Risk Factors for Recurrence Following Robot-Assisted Laparoscopic Partial Nephrectomy (RAPN): A Single-Center Retrospective Study

Risk Factors for Recurrence Following Robot-Assisted Laparoscopic Partial Nephrectomy (RAPN): A Single-Center Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk Factors for Recurrence Following Robot-Assisted Laparoscopic Partial Nephrectomy (RAPN): A Single-Center Retrospective Study Masaharu Oki, Kojiro Ohba, Tsuyoshi Matsuda, Kensuke Mitsunari, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8609417/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background The recurrence rate after robot-assisted laparoscopic partial nephrectomy (RAPN) for renal cell carcinoma varies, and few established risk factors have been identified. We investigated the postoperative recurrence rate and its risk factors following RAPN. Methods Among 221 patients who underwent RAPN at our institution from 2016 to 2024, we collected patient background and surgical information for 205 patients diagnosed with renal cell carcinoma (excluding benign diseases). We retrospectively examined postoperative recurrence rates and risk factors for recurrence. Results Postoperative recurrence was observed in 11 cases: 3 local recurrences and 8 non-local recurrences. The postoperative recurrence rate was 5.3%. The median time to postoperative recurrence was 15 months. Univariate analysis identified sex, lateral renal fat thickness, dorsal renal fat thickness, tumor size, operative time, warm ischemia time, pathological tumor (pT) stage ≥ 3a, and Fuhrman grade ≥ 3 as factors associated with postoperative recurrence. Receiver operating characteristic curve analysis identified the following cutoff values: tumor size: 34 mm, lateral renal fat thickness: 20.73 mm, dorsal renal fat thickness: 11.85 mm, and warm ischemia time: 24 minutes. Multivariate analysis identified pT stage ≥ 3a (odds ratio: 6.61, 95% confidence interval: 1.05–41.6; p = 0.04) and Fuhrman grade ≥ 3 (odds ratio: 7.81, 95% confidence interval: 1.69–36.1; p < 0.01) as independent predictors of postoperative recurrence. Positive resection margins were observed in seven cases (3.4%); however, postoperative recurrence occurred in only one of these seven cases, suggesting no association with postoperative recurrence. Conclusions Positive resection margins were not associated with the risk of postoperative recurrence after RAPN for renal cell carcinoma. pT stage ≥ 3a and Fuhrman grade ≥ 3 were significantly and independently associated with postoperative recurrence. renal cell carcinoma robot-assisted partial nephrectomy recurrence risk factor Figures Figure 1 Figure 2 Background More than 400 000 people worldwide are diagnosed with renal cell carcinoma (RCC) each year 1) . Recent advances in diagnostic imaging have led to more than half of all RCC being discovered incidentally in asymptomatic patients 2) . In 85% of patients with incidentally discovered renal cell carcinomas, tumors measure < 4 cm in size 3) , and the National Comprehensive Cancer Network guidelines recommend partial nephrectomy (PN) as the first-line treatment option in such cases 4) . The background to this recommendation is that PN has advantages over radical nephrectomy (RN) in preserving renal function. Furthermore, the recurrence rate after PN in localized RCC is approximately 1.9%–3.2% 5–7) , and PN is considered to carry no greater risk of recurrence compared with RN 8) . However, PN is associated with a higher risk of perioperative complications compared with RN 9) . Robot-assisted surgery enables precise surgery by tremor filtration and providing a clear, three-dimensional surgical field. These technological advances have led to the widespread implementation of robot-assisted partial nephrectomy (RAPN). Many studies have reported that RAPN has a lower complication rate compared with open PN 10) . The number of cases in which RAPN is performed even for renal tumors larger than 4 cm has recently increased; therefore, the importance of RAPN is increasing 11) . However, PN is associated with a risk of positive resection margins 12) . This is because it may be difficult to recognize the tumor outline, which may result in cutting into the tumor, even if RAPN involves renal arterial clamping to decrease bleeding from the resection surface. Some reports indicate that positive margins are associated with recurrence risk 13) and poorer overall survival 14) . Furthermore, even for small renal masses, it is often difficult to decide whether the clinical stage is T1 or T3, and it is unclear to what extent this decision contributes to postoperative recurrenc 15) . Therefore, understanding recurrence risk factors, including positive margins, is crucial to appropriately determine PN indications. While reports on recurrence risk factors exist for PN, few have specifically identified recurrence risk factors for RAPN 6) . The objectives of the present study were to examine recurrence risk factors in patients who underwent RAPN for localized renal cell carcinoma at our institution and to evaluate outcomes in cases with positive resection margins. Methods We retrospectively analyzed 205 patients diagnosed with renal cell carcinoma, excluding benign diseases, among 221 patients who underwent RAPN at our institution between 2016 and 2024. RAPN was performed using a Da Vinci Si or Xi surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). The surgical approach, either transperitoneal or retroperitoneal, was selected on the basis of the tumor location. Recurrence was defined as local recurrence when new lesions were identified within the surgical field of PN on postoperative follow-up computed tomography, and as non-local recurrence for all other recurrences, including distant metastases. Evaluation items comprised the following preoperative features: age, sex, side (left/right), body mass index, estimated glomerular filtration rate, creatinine concentration, RENAL nephrectomy score (tumor size, exophytic growth, distance to renal hilum, anterior or posterior, tumor location), and perirenal fat thickness (dorsal fat thickness, lateral fat thickness). Operative features comprised operative time, console time, warm ischemia time, approach method (intra-peritoneal or retroperitoneal), blood loss, presence of a urinary tract opening, and presence of renal parenchymal suturing. The examined pathological features comprised pathological diagnosis, pathological tumor (pT) stage, Fuhrman grade, sarcomatoid change, rhabdoid change, and positive margins. Perirenal fat thickness is an item in the Mayo adhesive probability score, recently reported as an indicator of RAPN surgical difficulty 16) , and was included in this study. As shown in Fig. 1 , perirenal fat thickness (from the renal capsule to the muscle) was measured at the level of the renal hilum. Statistical analysis Continuous variables were analyzed using the Mann–Whitney U test, and categorical variables were analyzed using the chi-square test. Odds ratios for recurrence risk factors were calculated using logistic regression models. Kaplan–Meier survival curves were plotted for recurrence-free survival (RFS), and the log-rank test was used for comparisons between groups. Statistical analyses were performed using EZR (Easy R, Version 1.68; Saitama Medical University, Saitama, Japan) and GraphPad Prism, Ver. 7.01 (GraphPad, San Diego, CA, USA). Statistical significance was defined as p < 0.05. This study was performed in accordance with the principles outlined in the Declaration of Helsinki, and was approved by the Ethics Review Committee of Nagasaki University hospital (Approval Number: 