Comparative investigation of therapeutic efficacy in tumor resection between robotic and open partial nephrectomy: A meta-analysis supplemented by time-series and quality-based meta-regression

Comparative investigation of therapeutic efficacy in tumor resection between robotic and open partial nephrectomy: A meta-analysis supplemented by time-series and quality-based meta-regression | 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 Comparative investigation of therapeutic efficacy in tumor resection between robotic and open partial nephrectomy: A meta-analysis supplemented by time-series and quality-based meta-regression Sotirios Artsitas, Dimitrios Artsitas, Irene Koronaki, Konstantinos G. Toutouzas, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5174620/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Differential tumor resection efficacy between robotic and open partial nephrectomy has been extensively explored. This study comparatively evaluates the above nephron-sparing approaches focusing on the Trifecta outcome, along with its individual components, as a metric for surgical quality assessment. Methods: A literature review from August 2022 to August 2024 yielded 51 relevant studies. Trifecta attainment served as the primary outcome, while secondary end-points included the incidence of major and minor postoperative complications, positive surgical margin rates, the absolute ischemia duration, as well as the corresponding postoperative alterations in estimated glomerular filtration rate and plasma creatinine levels. Analyses were conducted using random-effects meta-analysis models, with subgroup analyses performed to manage heterogeneity. Additionally, meta-regression was implemented on a temporal and qualitative basis, and sensitivity analysis was carried out on the most statistically robust studies. Results: The robotic approach exhibited clear superiority in overall Trifecta achievement, with odds ratios ranging between 1.3-1.8 and indicating a quasi-constant comparative effect over time. Major and minor complication rates, as defined by the Clavien-Dindo classification, favored robotic surgery, demonstrating odds ratios of 0.5-0.7 and 0.5-0.6, respectively. Specifically, a consistent to increasing trend of advantage was observed for severe complications over time and across qualitative measures. Conversely, a stable and significant benefit was noted for mild complications on the chronological scale. The robotic intervention also significantly impacted the estimated glomerular filtration rate, preserving an additional 2-3 ml/min/1.73m 2 postoperatively compared to open surgery. However, this finding was considered of limited clinical importance due to the low magnitude of the effect. Ischemic times and positive surgical margin rates did not significantly differ between the two approaches. Finally, the findings regarding the postoperative increase in serum creatinine levels from baseline were inconclusive, with neither modality demonstrating superiority over the other. Conclusion: Robotic partial nephrectomy surpasses open surgery in Trifecta attainment and in mitigating major and minor complications. However, the clinical significance of renal function preservation is marginal and requires further prospective investigation. Robot-assisted partial nephrectomy open partial nephrectomy surgical precision Trifecta complications surgical margins ischemia time renal function meta-analysis. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 BACKGROUND Prior research indicates that partial nephrectomy (PN) practically equals radical surgery in terms of oncological outcomes, concurrently providing additional functional advantages in patients with small renal masses (SRMs), typically ranging from 4 to 7 cm in size. Limited data exists as for tumors of larger sizes, particularly of maximum diameters greater than 7 cm [1]. In contemporary kidney surgery practice, SRMs are commonly managed through active surveillance or PN. Minimally invasive procedures conventionally involve laparoscopic PN (LPN) and robotic PN (RPN). This study was conducted with the aim to primarily compare Trifecta rates between robotic / robot-assisted PN (RPN/ RAPN) and open partial nephrectomy (OPN). The Trifecta outcome, originally formulated for the qualitative evaluation of radical prostatectomy procedures, also standardizes the quantification of therapeutic efficacy in PN [2]. Trifecta encompasses the combined avoidance of positive surgical margins (PSM), severe complications, as well as substantial ischemic impact or decline in renal function [3]. Within the Trifecta framework, PN essentially targets resections with negative margins, minimal strain on renal function, and mitigation of severe postoperative morbidity. OPN is still considered as the standard approach, albeit RAPN provides similar oncological outcomes, reduced morbidity, and faster recovery times. In general, PN is primarily recommended in patients with cT1 renal tumors, with an extending spectrum during the last decade in managing hilar or multifocal lesions [4-6]. In this concept, minimally invasive surgery, including LPN, RPN, and RAPN, is preferably adopted in cases of SRMs, with RPN/RAPN addressing LPN's technical challenges [7]. The focal point of this study involves the comparison between RPN/RAPN and open surgery, specifically examining the overall quality of tumor excision as a component of precision in surgical tissue handling. Therefore, an in-depth evaluation of both the Trifecta outcome and its individual components will be performed. Fundamentally, the objective was to juxtapose robotic and open approaches in PN within the broader context of surgical precision from a therapeutic perspective. The latter covers the spectrum of surgical safety through postoperative complications, oncological control through recurrence risk, and functional recovery through the intraoperative ischemic impact and postoperative decrease in glomerular filtration rate (GFR). The selection of Trifecta as a measure of surgical precision is based on its strong correlation with the surgeon's technical expertise and level of experience [8]. Building upon this association, a causal link is established, connecting surgical capacity to an increased likelihood of achieving Trifecta, while simultaneously resulting in reduced operative time (OT) in RAPN [9]. Limiting OT to levels comparable with OPN facilitates a synchronous comparison (within the same operative timeframe) of quantitative variables such as blood loss and ischemia time (IT), both of which are integral to defining surgical precision in PN [10, 