently linked with outcome achievement. High-complexity tumors showed increased operative duration, extended ischemia exposure, and a more pronounced decline in postoperative renal function (all p < 0.001). RAPN remains a viable option for high-complexity renal tumors, despite increased surgical challenges. Tumor size and collecting system involvement were the primary independent predictors of perioperative composite success, which may help refine preoperative risk assessment alongside composite nephrometry scores.