24111405). Because this was a retrospective observational study, the need to obtain patient informed consent was waived by the Ethics Review Committee of Nagasaki University hospital. Results The median age of all patients was 69 years (range, 61–76 years). Of the 205 cases, 146 (71%) were male, and the median body mass index was 24.0 kg/m². The median preoperative estimated glomerular filtration rate was 63 mL/min/1.73 m², and the median preoperative serum creatinine concentration was 0.87 mg/dL. The median lateral perirenal fat thickness was 15.4 mm, and the median dorsal perirenal fat thickness was 11.1 mm. Preoperative clinical tumor (cT) stage was cT1a in 153 cases (75%), cT1b in 50 cases (24%), and cT2a in 2 cases (1%). Regarding the RENAL nephrectomy score factors, the median tumor diameter was 31.9 mm, and 19 cases (9.2%) had a score of 3 (medial extension) for lateral extension. The median distance to the renal sinus was 2.18 mm. Tumor location was anterior in 114 cases (55.6%), and the relationship between tumor position and the upper/lower pole line was 3 points in 72 cases (35.1%). Overall recurrence was observed in 11 cases (5.3%), namely 3 cases (1.4%) of local recurrence and 8 cases (3.9%) of non-local recurrence. Table 1 shows the details of the patients with recurrence. The median period from RAPN to local recurrence was 14 months (range: 6–16 months), and the median period from RAPN to non-local recurrence was 18.5 months (range: 3–71 months). Among cases of non-local recurrence, five included distant metastases. Metastatic sites comprised the lung in three cases, bone in two cases, and liver in two cases (including overlapping cases). None of the three cases with local recurrence had a positive surgical margin. Table 1. Details of the Patients with Recurrence after RAPN Cases of local recurrence (n=3) Age Size(mm) Fuhrman grade Sarcomatoid pT Margin Time to recurrence Recurrence site 1 73 42.7 4 (+) 1a (-) 6 months Local recurrence 2 57 42.3 4 (-) 3a (-) 14 months Local recurrence 3 79 37.9 2 (-) 3a (-) 16 months Local recurrence Cases of non-local recurrence (n=8) Age Size(mm) Fuhrman grade Sarcomatoid pT Margin Time to recurrence Recurrence site 1 84 64.5 3 (-) 3a (+) 3 months Peritoneal dissemination 2 61 26.9 3 (-) 1a (-) 6 months Right iliac metastasis 3 65 34.2 3 (+) 3a (-) 6 months Lung and liver metastases, Peritoneal dissemination 4 72 37.4 4 (-) 1a (-) 15 months Lung metastasis 5 59 60.1 3 (-) 1b (-) 22 months Surgical wound recurrence 6 68 40.7 2 (-) 1a (-) 36 months Lung and bone metastases 7 56 30.8 2 (-) 1a (-) 60 months Ipsilateral renal recurrence 8 69 40.1 2 (-) 1a (-) 71 months Liver metastasis RAPN, robot-assisted partial nephrectomy; pT, pathological tumor stage Table 2 shows the preoperative features associated with recurrence. In the univariate analysis, male sex ( p = 0.03), lateral perirenal fat thickness ( p < 0.01), dorsal perirenal fat thickness ( p = 0.02), and tumor size ( p = 0.01) were significantly associated with recurrence. Table 3 shows the factors related to surgery (operative features). In the univariate analysis, operative time ( p = 0.01), console time ( p = 0.01), and warm ischemia time ( p = 0.04) were significantly associated with recurrence. Table 4 shows the pathological features. In the univariate analysis, pT stage (p < 0.01), Fuhrman grade (p < 0.01), and sarcomatoid change (p < 0.01) were significantly associated with recurrence. Among the seven cases with positive margins, recurrence developed in only one case (14.2%), indicating no association with recurrence (p = 0.32). Table 2 Patients’ preoperative characteristics No recurrence (n = 194) Recurrence (n = 11) p value Age * 69 [61–76] 68[60–72] 0.69 Sex (M/F) 135/59 11/0 0.03 R/L 96/98 3/8 0.21 BMI (kg/m²) * 23.9[21.6–26.3] 24.4[22-26.2] 0.71 eGFR (mL/min/.73m²) * 63[48.8–75] 62.3[51.2–88.9] 0.8 Cre (mg/dL) * 0.87[0.72–1.09] 0.96[0.81–1.14] 0.24 Thickness of lateral renal fat (mm) * 15[8.8–22] 255.6[22.2–29.6] < 0.01 Thickness of back renal fat (mm) * 10.3[4.3–17.6] 16.7[14.5–22.3] 0.02 RENAL score all score (4/5/6/7/8/9/10) 7/9/40/46/33/42/16 0/0/1/2/4/3/1 0.77 R (mm) * 31.8[26.2–38.8] 40.1[35.8–42.5] 0.01 E (1/2/3) 80/96/18 6/4/1 0.65 N (mm) * 2.23[1.22–4.77] 1.73[0.79–3.09] 0.24 A (a/p/unclassified) 110/83/1 4/7/0 L (1/2/3/unclassified) 72/53/68/1 3/4/4/0 0.68 M, male; F, female; R/L, right/left; BMI, body mass index; eGFR, estimated glomerular filtration rate; Cre, creatinine; R, radius (maximal diameter); E, exophytic/endophytic properties; N, nearness of the tumor to the collecting system or sinus; A, anterior/posterior; L, tumor location relative to the polar lines Table 3 Operative features No recurrence (n = 194) Recurrence (n = 11) p value Operation time (minutes) 198[174–226] 249[194–278] 0.01 Console time (minutes) 129[103–153] 171[126–206] 0.01 Ischemia time (minutes) 17[ 14 – 22 ] 26[16–28] 0.04 Transperitoneal/retroperitoneal 122/72 5/6 0.33 Bleeding (mL) 60[30–200] 130[105–244] 0.08 Urinary tract opening 98 (50%) 8 (72%) 0.21 Inner suture 88 (45%) 5 (45%) 1 Table 4 Pathological features No recurrence (n = 194) Recurrence (n = 11) p value Pathology 0.37 clear 165 (85%) 11(100%) papillary 12 (6%) 0 chromophobe 7 (4%) 0 mucinous tubular and spindle 4 (2%) 0 others 6 (3%) 0 pT stage < 0.01 T1a 169(87%) 6 (55%) T1b 16(8%) 1 (9%) T3a 9 (5%) 4 (36%) Fuhrman grade < 0.01 grade 1 39 (20%) 0 grade 2 131 (67%) 4 (36%) grade 3 17 (9%) 4 (36%) grade 4 5 (3%) 3 (28%) unknown 3 (1%) 0 Sarcomatoid change 1 (1%) 2 (18%) < 0.01 Rhabdoid change 0 (0%) 1 (9%) 0.05 Positive surgical margin 6 (3%) 1 (9%) 0.32 pT, pathological tumor stage Logistic regression analysis was performed using factors significantly associated with recurrence in the univariate analysis (Table 5 ). Positive margins again showed no association with recurrence (p = 0.31; hazard ratio (HR): 3.13, 95% confidence interval (CI): 0.34–28.6). In the multivariate analysis, pT stage ≥ 3a (p = 0.04; HR: 6.61; 95% CI: 1.05–41.6) and Fuhrman grade ≥ 3 (p = 0.008; HR: 7.81; 95% CI: 1.69–36.1) were significantly and independently associated with recurrence. Table 5 Logistic regression analysis of the risk factors for recurrence of renal cell carcinoma after RAPN Univariable Multivariable OR (95%CI) p OR (95%CI) p Thickness of lateral renal fat 1.09 (1.02–1.15) < 0.01 Tumor size 1.05 (1.01–1.10) 0.02 Console time 1.02 (1.01–1.04) < 0.01 pT≥3a 11.7 (2.9–47.6) < 0.01 6.61 (1.05–41.6) 0.04 Fuhrman ≥ 3 13.5 (3.66–49.9) < 0.01 7.81 (1.69–36.1) < 0.01 Positive surgical margin 3.13 (0.34–28.6) 0.31 RAPN, robot-assisted partial nephrectomy; OR, odds ratio; CI, confidence interval; pT, pathological tumor stage Thirty-seven (18%) patients had either pT stage ≥ 3a or Fuhrman grade ≥ 3 (high-risk group). Compared with the 169 patients in the low-risk group (i.e., neither pT stage ≥ 3a nor Fuhrman grade ≥ 3), RFS was significantly shorter in patients meeting either criterion (HR: 15.6; 95% CI: 4.1–59.9; p < 0.01) (Fig. 2 ). Discussion In the present study, we demonstrated that male gender, operative time, perirenal fat thickness, tumor size, pT stage ≥ 3, Fuhrman grade ≥ 3, and sarcomatoid change were risk factors for postoperative recurrence after RAPN in the univariate analysis. Multivariate analysis revealed that pT stage ≥ 3 and Fuhrman grade ≥ 3 were significant and independent risk factors. Furthermore, among the seven cases with positive margins, only one case (14.2%) developed recurrence, indicating no association with recurrence. Numerous reports have identified pT stage, tumor size, and malignancy grade (Fuhrman grade in the present study) as risk factors for recurrence after PN 5–7, 