11]. MATERIALS AND METHODS Literature search The literature search covered the period from August 15, 2022, to August 15, 2024, targeting all studies investigating the comparison: RPN/RAPN vs. OPN, using the keywords: "robot-assisted", "robotic", "open", and "partial nephrectomy". A title-centered method was chosen due to the abundance of pertinent studies. The databases consulted included: "MEDLINE", "CENTRAL", "Scopus", "Google Scholar" and "ScienceDirect", with monthly alerts for updates. The study protocol (ID: CRD42023483593) was developed on PROSPERO online platform, where the applicable search strategy is accessible in PDF format (https://www.crd.york.ac.uk/prospero) [12]. Study selection The research strategy yielded an initial study set imported into the Sysrev platform in ".ris" format for inclusion assessment [13]. The primary criteria comprised English language, non-duplicated records, availability of full-text articles, and comparative data between RPN/RAPN and OPN. Non-comparative or single-arm analyses were excluded, along with studies with special patient populations such as pediatric, single-kidney, or multiple prior abdominal surgery cases. No upper age or tumor size thresholds were set due to the increasing adoption of robotic surgery during the last decade. The primary aim was to initially gather diverse studies reflecting current comparative literature for RPN/RAPN vs. OPN. Thereafter, secondary criteria for inclusion were applied, considering field of interest and reported outcomes, with the goal of standardizing the final dataset for analysis. The primary inclusion criteria project is accessible on Sysrev (https://sysrev.com/p/119881). The inclusion process comprised two stages: binary suitability criteria application and outcome-based labeling, conducted by an individual author ([S.A.]). Three investigators ([S.A.], [D.A.], and [I.K.]) applied the secondary criteria, isolating studies for final analysis. For each outcome, distinct ".xlsx" tables were generated. Every study had to provide comparative data for at least one outcome to be incorporated. The finalized dataset was tabulated in a ".csv" file containing individual outcome data and metadata, including the author’s name, year of first publication, number of involved centers, matching application in patient groups, risk of bias (ROB) assessment, and baseline differences between patient subpopulations. Outcomes As previously delineated, the principal aim of this investigation revolves around the RPN/RAPN vs. OPN comparison, with specific attention directed towards Trifecta achievement. Typically, the Trifecta concept can be summarized by two distinct definitions commonly observed in the pertinent international literature. On one hand, the triple criterion involves achieving negative surgical margins, avoiding significant complications, and maintaining a percentage reduction in estimated GFR (ΔeGFR % ) below 10%. On the other hand, the second set of combined requirements replaces the ΔeGFR % threshold with an upper limit of 20-25 minutes for absolute ischemia time (IT). These definitions converge in evaluating PN's impact on renal function decline [14]. Secondary outcomes explored Trifecta parameters individually. Postoperative complications were dichotomized into severe (major) or mild (minor) based on the Clavien-Dindo (CD) classification scale, with "CD ≥ 3" indicating the former and "CD ≤ 2" representing the latter [15]. The comparative analysis of PSM rates contrasts RAPN and OPN in terms of oncological effectiveness, indicating local recurrence risk. Renal function analysis included absolute ischemia duration, eGFR change from baseline, and the corresponding change in serum creatinine (Cr) levels. Evidence acquisition After formulating the final study set, data extraction for primary and secondary outcomes was conducted. Each variable was linked with a corresponding ".csv" file, containing study metadata as well as numerical outcome-oriented data. Three investigators ([S.A.], [D.A.], and [I.K.]) independently conducted the procedure outlined above. Frequencies of nominal variables in RPN/RAPN vs. OPN cases were systematically documented. Continuous variables that followed a normal distribution were characterized by their mean and standard deviation (SD). In instances where only medians and interquartile ranges were available, they were appropriately converted to means and SDs as required [16]. The expressions (1) and (2) detailed below were employed to obtain the required summary statistics for changes in eGFR and serum Cr from baseline [17, 18]. In the aforementioned expressions, "Δ" denotes the change from baseline levels (ΔeGFR or ΔCr), while "X̄" refers to the average of the random variable corresponding to eGFR or Cr. Similarly, "S" pertains to the respective standard deviations. The indices "post" and "pre" describe the postoperative and preoperative measurements respectively, with "n post " and "n pre " denoting the corresponding patient populations. As evident, the aim was to estimate the expected values and standard errors of ΔeGFR and ΔCr, denoted as EV Δ and SE Δ in the expressions above, respectively. In the next step, missing values were identified and used to estimate the standard errors per comparison arm. Metadata included author, publication year, patient matching, referral center count, Trifecta definition, timeframe of activity, qualitative status, and baseline differences between patient groups. These metadata were combined into a final ".csv" file along with the frequentist or quantitative data for each outcome in the RPN/RAPN vs. OPN comparison arms. Quality assessment Numerical data from each comparison arm were meticulously tabulated, followed by a two-tiered qualitative assessment of study design and methodology. The Newcastle-Ottawa Scale (NOS) was initially implemented to assess patient selection, comparability, and outcome ascertainment by two team members ([S.A.] and [I.K.]) [19]. In sequence, the ROBINS-I tool was collectively employed by three investigators ([S.A.], [D.A.], and [I.K.]) to assess the ROB classification of each study across its 7 domains [20]. Integrating these frameworks aimed to inform the subgroup analysis (SGA) and establish appropriate moderators in the subsequent meta-regression analysis (MRA). More specifically, the joint application of NOS and ROBINS-I assisted in eliminating confounding issues in appraising study quality. Statistical analysis The data analysis aimed to compare RAPN and OPN as for their effectiveness in achieving the Trifecta outcome, and further investigate individual parameters such as