14) . Systematic reviews have reported similar findings 17) , and these factors are increasingly recognized as established risk factors for recurrence after PN. The present study also demonstrated that pT stage ≥ 3a and Fuhrman grade ≥ 3 were independent risk factors for recurrence. However, both factors are reported risk factors for recurrence not only after PN but also after RN 18, 19) . Combined with the finding in the present study that positive resection margins were not associated with recurrence risk, we consider that in cases with pT stage ≥ 3a and Fuhrman grade ≥ 3, circulating cancer cells or microscopic distant metastases are highly likely at the time of surgery. Therefore, this should not be the basis for avoiding PN. In contrast, even with a negative resection margin, careful imaging follow-up with computed tomography or similar modalities is likely necessary in cases with pT stage ≥ 3a and Fuhrmann grade ≥ 3. Perirenal fat thickness was measured as a simple indicator of perirenal fat volume and was identified as a risk factor for recurrence in the present study. Some reports suggest that adipose tissue has a favorable prognostic effect on RCC, such as the finding that a larger visceral fat area was associated with prolonged progression-free survival and overall survival in metastatic renal cell carcinoma 20) . However, other reports indicate that Wnt-related factors secreted from perirenal adipose tissue increase the cell motility of clear cell RCC; thereby, promoting progression from localized RCC to locally advanced RCC 21) . Thus, the impact of perirenal fat thickness on RCC remains unclear. In the present study, perirenal fat thickness was identified as a risk factor for recurrence after PN. Beyond the mechanisms described above, increased surgical difficulty owing to perirenal fat may also have contributed to recurrence. While the poor prognosis of sarcomatoid RCC is well-established 22) , few studies have reported its association with recurrence risk after PN. This lack of studies may be because of the rarity of sarcomatoid RCC and the fact that most cases are advanced, making affected individuals less suitable candidates for PN. However, reports indicate no difference in postoperative outcomes between RN and PN for sarcomatoid RCC 23) and that PN shows non-inferiority regarding cancer-specific survival compared with RN 24) . Therefore, sarcomatoid transformation itself should not be considered a reason to avoid PN. Although operative time, console time, and warm ischemia time were associated with postoperative recurrence after PN in the present study, this likely reflects increased surgical difficulty owing to other risk factors, such as tumor size and perirenal fat thickness, rather than the impact of operative time itself. However, similar to the findings in the present study, other reports 6) have also found an association between operative time and postoperative recurrence after PN. On the basis of findings suggesting that intraoperative seeding of tumor cells affects outcomes 25) , we consider that prolonged operative time, reflecting increased intraoperative manipulation, could be a risk factor for recurrence after PN. There is currently no consensus regarding whether positive resection margins constitute a risk factor for postoperative recurrence after PN. A large single-center cohort study by Morrone et al. reported a close relationship between positive resection margins and RFS 26) . Similarly, the large-scale, multicenter retrospective MARGINS study 27) , which also examined the impact of positive surgical margins on prognosis, reported that RFS and overall survival were unaffected by positive margins, and local recurrence was observed in only 5.9% of cases with positive margins. Although positive resection margins appear to be associated with recurrence risk, residual tumor cells may undergo ischemia or necrosis owing to intraoperative hemostasis or cauterization. Alternatively, cells present at the margins of the surgical specimen may not remain at the resection bed. Further research is needed. This study has limitations. First, as a single-center, non-randomized, retrospective study, the sample size was small, and there is high potential for treatment selection bias. Furthermore, because postoperative follow-up was often performed at other institutions, the observation period at our hospital was short, preventing evaluation of long-term prognosis. However, because patients with recurrence during follow-up were generally referred back to our hospital for treatment of the recurrent lesion, recurrence events are unlikely to have been missed. Additionally, while local recurrence and distant metastasis were both defined as recurrence, their underlying mechanisms differ. Therefore, this definition of recurrence may not accurately reflect the specific risk factors for each scenario. Because of the small number of recurrence events and the difficulty of statistical analysis, these events were treated as similar recurrence events in the present study. Conclusions Regarding risk factors for postoperative recurrence of renal cell carcinoma after RAPN, positive resection margins showed no association, while pT stage ≥ 3a and Fuhrman grade ≥ 3 were significantly and independently associated with recurrence. Abbreviations RAPN; robot assisted laparoscopic partial nephrectomy pT stage; pathological tumor stage cT stage; clinical tumor stage RCC; renal cell carcinoma PN; partial nephrectomy RN; radical nephrectomy RFS; recurrence-free survival HR; hazard ratio CI; confidence interval Declarations Ethics approval and consent to participate This study was performed in accordance with the principles outlined in the Declaration of Helsinki, and was approved by the Ethics Review Committee of Nagasaki University hospital (Approval Number: 24111405). Because this was a retrospective observational study, the need to obtain patient informed consent was waived by the Ethics Review Committee of Nagasaki University hospital. Consent for publication Not applicable. Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing interest The authors have nothing to disclose. Funding No funding was received for this study. Author’s contributions Masaharu Oki: Writing – original draft and visualization; Kojiro Ohba: Conceptualization, methodology, and writing – review & editing; Tsuyoshi Matsuda: Investigation, formal analysis; Kensuke Mitsunari: Software, data curation; Tomohiro Matsuo: Investigation, formal analysis; Yasushi Mochizuki: Project administration; Ryoichi Imamura: Supervision. Acknowledgments We thank Jane Charbonneau, DVM, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript. References Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. Cancer J Clin. 2024;74(3):229–63. 10.3322/caac.21834 . Kane CJ, Mallin K, Ritchy J, et al. Renal cell cancer stage migration: analysis of the National Cancer Data Base. Cancer. 2008;113(1):78–83. 10.1002/cncr.23518 . Ha SC, Zlomke HA, Cost N et al. The past, present, and future in management of small renal masses. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8609417","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":597700736,"identity":"8a71b1ee-0e84-4c48-b6a4-e31a8c140599","order_by":0,"name":"Masaharu Oki","email":"","orcid":"","institution":"Nagasaki University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Masaharu","middleName":"","lastName":"Oki","suffix":""},{"id":597700737,"identity":"47fdca2f-3ab3-4c32-854c-56125c9cb0f6","order_by":1,"name":"Kojiro Ohba","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYDACCR4gccAGyjsgAWXwENSSRrqWwzAtRLiLX7r34AeGM+fz+PsXP/7w44wFg8EB5ocfGGTu4NQiOedcsgTDjdvFEjeemUn23JAAamEzlmDgeYZTi8GNHAPpPx9uJzbcOGDGwPNBon7DAQYzoF8O49Ni/IPhw7nE+TeOf/745wPIFvZvhLSYAR12IHHD+R4DaR6ww3jw2yI5Iy/NguFMcuLGGzxl0jJnJBgkD/MUSyTg8Qu/RO7hGwzH7BLnnT+++eObY3UMfMfbN3742IM7xBBAIgHKYAbixJ4DRGjhR1H0gxgto2AUjIJRMEIAAK/nXJMUKTNSAAAAAElFTkSuQmCC","orcid":"","institution":"Nagasaki University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Kojiro","middleName":"","lastName":"Ohba","suffix":""},{"id":597700738,"identity":"62465fed-ee47-47d8-80bb-0b6023dce109","order_by":2,"name":"Tsuyoshi Matsuda","email":"","orcid":"","institution":"Nagasaki University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tsuyoshi","middleName":"","lastName":"Matsuda","suffix":""},{"id":597700739,"identity":"f8c9b0b2-4f0f-4071-9482-3d7c576d79cb","order_by":3,"name":"Kensuke Mitsunari","email":"","orcid":"","institution":"Nagasaki University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kensuke","middleName":"","lastName":"Mitsunari","suffix":""},{"id":597700740,"identity":"c54f329f-6a5b-4ace-92cb-9b2d461afbf1","order_by":4,"name":"Tomohiro Matsuo","email":"","orcid":"","institution":"Nagasaki University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tomohiro","middleName":"","lastName":"Matsuo","suffix":""},{"id":597700741,"identity":"6aff02de-61c5-4236-8682-2f66270385ed","order_by":5,"name":"Yasushi Mochizuki","email":"","orcid":"","institution":"Nagasaki University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yasushi","middleName":"","lastName":"Mochizuki","suffix":""},{"id":597700742,"identity":"19e3166d-ccf5-4a42-b084-7689135f646d","order_by":6,"name":"Ryoichi Imamura","email":"","orcid":"","institution":"Nagasaki University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ryoichi","middleName":"","lastName":"Imamura","suffix":""}],"badges":[],"createdAt":"2026-01-15 10:23:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8609417/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8609417/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103733621,"identity":"35aea0c5-a310-435b-8c22-8ac1903ef430","added_by":"auto","created_at":"2026-03-02 09:28:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":536628,"visible":true,"origin":"","legend":"\u003cp\u003eDefinition of perirenal fat thickness\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8609417/v1/6ab7767374feeff9f1c27f3f.png"},{"id":103733615,"identity":"9e3c4979-cae6-41ac-97c3-82c3903b29cf","added_by":"auto","created_at":"2026-03-02 09:28:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":36473,"visible":true,"origin":"","legend":"\u003cp\u003eRecurrence-free survival by risk category in patients with renal cell carcinoma who underwent robot-assisted partial nephrectomy\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8609417/v1/423bf7993570eed55c02c030.png"},{"id":103733675,"identity":"8eed3155-5e82-428e-9c00-7c21ddc663ad","added_by":"auto","created_at":"2026-03-02 09:29:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1479699,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8609417/v1/166b6ddb-8c19-47e3-bb65-7702056822b6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk Factors for Recurrence Following Robot-Assisted Laparoscopic Partial Nephrectomy (RAPN): A Single-Center Retrospective Study","fulltext":[{"header":"Background","content":"\u003cp\u003eMore than 400 000 people worldwide are diagnosed with renal cell carcinoma (RCC) each year\u003csup\u003e1)\u003c/sup\u003e. Recent advances in diagnostic imaging have led to more than half of all RCC being discovered incidentally in asymptomatic patients\u003csup\u003e2)\u003c/sup\u003e. In 85% of patients with incidentally discovered renal cell carcinomas, tumors measure\u0026thinsp;\u0026lt;\u0026thinsp;4 cm in size\u003csup\u003e3)\u003c/sup\u003e, and the National Comprehensive Cancer Network guidelines recommend partial nephrectomy (PN) as the first-line treatment option in such cases\u003csup\u003e4)\u003c/sup\u003e. The background to this recommendation is that PN has advantages over radical nephrectomy (RN) in preserving renal function. Furthermore, the recurrence rate after PN in localized RCC is approximately 1.9%\u0026ndash;3.2%\u003csup\u003e5\u0026ndash;7)\u003c/sup\u003e, and PN is considered to carry no greater risk of recurrence compared with RN\u003csup\u003e8)\u003c/sup\u003e. However, PN is associated with a higher risk of perioperative complications compared with RN\u003csup\u003e9)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRobot-assisted surgery enables precise surgery by tremor filtration and providing a clear, three-dimensional surgical field. These technological advances have led to the widespread implementation of robot-assisted partial nephrectomy (RAPN). Many studies have reported that RAPN has a lower complication rate compared with open PN\u003csup\u003e10)\u003c/sup\u003e. The number of cases in which RAPN is performed even for renal tumors larger than 4 cm has recently increased; therefore, the importance of RAPN is increasing\u003csup\u003e11)\u003c/sup\u003e. However, PN is associated with a risk of positive resection margins\u003csup\u003e12)\u003c/sup\u003e. This is because it may be difficult to recognize the tumor outline, which may result in cutting into the tumor, even if RAPN involves renal arterial clamping to decrease bleeding from the resection surface. Some reports indicate that positive margins are associated with recurrence risk\u003csup\u003e13)\u003c/sup\u003e and poorer overall survival\u003csup\u003e14)\u003c/sup\u003e. Furthermore, even for small renal masses, it is often difficult to decide whether the clinical stage is T1 or T3, and it is unclear to what extent this decision contributes to postoperative recurrenc\u003csup\u003e15)\u003c/sup\u003e. Therefore, understanding recurrence risk factors, including positive margins, is crucial to appropriately determine PN indications.\u003c/p\u003e \u003cp\u003eWhile reports on recurrence risk factors exist for PN, few have specifically identified recurrence risk factors for RAPN\u003csup\u003e6)\u003c/sup\u003e. The objectives of the present study were to examine recurrence risk factors in patients who underwent RAPN for localized renal cell carcinoma at our institution and to evaluate outcomes in cases with positive resection margins.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe retrospectively analyzed 205 patients diagnosed with renal cell carcinoma, excluding benign diseases, among 221 patients who underwent RAPN at our institution between 2016 and 2024. RAPN was performed using a Da Vinci Si or Xi surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA). The surgical approach, either transperitoneal or retroperitoneal, was selected on the basis of the tumor location. Recurrence was defined as local recurrence when new lesions were identified within the surgical field of PN on postoperative follow-up computed tomography, and as non-local recurrence for all other recurrences, including distant metastases.\u003c/p\u003e \u003cp\u003eEvaluation items comprised the following preoperative features: age, sex, side (left/right), body mass index, estimated glomerular filtration rate, creatinine concentration, RENAL nephrectomy score (tumor size, exophytic growth, distance to renal hilum, anterior or posterior, tumor location), and perirenal fat thickness (dorsal fat thickness, lateral fat thickness). Operative features comprised operative time, console time, warm ischemia time, approach method (intra-peritoneal or retroperitoneal), blood loss, presence of a urinary tract opening, and presence of renal parenchymal suturing. The examined pathological features comprised pathological diagnosis, pathological tumor (pT) stage, Fuhrman grade, sarcomatoid change, rhabdoid change, and positive margins. Perirenal fat thickness is an item in the Mayo adhesive probability score, recently reported as an indicator of RAPN surgical difficulty\u003csup\u003e16)\u003c/sup\u003e, and was included in this study. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, perirenal fat thickness (from the renal capsule to the muscle) was measured at the level of the renal hilum.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were analyzed using the Mann\u0026ndash;Whitney U test, and categorical variables were analyzed using the chi-square test. Odds ratios for recurrence risk factors were calculated using logistic regression models. Kaplan\u0026ndash;Meier survival curves were plotted for recurrence-free survival (RFS), and the log-rank test was used for comparisons between groups. Statistical analyses were performed using EZR (Easy R, Version 1.68; Saitama Medical University, Saitama, Japan) and GraphPad Prism, Ver. 7.01 (GraphPad, San Diego, CA, USA). Statistical significance was defined as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. This study was performed in accordance with the principles outlined in the Declaration of Helsinki, and was approved by the Ethics Review Committee of Nagasaki University hospital (Approval Number: 24111405). Because this was a retrospective observational study, the need to obtain patient informed consent was waived by the Ethics Review Committee of Nagasaki University hospital.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe median age of all patients was 69 years (range, 61\u0026ndash;76 years). Of the 205 cases, 146 (71%) were male, and the median body mass index was 24.0 kg/m\u0026sup2;. The median preoperative estimated glomerular filtration rate was 63 mL/min/1.73 m\u0026sup2;, and the median preoperative serum creatinine concentration was 0.87 mg/dL. The median lateral perirenal fat thickness was 15.4 mm, and the median dorsal perirenal fat thickness was 11.1 mm. Preoperative clinical tumor (cT) stage was cT1a in 153 cases (75%), cT1b in 50 cases (24%), and cT2a in 2 cases (1%). Regarding the RENAL nephrectomy score factors, the median tumor diameter was 31.9 mm, and 19 cases (9.2%) had a score of 3 (medial extension) for lateral extension. The median distance to the renal sinus was 2.18 mm. Tumor location was anterior in 114 cases (55.6%), and the relationship between tumor position and the upper/lower pole line was 3 points in 72 cases (35.1%).\u003c/p\u003e \u003cp\u003eOverall recurrence was observed in 11 cases (5.3%), namely 3 cases (1.4%) of local recurrence and 8 cases (3.9%) of non-local recurrence. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the details of the patients with recurrence. The median period from RAPN to local recurrence was 14 months (range: 6\u0026ndash;16 months), and the median period from RAPN to non-local recurrence was 18.5 months (range: 3\u0026ndash;71 months). Among cases of non-local recurrence, five included distant metastases. Metastatic sites comprised the lung in three cases, bone in two cases, and liver in two cases (including overlapping cases). None of the three cases with local recurrence had a positive surgical margin.\u003c/p\u003e \n\u003cp\u003eTable 1. Details of the Patients with Recurrence after RAPN\u003c/p\u003e\n\u003cp\u003eCases of local recurrence (n=3)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"677\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSize(mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFuhrman grade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSarcomatoid\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cstrong\u003epT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMargin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecurrence site\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e42.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e(+)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eLocal recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e42.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e14 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eLocal recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 45px;\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e37.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e16 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eLocal recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eCases of non-local recurrence (n=8)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"690\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSize(mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFuhrman grade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSarcomatoid\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003epT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMargin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecurrence site\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e64.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e(+)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003ePeritoneal dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e26.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003eRight iliac metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e34.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e(+)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003eLung and liver metastases, Peritoneal dissemination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e37.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e15 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003eLung metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e60.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e1b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e22 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003eSurgical wound recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e40.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e36 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003eLung and bone metastases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e30.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e60 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003eIpsilateral renal recurrence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e40.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e1a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e(-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e71 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003eLiver metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eRAPN, robot-assisted partial nephrectomy; pT, pathological tumor stage\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the preoperative features associated with recurrence. In the univariate analysis, male sex (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.03), lateral perirenal fat thickness (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), dorsal perirenal fat thickness (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.02), and tumor size (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01) were significantly associated with recurrence. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the factors related to surgery (operative features). In the univariate analysis, operative time (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01), console time (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.01), and warm ischemia time (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04) were significantly associated with recurrence. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the pathological features. In the univariate analysis, pT stage (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), Fuhrman grade (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and sarcomatoid change (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) were significantly associated with recurrence. Among the seven cases with positive margins, recurrence developed in only one case (14.2%), indicating no association with recurrence (p\u0026thinsp;=\u0026thinsp;0.32).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatients\u0026rsquo; preoperative characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo recurrence (n\u0026thinsp;=\u0026thinsp;194)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecurrence (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 [61\u0026ndash;76]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68[60\u0026ndash;72]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (M/F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135/59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR/L\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96/98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u0026sup2;) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.9[21.6\u0026ndash;26.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.4[22-26.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eeGFR (mL/min/.73m\u0026sup2;) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63[48.8\u0026ndash;75]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.3[51.2\u0026ndash;88.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCre (mg/dL) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.87[0.72\u0026ndash;1.09]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.96[0.81\u0026ndash;1.14]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThickness of lateral renal fat (mm) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15[8.8\u0026ndash;22]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e255.6[22.2\u0026ndash;29.6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThickness of back renal fat (mm) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.3[4.3\u0026ndash;17.6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7[14.5\u0026ndash;22.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRENAL score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eall score (4/5/6/7/8/9/10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7/9/40/46/33/42/16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0/0/1/2/4/3/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR (mm) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.8[26.2\u0026ndash;38.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.1[35.8\u0026ndash;42.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eE (1/2/3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80/96/18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6/4/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN (mm) *\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.23[1.22\u0026ndash;4.77]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.73[0.79\u0026ndash;3.09]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA (a/p/unclassified)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110/83/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/7/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL (1/2/3/unclassified)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72/53/68/1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/4/4/0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eM, male; F, female; R/L, right/left; BMI, body mass index; eGFR, estimated glomerular filtration rate; Cre, creatinine; R, radius (maximal diameter); E, exophytic/endophytic properties; N, nearness of the tumor to the collecting system or sinus; A, anterior/posterior; L, tumor location relative to the polar lines\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOperative features\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo recurrence (n\u0026thinsp;=\u0026thinsp;194)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecurrence (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e198[174\u0026ndash;226]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e249[194\u0026ndash;278]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsole time (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e129[103\u0026ndash;153]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e171[126\u0026ndash;206]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIschemia time (minutes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17[\u003cspan additionalcitationids=\"CR15 CR16 CR17 CR18 CR19 CR20 CR21\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26[16\u0026ndash;28]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransperitoneal/retroperitoneal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122/72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60[30\u0026ndash;200]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e130[105\u0026ndash;244]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary tract opening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (72%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInner suture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (45%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePathological features\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo recurrence (n\u0026thinsp;=\u0026thinsp;194)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecurrence (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e165 (85%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epapillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003echromophobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emucinous tubular and spindle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epT stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e169(87%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT1b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16(8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT3a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFuhrman grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egrade 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (20%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egrade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e131 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egrade 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (36%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egrade 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (28%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eunknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSarcomatoid change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (18%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRhabdoid change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive surgical margin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003epT, pathological tumor stage\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eLogistic regression analysis was performed using factors significantly associated with recurrence in the univariate analysis (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Positive margins again showed no association with recurrence (p\u0026thinsp;=\u0026thinsp;0.31; hazard ratio (HR): 3.13, 95% confidence interval (CI): 0.34\u0026ndash;28.6). In the multivariate analysis, pT stage\u0026thinsp;\u0026ge;\u0026thinsp;3a (p\u0026thinsp;=\u0026thinsp;0.04; HR: 6.61; 95% CI: 1.05\u0026ndash;41.6) and Fuhrman grade\u0026thinsp;\u0026ge;\u0026thinsp;3 (p\u0026thinsp;=\u0026thinsp;0.008; HR: 7.81; 95% CI: 1.69\u0026ndash;36.1) were significantly and independently associated with recurrence.