complications incidence, PSM rates, IT, as well as eGFR and serum Cr changes from baseline. These comparisons were derived from separate datasets within Sysrev to ensure objectivity. Two random effects models were employed for the analysis, utilizing odds ratios (OR) regarding nominal variables and mean differences (MD) as for continuous outcomes. These measures were uniformly applied as effect size indicators [21, 22]. Heterogeneity was probed and quantified using Higgins I 2 [23]. Assessment of publication bias (PB) involved the use of suitable funnel and radial plots. In the latter, Egger's test was visually depicted by evaluating the deviation trend of the dashed regression line representing reported results with the solid line corresponding to the threshold of no relative bias [24]. The impact of small-scale studies was modeled by fitting a regression curve onto appropriately configured funnel plots. In these diagrams, the magnitude of relative bias was assessed through the geometric deviation of the curve from the vertical line that indicates the absence of small-study effects (SSEs). Study groups were analyzed based on various criteria including publication year, matching of patient subpopulations, analysis type according to referral centers, ROB class, and Trifecta definition cluster. Forest plots and multilevel MRA plots were used to represent the dynamics of the effects, with circles representing individual studies and their radii being inversely proportional to the 95% confidence interval (CI 95% ) of the reported results. In these plots, the evolution of each comparative effect corresponds to a regression line geometrically related to the horizontal line of neutrality, with its direction indicated by appropriate labels. A subsequent sensitivity analysis (SA) focused on more accurate analyses by considering only those results with a CI 95% width not exceeding a threshold of 2 standard deviations (SDs) of the respective widths in the pooled data. Ultimately, the SA ensured statistical robustness, while the SGA confirmed methodological reliability based on patient matching and referral center count. Reporting of results & Data availability The present systematic review adheres to the PRISMA 2020 guidelines [25]. Results are presented as: "OR - CI 95% " or "MD - CI 95% ", at a confidence level of α = 0.05. All primary and secondary outcome-related datasets, along with the analytic code, are publicly available on GitHub (https://github.com/sotbike/NESTOR.git). Data files are made available in ".csv" format, while the computational code is appropriately rendered in ".txt" format [26]. Additional details regarding the subject under investigation for each code file, along with specifications ensuring result reproducibility, are also included. The code implementation for results extraction and graph generation was performed using the R programming language, version 4.4.0 [27]. RESULTS Study retrieval Figure 1 outlines the inclusion and exclusion process from the initially isolated dataset. Specifically, 604 studies were retrieved from the databases investigated. Following the removal of records in languages other than English, duplicated references, and entries with ineligible titles and/or abstracts, 191 analyses with available manuscripts and appropriately formatted comparative data were screened. Subsequently, 155 studies providing statistically utilizable data were evaluated, leading to the exclusion of systematic reviews & meta-analyses, non-comparative analyses, investigations lacking relevant comparative data, and presentation supplements. The above procedure yielded a dataset of 77 records, which were further evaluated to obtain the most homogeneous study set possible for analysis. For this reason, comparisons involving specific patient populations were excluded, resulting in a final set of 51 studies encompassing 20,844 patients in total (RPN/RAPN: 10,996 vs. OPN: 9,848). Comparative data included Trifecta rates, major and minor complication occurrences, PSM incidences, absolute IT durations, ΔeGFR, and ΔCr. There were 15 RPN vs. OPN and 36 RAPN vs. OPN comparisons. Regarding the missing data, they involved a total of 87 patients as for major complications (RPN/RAPN: 43 vs. OPN: 44), one case in the OPN group for minor complications, 240 individuals concerning PSM rates (RPN/RAPN: 127 vs. OPN: 113), and 1,679 cases in the IT dataset (RPN/RAPN: 350 vs. OPN: 1,329). Finally, there were no missing data in the datasets for Trifecta rates, ΔeGFR, and ΔCr. Table 1 displays the selected studies included in the analysis, showcasing their methodological and qualitative features, along with baseline differences between the compared arms. Study demographics This subsection details the individual characteristics of records regarding the collected metadata. Study features included title, author, country of origin, publication year, implementation of patient matching, type of analysis based on referral center count, ROB class, NOS-based quality star rating, time period of activity, and baseline differences between patient groups. The stratification of data origin by country was conducted at both the study level and the patient population level. Figure 2a depicts the geographical distribution of studies in a pie chart, whereas Figure 2b presents a map chart illustrating the above distribution at both the study- & patient-level data. The majority of analyzed records originated from the United States, followed by Eastern countries (South Korea and Japan), and the broader European region (Italy, Germany, and France). Roughly 55% of the data emerged from comparative studies published during the last five years, representing about 77% of the total patient population. Furthermore, around 45% of the study-level data, comprising a nearly equivalent proportion of the total patient population, stemmed from analyses employing patient matching protocols. Multicenter comparisons contributed to 25.5% of study-level & 60.4% of patient-level data. Regarding the ROB clustering, 35.3% of study-level & 48% of patient-level data were classified as of low risk. Conversely, moderate & serious ROB records accounted for 39.2% & 25.5% of studies, and 40% & 12% of patients, respectively. This favorable profile in terms of the proportion of studies with optimum ROB, may be attributed to the homogenization of the included dataset through the exclusion of comparative analyses involving specific patient populations. Supplementary Figure 1 contains the pertinent diagrams illustrating the above distributions. Supplementary Figure 2a displays active timeframes of included studies stratified by patient matching, showing uniform coverage from 2008 to 2018. In Supplementary Figure 2b, a similar diagram driven by referral center count, indicates data predominantly originating from single-center studies during this period. Supplementary Figure 2c illustrates activity periods based on the ROB cluster of each study, aligning with the previously described distributions as per ROBINS-I category during the above decade. Qualitative profiles Figure 3a displays a histogram illustrating the distribution of percentages across the entire study set for each NOS quality level, as indicated by the overall star count. The distribution appears nearly normal, centered around studies rated with 7 stars and ranging from 5 to 9 quality stars. Supplementary Figure 3 illustrates the corresponding distributions at the subgroup level. Notably, comparative population matching emerges as a crucial parameter directly linked to study quality (Supplementary Figure 3b). Additionally, a similar qualitative profile emerged for studies conducted across multiple centers (Supplementary Figure 3c). The above observations underscore the consistency of results obtained from matched and multicenter analyses in reporting the primary and secondary outcomes in the present investigation. Complementarily, Figure 3b depicts the percentage distribution of studies across the individual components of the ROBINS-I tool. Minimal ROB is observed in domains such as "Deviations from intended interventions" and "Missing data", while the fields of "Confounding", "Selection of participants", "Selection of reported results", and "Classification of interventions" indicate evident ROB. Supplementary Figure 4a presents the ROBINS-I clusterization for subgroups based on publication year, revealing limited overall ROB in studies from the last 5-year period, with "ROBINS-I: Low" records approaching 40%, compared to older publications (approximately 30%). Supplementary Figure 4b illustrates the above distribution based on the application of patient matching, confirming a connection between protocol application and minimization of ROB. Matched comparisons include approximately 60% of low-ROB analyses, contrasting with a respective proportion of about 15% in those without matching. Lastly, supplementary Figure 4c depicts subgroups based on single- or multicenter types of analysis, indicating a more favorable ROB profile in multicenter studies, particularly in areas like "Confounding", "Selection of participants", "Selection of reported results", and "Classification of interventions". Low-ROB records accounted for 60% in multicenter studies, while in single-center comparisons the corresponding percentage was below 30%. Supplementary Figures 5-11 provide the respective traffic light plots for aggregated data and subgroups, specifying the ROB class for each study across all seven ROBINS-I domains. Meta-analysis of primary outcomes (Trifecta outcome) In the current subsection, we illustrate the meta-analysis (MA) findings on Trifecta rates. The initially derived study set consisted of 15 studies involving 4,913 patients (RPN/RAPN: 2,139 vs. OPN: 2,774). Figure 4a displays the forest plot for the entire study set, showing 50% increased odds for RAPN compared to OPN in achieving the Trifecta outcome (OR = 1.505, with CI 95% = [1.122; 2.018], and I 2 = 77%). Figure 4b shows the funnel plot assessing PB, demonstrating rough symmetry. Supplementary Figure 12a captures the radial plot with the regression line from Egger’s test, showing notable geometric divergence between the two lines. Additionally, Supplementary Figure 12b depicts the funnel plot for small-scale analyses, where the respective effects appear as marginally significant. In Supplementary Figure 13a, results by publication year reveal RAPN's significant superiority in recent (post-2018) studies (OR = 1.471, with CI 95% = [1.042; 2.077], and I 2 = 74%). However, older publications (pre-2018) showed only a trend towards superior Trifecta achievement with RAPN (OR = 1.656, with CI 95% = [0.885; 3.100], and I 2 = 75%). Supplementary Figure 13b highlights subsets based on patient matching, marginally indicating 63% higher odds for RAPN in matched comparisons (OR = 1.631, with CI 95% = [0.903; 2.948], and I 2 = 76%). On the other hand, non-matched analyses showed 46% higher odds for RAPN in Trifecta rates (OR = 1.459, with CI 95% = [1.025; 2.075], and I 2 = 81%). In Supplementary Figure 14a, no statistically significant odds ratio emerged from multicenter studies (OR = 0.998, with CI 95% = [0.747; 1.334], and I 2 = 45%). On the contrary, single-center studies showed 81% higher odds for Trifecta achievement with RAPN (OR = 1.814, with CI 95% = [1.270; 2.592], and I 2 = 73%). Despite its qualitative limitations, this discovery underscores noteworthy advantages for the robotic approach, suggesting an added margin of benefit compared to the findings of the pooled analysis. Supplementary Figure 14b presents results stratified by the ROBINS-I tool, marginally advocating for nearly double odds for Trifecta achievement in studies with optimal ROB (OR = 2.090, with CI 95% = [0.968; 4.514], and I 2 = 79%). Furthermore, studies with intermediate ROB displayed a trend for a 23% increase in Trifecta attainment rates with RAPN (OR = 1.231, with CI 95% = [0.923; 1.643], and I 2 = 66%), while those with the highest ROB also marginally implied doubled odds (OR = 2.111, with CI 95% = [0.956; 4.663], and I 2 = 54%). In Supplementary Figure 14c, studies utilizing postoperative eGFR change in the Trifecta definition (ΔeGFR % ≤ 10%) showed a strong tendency favoring RAPN (OR = 1.797, with CI 95% = [1.009; 3.202], and I 2 = 88%). Conversely, studies defining Trifecta by ischemic impact (IT ≤ 20-25 min) showed an additional 1 / 3 increase in the odds of achieving the Trifecta (OR = 1.326, with CI 95% = [1.021; 1.723], and I 2 = 57%), adequately reaching statistical significance. The above results are descriptively summarized in Table 2. In the context of MRA, Figure 4c illustrates the variation of logOR for Trifecta rates per year of publication, revealing a marginally significant and consistent superiority of RAPN from 2018 onwards. In Figure 4d, analyses with 6 to 8-star quality, which are predominant in the definitive study set, exhibited a similar trend towards higher Trifecta achievement rates through RAPN. Supplementary Figure 15a presents the MRA results for subgroups by publication year, focusing on population matching. Studies without matching protocols after 2016 reported a trend for higher odds for Trifecta with RAPN, with a gradual contraction of the