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression analysis of the risk factors for recurrence of renal cell carcinoma after RAPN\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUnivariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMultivariable\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThickness of lateral renal fat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.09 (1.02\u0026ndash;1.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor size\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.05 (1.01\u0026ndash;1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsole time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.02 (1.01\u0026ndash;1.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epT\u0026ge;3a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11.7 (2.9\u0026ndash;47.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.61 (1.05\u0026ndash;41.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFuhrman\u0026thinsp;\u0026ge;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13.5 (3.66\u0026ndash;49.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.81 (1.69\u0026ndash;36.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive surgical margin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.13 (0.34\u0026ndash;28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eRAPN, robot-assisted partial nephrectomy; OR, odds ratio; CI, confidence interval; pT, pathological tumor stage\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThirty-seven (18%) patients had either pT stage\u0026thinsp;\u0026ge;\u0026thinsp;3a or Fuhrman grade\u0026thinsp;\u0026ge;\u0026thinsp;3 (high-risk group). Compared with the 169 patients in the low-risk group (i.e., neither pT stage\u0026thinsp;\u0026ge;\u0026thinsp;3a nor Fuhrman grade\u0026thinsp;\u0026ge;\u0026thinsp;3), RFS was significantly shorter in patients meeting either criterion (HR: 15.6; 95% CI: 4.1\u0026ndash;59.9; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn the present study, we demonstrated that male gender, operative time, perirenal fat thickness, tumor size, pT stage\u0026thinsp;\u0026ge;\u0026thinsp;3, Fuhrman grade\u0026thinsp;\u0026ge;\u0026thinsp;3, and sarcomatoid change were risk factors for postoperative recurrence after RAPN in the univariate analysis. Multivariate analysis revealed that pT stage\u0026thinsp;\u0026ge;\u0026thinsp;3 and Fuhrman grade\u0026thinsp;\u0026ge;\u0026thinsp;3 were significant and independent risk factors. Furthermore, among the seven cases with positive margins, only one case (14.2%) developed recurrence, indicating no association with recurrence.\u003c/p\u003e \u003cp\u003eNumerous reports have identified pT stage, tumor size, and malignancy grade (Fuhrman grade in the present study) as risk factors for recurrence after PN\u003csup\u003e5\u0026ndash;7, 14)\u003c/sup\u003e. Systematic reviews have reported similar findings\u003csup\u003e17)\u003c/sup\u003e, and these factors are increasingly recognized as established risk factors for recurrence after PN. The present study also demonstrated that pT stage\u0026thinsp;\u0026ge;\u0026thinsp;3a and Fuhrman grade\u0026thinsp;\u0026ge;\u0026thinsp;3 were independent risk factors for recurrence. However, both factors are reported risk factors for recurrence not only after PN but also after RN\u003csup\u003e18, 19)\u003c/sup\u003e. Combined with the finding in the present study that positive resection margins were not associated with recurrence risk, we consider that in cases with pT stage\u0026thinsp;\u0026ge;\u0026thinsp;3a and Fuhrman grade\u0026thinsp;\u0026ge;\u0026thinsp;3, circulating cancer cells or microscopic distant metastases are highly likely at the time of surgery. Therefore, this should not be the basis for avoiding PN. In contrast, even with a negative resection margin, careful imaging follow-up with computed tomography or similar modalities is likely necessary in cases with pT stage\u0026thinsp;\u0026ge;\u0026thinsp;3a and Fuhrmann grade\u0026thinsp;\u0026ge;\u0026thinsp;3.\u003c/p\u003e \u003cp\u003ePerirenal fat thickness was measured as a simple indicator of perirenal fat volume and was identified as a risk factor for recurrence in the present study. Some reports suggest that adipose tissue has a favorable prognostic effect on RCC, such as the finding that a larger visceral fat area was associated with prolonged progression-free survival and overall survival in metastatic renal cell carcinoma\u003csup\u003e20)\u003c/sup\u003e. However, other reports indicate that Wnt-related factors secreted from perirenal adipose tissue increase the cell motility of clear cell RCC; thereby, promoting progression from localized RCC to locally advanced RCC\u003csup\u003e21)\u003c/sup\u003e. Thus, the impact of perirenal fat thickness on RCC remains unclear. In the present study, perirenal fat thickness was identified as a risk factor for recurrence after PN. Beyond the mechanisms described above, increased surgical difficulty owing to perirenal fat may also have contributed to recurrence.\u003c/p\u003e \u003cp\u003eWhile the poor prognosis of sarcomatoid RCC is well-established\u003csup\u003e22)\u003c/sup\u003e, few studies have reported its association with recurrence risk after PN. This lack of studies may be because of the rarity of sarcomatoid RCC and the fact that most cases are advanced, making affected individuals less suitable candidates for PN. However, reports indicate no difference in postoperative outcomes between RN and PN for sarcomatoid RCC\u003csup\u003e23)\u003c/sup\u003e and that PN shows non-inferiority regarding cancer-specific survival compared with RN\u003csup\u003e24)\u003c/sup\u003e. Therefore, sarcomatoid transformation itself should not be considered a reason to avoid PN.\u003c/p\u003e \u003cp\u003eAlthough operative time, console time, and warm ischemia time were associated with postoperative recurrence after PN in the present study, this likely reflects increased surgical difficulty owing to other risk factors, such as tumor size and perirenal fat thickness, rather than the impact of operative time itself. However, similar to the findings in the present study, other reports\u003csup\u003e6)\u003c/sup\u003e have also found an association between operative time and postoperative recurrence after PN. On the basis of findings suggesting that intraoperative seeding of tumor cells affects outcomes\u003csup\u003e25)\u003c/sup\u003e, we consider that prolonged operative time, reflecting increased intraoperative manipulation, could be a risk factor for recurrence after PN.\u003c/p\u003e \u003cp\u003eThere is currently no consensus regarding whether positive resection margins constitute a risk factor for postoperative recurrence after PN. A large single-center cohort study by Morrone et al. reported a close relationship between positive resection margins and RFS\u003csup\u003e26)\u003c/sup\u003e. Similarly, the large-scale, multicenter retrospective MARGINS study\u003csup\u003e27)\u003c/sup\u003e, which also examined the impact of positive surgical margins on prognosis, reported that RFS and overall survival were unaffected by positive margins, and local recurrence was observed in only 5.9% of cases with positive margins. Although positive resection margins appear to be associated with recurrence risk, residual tumor cells may undergo ischemia or necrosis owing to intraoperative hemostasis or cauterization. Alternatively, cells present at the margins of the surgical specimen may not remain at the resection bed. Further research is needed.