comparative advantage over open surgery. In Supplementary Figure 15b, multicenter comparisons displayed a neutral effect, while single-center studies after 2018 consistently reported higher Trifecta odds with RAPN. Supplementary Figure 16a provides results per ROBINS-I stratum. Low ROB studies after 2019 supported a trend of progressively higher logOR in favor of RAPN, reflecting a potentially successful robotic integration over the years. Supplementary Figure 16b presents the MRA plots based on Trifecta definition. Studies using the eGFR criterion indicated a non-significant effect, while those defining Trifecta through IT revealed an almost consistently marginal advantage of RAPN over OPN during the last five years. In Supplementary Figure 17a, the MRA plots for NOS quality star groups based on patient matching revealed only a limited trend of advantage for RAPN, which diminishes between 6- and 7-star ratings in the unmatched comparisons. Supplementary Figure 17b illustrates the variation in comparative effect across the qualitative scale based on the number of referral centers. Single-center analyses exhibited an expanding advantage for RAPN as quality stars increased from 7 to 9. Lastly, in Supplementary Figure 17c, subgroup diagrams based on Trifecta definition demonstrated non-significant trends from records adopting the ΔeGFR-based criterion across all NOS quality levels. Conversely, in studies defining Trifecta through the ischemia duration threshold, RAPN's advantage appeared homogenous and marginally significant among records with 7 to 8 quality stars. Meta-analysis of secondary outcomes (Trifecta components) In the present subsection, we provide a thorough examination of secondary outcomes, furnishing their summarized MA results in Table 2 and detailed findings from the 2-modal MRA in Table 3. In terms of the RPN/RAPN vs. OPN comparison for major complications (CD ≥ 3), the source dataset consisted of 38 studies with 12,717 patients (RPN/RAPN: 6,701 vs. OPN: 6,016). Figure 5a illustrates a trend of a 35% reduction in pooled odds with the adoption of RAPN (OR = 0.648, with CI 95% = [0.468; 0.898], and I 2 = 66%). The relevant funnel plot of Figure 5b and the additional radial and funnel plots of Supplementary Figure 18 indicate symmetrical reporting of effects with minimal PB. In Supplementary Figure 19a, a non-significant reduction of the same magnitude (35%) emerged concerning the odds for CD ≥ 3 complications from post-2018 studies (OR = 0.650, with CI 95% = [0.417; 1.013], and I 2 = 76%). Studies published pre-2018 reported a marginally significant 34% reduction (OR = 0.660, with CI 95% = [0.434; 1.004], and I 2 = 21%). Supplementary Figure 19b highlights a trend for 33% (OR = 0.674, with CI 95% = [0.473; 0.961], and I 2 = 38%) and 43% (OR = 0.567, with CI 95% = [0.326; 0.987], and I 2 = 78%) reduction in odds for matched and non-matched analyses, respectively. Supplementary Figure 20a depicts SGA based on referral centers, showing a significant 47% reduction in odds for multicenter studies (OR = 0.534, with CI 95% = [0.318; 0.896], and I 2 = 51%). Conversely, single-center analyses reported a non-significant 29% reduction (OR = 0.707, with CI 95% = [0.480; 1.039], and I 2 = 69%). In Supplementary Figure 20b, studies of low ROB showed a non-significant 21% reduction in odds for severe complications with RAPN (OR = 0.793, with CI 95% = [0.596; 1.056], and I 2 = 4%). Intermediate ROB studies also exhibited an insignificant reduction in odds (OR = 0.546, with CI 95% = [0.294; 1.016], and I 2 = 84%). Lastly, the dataset of high ROB studies demonstrated a significant 46% reduction in odds for major complications within the RAPN patient group (OR = 0.539, with CI 95% = [0.359; 0.808], and I 2 ≈ 0%). The combination of strong trends favoring robotic access in substantial portions of the investigated subgroups, along with the significant 47% reduction in odds for CD ≥ 3 complications from multicenter analyses, underscores the need for further studies to accurately determine the additional benefits of selecting RAPN over OPN. Figure 5c presents the pooled MRA by publication year, demonstrating a steady trend of advantage for the robotic approach in severe complications from 2016 to 2022. Supplementary Figure 21a supports the presence of a widening benefit from RAPN after 2019 in matched analyses, likely reflecting the increasingly effective adoption of robotic PN and the refinement of relevant surgical practices. Conversely, non-matched analyses showed a stable effect with only a marginal benefit from RAPN between 2015 and 2019. Supplementary Figure 21b illustrates similar trends in multi- & single-center studies, with logORs supporting RAPN’s superiority from 2017 onwards. Supplementary Figure 21c displays MRA plots for ROB clusters, also showing a trend of stable effects in favor of RAPN in low ROB studies from 2019 onwards. Intermediate and high ROB comparisons showed marginally significant results, respectively indicating expanding and homogeneous benefits of RAPN from 2015 and 2019 onwards. Figure 5d depicts the pooled MRA for CD ≥ 3 complications across the NOS quality levels, showing a consistent trend favoring RAPN in studies rated with 6-8 quality stars. Supplementary Figures 22a & 22b detail the MRA plots by patient matching and referral center count, respectively. Matched analyses showed a slight contraction in RAPN's advantage at 6-7 NOS stars, while non-matched studies demonstrated an increasing benefit in the 7-9 quality-star ratings interval. In single-center analyses, a marginally significant and homogeneous logOR favoring RAPN was observed within the 6-7 quality-star range. Regarding minor postoperative complications (CD ≤ 2), the study set comprised 27 studies incorporating 6,950 patients (RPN/RAPN: 3,179 vs. OPN: 3,771). The pooled analysis forest plot in Figure 6a illustrates a 44% decrease in odds for minor complications with RAPN vs. OPN (OR = 0.565, with CI 95% = [0.467; 0.684], and I 2 = 35%). The funnel plot in Figure 6b examines PB, demonstrating sustained symmetry despite a noticeable deviation between the regression lines derived from Egger’s test, as depicted in the radial plot of Supplementary Figure 23a. SSEs were considered marginal in this case, as demonstrated in Supplementary Figure 23b. Supplementary Figure 24a shows a 45% reduction in odds for mild complications with the adoption of RAPN post-2018 (OR = 0.546, with CI 95% = [0.413; 0.722], and I 2 = 48%). Similarly, previous publications demonstrated a 42% reduction in odds for CD ≤ 2 complications (OR = 0.577, with CI 95% = [0.435; 0.765], and I 2 = 19%). Matched analyses in Supplementary Figure 24b also report a 42% reduction (OR = 0.584, with CI 95% = [0.409; 0.834], and I 2 = 56%), contrasting with a 47% reduction in non-matched comparisons (OR = 0.531, with CI 95% = [0.424; 0.667], and I 2 ≈ 0%). Supplementary Figure 24c indicates a 42% reduction in odds from multicenter studies (OR = 0.578, with CI 95% = [0.372; 0.897], and I 2 = 17%), not substantially different from that of 44% from single-center analyses (OR = 0.562, with CI 95% = [0.452; 0.700], and I 2 = 40%). Supplementary Figure 24d shows almost halved odds (approximately 49%) from RAPN in "ROBINS-I: Low" studies (OR = 0.511, with CI 95% = [0.322; 0.811], and I 2 = 45%). On the other hand, moderate and serious ROB studies exhibited reductions of 43% (OR = 0.570, with CI 95% = [0.430; 0.756], and I 2 = 45%) and 44% (OR = 0.563, with CI 95% = [0.390; 0.814], and I 2 ≈ 0%), respectively. Figure 6c presents the pooled MRA results regarding publication year, showing a temporally consistent and significant reduction in minor complication rates with RAPN from 2012 onwards. The MRA plots of Supplementary Figure 25a reveal a time-expanding benefit from RAPN in studies with patient matching post-2017, possibly reflecting the successful robotic integration in SRMs management. On the contrary, a quasi-stable pattern of RAPN’s beneficial effect was observed in non-matched analyses, with the statistical significance beginning in 2012 through 2024. Supplementary Figure 25b displays MRA plots by referral center count, showing a progressively diminishing advantage on the part of RAPN from 2014 until 2019. On the other hand, single-center analyses indicated a nearly homogeneous advantage for RAPN from 2015 onwards. Supplementary Figure 25c illustrates the MRA for each ROBINS-I class, highlighting an expanding benefit from RAPN in reducing minor complications, starting from 2016 in low ROB studies. Comparative analyses of intermediate ROB demonstrated a stable benefit through RAPN after 2017, while those of high ROB only supported a trend of progressively diminishing reduction in absolute logOR between 2015 and 2018. Figure 6d illustrates the quality-based MRA in pooled data, showing a mild augmentation of RAPN's advantage with increasing NOS ratings from 6 to 9 quality stars. Supplementary Figure 26a shows a broadening relative benefit from RAPN in matched comparisons from 7 to 9 stars, while non-matched analyses illustrated a quasi-stable advantage across all quality ratings. Supplementary Figure 26b depicts the MRA in multicenter comparisons, displaying an expanding advantage with RAPN, significant in studies with quality ratings between 8 and 9 stars. Conversely, single-center studies exhibited a stable comparative effect favoring RAPN across studies with 6 to 8 quality-star ratings. The subsequently investigated secondary outcome concerns PSM rates. The pertinent study set included 37 studies involving 12,735 patients (RPN/RAPN: 6,562 vs. OPN: 6,173). From the MA comparing RAPN and OPN in aggregated data, the forest plot of Figure 7a indicates a non-significant reduction (approximately 10%) in odds for PSM via RAPN (OR = 0.903, with CI 95% = [0.682; 1.195], and I 2 = 30%). The funnel and radial plots presented in Figure 7b and Supplementary Figure 27, respectively, were used to evaluate PB, showing no substantial asymmetry or deviation. The SGA based on publication year, as shown in Supplementary Figure 28a, also revealed a non-significant reduction in odds for PSM with RAPN, estimated at approximately 13% for post-2018 studies (OR = 0.873, with CI 95% = [0.555; 1.375], and I 2 = 54%) and 9% for those published prior to 2018 (OR = 0.911, with CI 95% = [0.617; 1.344], and I 2 ≈ 0%). In terms of patient matching application, as shown in Supplementary Figure 28b, studies with matching protocols showed a non-significant 10% reduction in odds for PSM with the adoption of RAPN (OR = 0.896, with CI 95% = [0.707; 1.134], and I 2 = 1%), while non-matched comparisons also indicated a non-significant reduction of approximately 17% (OR = 0.826, with CI 95% = [0.508; 1.345], and I 2 = 46%). The SGA according to center count, as presented in Supplementary Figure 29a, indicated no significant differences in multicenter studies (OR = 0.928, with CI 95% = [0.587; 1.469], and I 2 = 58%), as well as single-center analyses (OR = 0.877, with CI 95% = [0.606; 1.267], and I 2 = 18%). The forest plot of Supplementary Figure 29b contains the individual comparative effects per ROBINS-I cluster. Among studies with low ROB, a non-significant 20% reduction in odds for PSM with RAPN compared to OPN was observed (OR = 0.805, with CI 95% = [0.607; 1.068], and I 2 ≈ 0%). Results from studies with intermediate ROB also supported an insignificant advantage from RAPN, with approximately 19% odds reduction (OR = 0.815, with CI 95% = [0.483; 1.377], and I 2 = 54%), while no significant difference emerged from studies with serious ROB as well (OR = 1.197, with CI 95% = [0.715; 2.004], and I 2 = 6%). The temporal MRA depicting the relevant variation of the comparative effect is illustrated in Figure 7c, showing non-significantly reduced odds for PSM rates via RAPN. The MRA for subgroups according to patient matching (Supplementary Figure 30a), and number of centers (Supplementary Figure 30b) revealed comparative effects without statistical significance. Similarly, the MRA plots for subgroups based on ROB clusters (Supplementary Figure 30c) showed non-significant comparative impacts of RAPN and OPN on PSM rates, except for the studies with low ROB which indicated a trend of stable benefit from the robotic approach during the last 5-year period. The NOS-based MRA on the qualitative spectrum, presented in Figure 7d, also demonstrated a non-significant variation in the logOR. The overall qualitative MRA for subgroups is outlined in Supplementary Figure 31, where no significant disparities between RAPN and open surgery were observed at any quality level. An exception was noted in single-center comparisons (Supplementary Figure 31b) where a trend of bolstering in the apparent benefit from RAPN was discerned in studies with 7-9 NOS quality-star count. At this point, the results emerging from the RPN/RAPN vs. OPN comparison within the context of IT are presented. The derived dataset encapsulated 47 studies with 18,767 patients (RPN/RAPN: 10,450 vs. OPN: 8,317). Figure 8a shows the MA results across the pooled set of studies. Aggregated data analysis indicated a non-significant difference between the two approaches (MD = 0.477 min, with CI 95% = [-1.516; 2.469], and I 2 = 97%). Figure 8b and