\u003c/p\u003e \u003cp\u003eThis study has limitations. First, as a single-center, non-randomized, retrospective study, the sample size was small, and there is high potential for treatment selection bias. Furthermore, because postoperative follow-up was often performed at other institutions, the observation period at our hospital was short, preventing evaluation of long-term prognosis. However, because patients with recurrence during follow-up were generally referred back to our hospital for treatment of the recurrent lesion, recurrence events are unlikely to have been missed. Additionally, while local recurrence and distant metastasis were both defined as recurrence, their underlying mechanisms differ. Therefore, this definition of recurrence may not accurately reflect the specific risk factors for each scenario. Because of the small number of recurrence events and the difficulty of statistical analysis, these events were treated as similar recurrence events in the present study.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eRegarding risk factors for postoperative recurrence of renal cell carcinoma after RAPN, positive resection margins showed no association, while pT stage\u0026thinsp;\u0026ge;\u0026thinsp;3a and Fuhrman grade\u0026thinsp;\u0026ge;\u0026thinsp;3 were significantly and independently associated with recurrence.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eRAPN; robot assisted laparoscopic partial nephrectomy\u003c/p\u003e\n\u003cp\u003epT stage; pathological tumor stage\u003c/p\u003e\n\u003cp\u003ecT stage; clinical tumor stage\u003c/p\u003e\n\u003cp\u003eRCC; renal cell carcinoma\u003c/p\u003e\n\u003cp\u003ePN; partial nephrectomy\u003c/p\u003e\n\u003cp\u003eRN; radical nephrectomy\u003c/p\u003e\n\u003cp\u003eRFS; recurrence-free survival\u003c/p\u003e\n\u003cp\u003eHR; hazard ratio\u003c/p\u003e\n\u003cp\u003eCI; confidence interval\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in accordance with the principles outlined in the Declaration of Helsinki, and was approved by the Ethics Review Committee of Nagasaki University hospital (Approval Number: 24111405). Because this was a retrospective observational study, the need to obtain patient informed consent was waived by the Ethics Review Committee of Nagasaki University hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have nothing to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMasaharu Oki: Writing \u0026ndash; original draft and visualization; Kojiro Ohba: Conceptualization, methodology, and writing \u0026ndash; review \u0026amp; editing; Tsuyoshi Matsuda: Investigation, formal analysis; Kensuke Mitsunari: Software, data curation; Tomohiro Matsuo: Investigation, formal analysis; Yasushi Mochizuki: Project administration; Ryoichi Imamura: Supervision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Jane Charbonneau, DVM, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBray F, Laversanne M, Sung H, et al. 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Sci Rep. 2022;12(1):18342. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41598-022-23146-4\u003c/span\u003e\u003cspan address=\"10.1038/s41598-022-23146-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"renal cell carcinoma, robot-assisted partial nephrectomy, recurrence, risk factor","lastPublishedDoi":"10.21203/rs.3.rs-8609417/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8609417/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe recurrence rate after robot-assisted laparoscopic partial nephrectomy (RAPN) for renal cell carcinoma varies, and few established risk factors have been identified. We investigated the postoperative recurrence rate and its risk factors following RAPN.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eAmong 221 patients who underwent RAPN at our institution from 2016 to 2024, we collected patient background and surgical information for 205 patients diagnosed with renal cell carcinoma (excluding benign diseases). We retrospectively examined postoperative recurrence rates and risk factors for recurrence.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePostoperative recurrence was observed in 11 cases: 3 local recurrences and 8 non-local recurrences. The postoperative recurrence rate was 5.3%. The median time to postoperative recurrence was 15 months. Univariate analysis identified sex, lateral renal fat thickness, dorsal renal fat thickness, tumor size, operative time, warm ischemia time, pathological tumor (pT) stage\u0026thinsp;\u0026ge;\u0026thinsp;3a, and Fuhrman grade\u0026thinsp;\u0026ge;\u0026thinsp;3 as factors associated with postoperative recurrence. Receiver operating characteristic curve analysis identified the following cutoff values: tumor size: 34 mm, lateral renal fat thickness: 20.73 mm, dorsal renal fat thickness: 11.85 mm, and warm ischemia time: 24 minutes. Multivariate analysis identified pT stage\u0026thinsp;\u0026ge;\u0026thinsp;3a (odds ratio: 6.61, 95% confidence interval: 1.05\u0026ndash;41.6; p\u0026thinsp;=\u0026thinsp;0.04) and Fuhrman grade\u0026thinsp;\u0026ge;\u0026thinsp;3 (odds ratio: 7.81, 95% confidence interval: 1.69\u0026ndash;36.1; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) as independent predictors of postoperative recurrence. Positive resection margins were observed in seven cases (3.4%); however, postoperative recurrence occurred in only one of these seven cases, suggesting no association with postoperative recurrence.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePositive resection margins were not associated with the risk of postoperative recurrence after RAPN for renal cell carcinoma. pT stage\u0026thinsp;\u0026ge;\u0026thinsp;3a and Fuhrman grade\u0026thinsp;\u0026ge;\u0026thinsp;3 were significantly and independently associated with postoperative recurrence.\u003c/p\u003e","manuscriptTitle":"Risk Factors for Recurrence Following Robot-Assisted Laparoscopic Partial Nephrectomy (RAPN): A Single-Center Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-02 09:26:37","doi":"10.21203/rs.3.rs-8609417/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-23T12:47:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-22T07:15:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T17:39:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T11:06:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217011745722841396181422913958951633039","date":"2026-03-02T03:16:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-01T14:09:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"269922841756719783566121378775920029157","date":"2026-03-01T13:29:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"333940948803269033807346607194880006070","date":"2026-02-27T14:58:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"306857870613731661078098863458090182917","date":"2026-02-26T17:05:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-25T11:26:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-23T14:39:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-27T06:54:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-23T12:46:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2026-01-23T12:32:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"36e78d24-4829-4412-9bfe-f3ff182c89be","owner":[],"postedDate":"March 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-30T19:39:42+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-02 09:26:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8609417","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8609417","identity":"rs-8609417","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}