Supplementary Figure 32 contain the relevant diagrams for PB assessment, indicating robust symmetry in funnel plots and minimal deviation in the radial plot. However, substantial SSEs were noted in the relevant funnel plot of Supplementary Figure 32b. The SGA by publication year (Supplementary Figure 33a) revealed a non-significant difference in IT from studies published post-2018 (MD = -0.227 min, with CI 95% = [-2.971; 2.516], and I 2 = 97%). Similarly, pre-2018 studies also showed no significant difference (MD = 1.342 min, with CI 95% = [-1.772; 4.457], and I 2 = 97%). Additionally, in terms of the patient-matching-based SGA (Supplementary Figure 33b), no substantial difference in IT emerged from matched analyses (MD = -0.595 min, with CI 95% = [-4.793; 3.603], and I 2 = 98%), while in non-matched comparisons, this difference appeared as marginally significant in favor of OPN (MD = 1.317 min, with CI 95% = [-0.233; 2.867], and I 2 = 95%). Supplementary Figure 34a contrasts multicenter and single-center analyses. Non-significant differences were observed in multicenter studies (MD = -1.356 min, with CI 95% = [-5.976; 3.265], and I 2 = 98%). Similarly, single-center analyses showed no difference in IT between robotic and open approaches (MD = 1.220 min, with CI 95% = [-1.010; 3.450], and I 2 = 97%). The SGA forest plots concerning the distinction of studies based on the ROBINS-I tool application are presented in Supplementary Figure 34b, where a non-significant benefit from RAPN was also observed in low ROB (MD = -2.014 min, with CI 95% = [-6.277; 2.248], and I 2 = 98%) and high ROB comparisons (MD = 2.351 min, with CI 95% = [-2.393; 7.096], and I 2 = 98%). Studies of moderate ROB on the other hand, revealed a trend favoring OPN in terms of IT limitation (MD = 1.605 min, with CI 95% = [-0.300; 3.511], and I 2 = 94%). The pooled MRA by publication year, presented in Figure 8c, suggests an insignificant difference in the mean IT between the robotic and open approaches. Supplementary Figure 35 illustrates the MRA plots categorized by feature matching, referral center count, and qualitative clustering based on ROBINS-I. These plots indicate insignificant temporal variations around the horizontal axis of neutrality in general. Exceptions include the unmatched comparisons (Supplementary Figure 35a) and the intermediate ROB studies (Supplementary Figure 35c), which reveal stable trends favoring OPN between 2016-2021 and 2015-2019, respectively. A similar non-significant pattern is observed in Figure 8d illustrating the NOS-based pooled MRA. Subgroup MRA plots, depicted in Supplementary Figure 36, for matched studies and multi- or single-center comparisons, also reveal non-significant disparities between the two approaches. In this case as well, an exception derives from non-matched analyses, indicating a tendency towards a homogeneous advantage for OPN within the narrow range of 6-7 quality stars (Supplementary Figure 36a). The comparison of robotic and open PN at this point focuses on the postprocedural reduction in eGFR, denoted as: ΔeGFR. The derived study set consisted of 24 comparisons encompassing 9,797 patients (RPN/RAPN: 5,245 vs. OPN: 4,552). Due to the typical postoperative pattern of eGFR reduction, positive overall estimates (MD ΔeGFR ) favored RPN/RAPN, while negative ones leaned toward OPN. Pooled data analysis favored RAPN by approximately 2.5 ml/min/1.73m 2 (MD = 2.545 ml/min/1.73m 2 , with CI 95% = [1.035; 4.054], and I 2 = 98%), as shown in Figure 9a. The relevant diagrams for PB assessment, presented in Figure 9b and Supplementary Figure 37, indicated insignificant impact, with adequately symmetric funnel plots, a minimally deviated radial plot, and negligible SSEs. The SGA according to publication year (Supplementary Figure 38a) demonstrated a trend of RAPN's consistent advantage. More specifically, the results obtained from records published in the past 5 years (MD = 2.478 ml/min/1.73m 2 , with CI 95% = [0.226; 4.730], and I 2 = 98%), and those from earlier publications (MD = 2.632 ml/min/1.73m 2 , with CI 95% = [0.317; 4.948], and I 2 = 92%) were marginally significant. Studies with patient matching (Supplementary Figure 38b) also supported the aforementioned trend of RAPN's superiority (MD = 2.951 ml/min/1.73m 2 , with CI 95% = [0.564; 5.339], and I 2 = 99%), in line with non-matched analyses (MD = 2.000 ml/min/1.73m 2 , with CI 95% = [0.026; 3.974], and I 2 = 70%). In multicenter studies (Supplementary Figure 38c), a similar tendency was observed (MD = 1.806 ml/min/1.73m 2 , with CI 95% = [-0.537; 4.148], and I 2 = 98%), consistent with findings from single-center analyses (MD = 2.822 ml/min/1.73m 2 , with CI 95% = [0.800; 4.843], and I 2 = 96%). Findings based on the ROBINS-I levels, presented in Supplementary Figure 38d, also showed a trend of superior eGFR preservation with RAPN in "ROBINS-I: Low" studies (MD = 3.075 ml/min/1.73m 2 , with CI 95% = [0.577; 5.572], and I 2 = 99%). The previous trend emerged as a statistically significant finding from the "ROBINS-I: Moderate" subgroup of studies (MD = 1.860 ml/min/1.73m 2 , with CI 95% = [1.018; 2.701], and I 2 ≈ 0%). In contrast, studies clustered as "ROBINS-I: Serious" did not yield significant results (MD = 1.704 ml/min/1.73m 2 , with CI 95% = [-3.248; 6.657], and I 2 = 77%). The temporal MRA on pooled studies, contained in Figure 9c, indicated an enlarging benefit from RAPN since 2016, possibly due to improved techniques and wider availability of robotic platforms, essentially suggesting an inherent advantage in preserving postoperative eGFR. The MRA according to patient matching, displayed in Supplementary Figure 39a, revealed a significant advantage for RAPN in renal function preservation, particularly in studies applying relevant protocols and from 2018 onwards, aligning with recent advancements in surgical robotics. Conversely, non-matched analyses indicated only a stable trend favoring RAPN over OPN between 2015 and 2019. Supplementary Figure 39b depicts the subgroup MRA plots based on the number of referral centers, showing a declining benefit from RAPN between 2016 and 2021 in multicenter comparisons, against an expanding comparative advantage in a wider timeframe (between 2016 and 2023) from the perspective of single-center analyses. Supplementary Figure 39c presents stacked temporal MRA plots for the different ROB levels. More specifically, studies with low ROB showed a consistently favorable comparative effect for RAPN, significant between 2018 and 2021. Intermediate ROB records indicated a contraction of this benefit between 2015 and 2019, while those of high ROB showed a relative amplification in the same timeframe. Figure 9d presents the MRA results on the qualitative scale, reflecting a growing benefit on the part of RAPN across studies with NOS ratings of 7 to 9 stars. Additionally, Supplementary Figure 40a reveals a similar finding in both matched and non-matched analyses, with more favorable outcomes concerning the robotic approaches. Lastly, Supplementary Figure 40b indicates non-significant variation in the comparative effect across different quality levels in studies conducted by multiple referral centers. On the contrary, single-center comparisons illustrated a widening pattern of significant benefit from RAPN among quality ratings of 7 to 9 stars according to the NOS. The final secondary outcome refers to the postoperative increase in plasma Cr concentrations from baseline, denoted as: ΔCr. The corresponding study set consisted of 11 analyses involving 1,817 patients (RPN/RAPN: 789 vs. OPN: 1,028). In this case, negative overall estimates (MD ΔCr ) favored RPN/RAPN, while positive mean differences favored OPN. The relevant pooled MA findings in Figure 10a revealed no difference between RAPN and OPN regarding ΔCr (MD = 0.009 mg/dl, with CI 95% = [-0.039; 0.056], and I 2 = 86%). Figure 10b and Supplementary Figure 41 provide the respective funnel and radial plots for PB assessment. In the above, the absence of substantial bias was observed, although SSEs impacted the overall MD between RAPN and open surgery. Supplementary Figure 42a displays the SGA forest plots by publication year. Studies published in the last 5 years (MD = 0.040 mg/dl, with CI 95% = [-0.135; 0.215], and I 2 = 85%), as well as earlier publications (MD = -0.002 mg/dl, with CI 95% = [-0.051; 0.048], and I 2 = 88%), did not indicate statistically significant findings. Similarly, the SGA according to patient matching, presented in Supplementary Figure 42b, did not uncover significant deviations in ΔCr between RAPN and OPN in either matched (MD = 0.011 mg/dl, with CI 95% = [-0.020; 0.041], and I 2 ≈ 0%) or non-matched comparisons (MD = 0.010 mg/dl, with CI 95% = [-0.059; 0.079], and I 2 = 89%). Supplementary Figure 42c presents the SGA forest plots based on single- or multicenter analyses. The subset of studies conducted by multiple centers consisted of a singular record and indicated a significant benefit favoring OPN in limiting postoperative ΔCr (MD = 0.100 mg/dl, with CI 95% = [0.054; 0.146]). On the other hand, the single-center comparisons did not reveal significant findings (MD = -0.002 mg/dl, with CI 95% = [-0.048; 0.044], and I 2 = 82%). Supplementary Figure 42d encapsulates the SGA forest plots originating from the ROBINS-I clustering, without any statistically significant disparities in ΔCr between the two compared approaches in low ROB (MD = 0.057 mg/dl, with CI 95% = [-0.450; 0.564], and I 2 = 90%), and high ROB studies (MD = 0.006 mg/dl, with CI 95% = [-0.085; 0.096], and I 2 = 88%). Conversely, the subgroup of records with intermediate ROB demonstrated a trend of superiority on the part of the robotic approach (MD = -0.023 mg/dl, with CI 95% = [-0.040; -0.006], and I 2 ≈ 0%). The pooled MRA plots in chronological and qualitative scales, presented in Figures 10c & 10d respectively, show no discernible superiority between robotic and open PN. Supplementary Figures 43a & 43b depict the MRA by patient matching, in relation to publication year and NOS quality-star rating, respectively, revealing no significant deviations from neutrality lines across the entire time series or quality ranges examined. Similarly, Supplementary Figure 44 includes the MRA plots for single-center studies, presented on chronological and qualitative scales, without indicating statistical significance. Finally, Supplementary Figure 45 displays the temporal MRA for studies with moderate and serious ROB, also without notable findings within the respective ranges of the examined time series. Sensitivity analysis In this subsection, we present the findings of the SA focused on isolating specific outcome-based study sets to achieve maximum accuracy in their reported results. The latter was determined using the inverse variance method. Firstly, we calculated the average range of the individual 95% confidence intervals (CI 95% ) in the initially retrieved study set, along with its SD. Subsequently, inclusion criteria were set at the threshold of 2 SDs for each CI 95% range to ensure the desired accuracy in the reported effect from every comparative investigation. The results of individual pooled sub-analyses for both primary and secondary outcomes at the MA level are summarized in Table 2, while Table 3 encapsulates the respective findings at the MRA level. The primary outcome of Trifecta rates was analyzed across 10 studies, involving a total of 4,558 patients (RPN/RAPN: 1,964 vs. OPN: 2,594). The corresponding forest plot is detailed in Supplementary Figure 46a. Specifically, the pooled analysis demonstrated a significant effect favoring RAPN, with an additional 54% of odds in achieving Trifecta compared to OPN (OR = 1.536, with CI 95% = [1.100; 2.144], and I 2 = 83%). Supplementary Figures 46b, 46c, and 46d summarize the PB assessment, with the funnel plots showing marginal symmetry and notable interference from SSEs, while the radial plot suggests substantial deviation based on Egger’s test. Supplementary Figures 47a & 47b contain the relevant graphs from the MRA, revealing a chronologically stable advantage of RAPN in achieving Trifecta from 2018 onwards. A similar trend emerged concerning the qualitative moderator and between 6-8 NOS ratings. These findings underscore the need for more large-scale comparative studies focusing on Trifecta rates as primary objectives. In the analysis of CD ≥ 3 postoperative complication rates, 18 studies comprising 9,929 patients (RPN/RAPN: 5,545 vs. OPN: 4,384) were included, as detailed in Supplementary Figure 48a. The analysis revealed a significant OR favoring RAPN, suggesting approximately 43% lower odds compared to OPN (OR = 0.574, with CI 95% = [0.367; 0.898], and I 2 = 81%). Supplementary Figures 48b, 48c & 48d contain the relevant PB assessment, demonstrating adequate symmetry around the overall effect estimate, acceptable deviation in Egger’s test, and notable impact from SSEs. Moreover, the MRA plots in Supplementary Figure 49 highlighted a trend of increasing advantage for RAPN in reducing CD ≥ 3 complications from 2018 onwards, while the magnitude of this apparent benefit diminished among studies with 6-7 NOS rating levels. The SA of CD ≤ 2 complication rates followed, including 20 records with 6,003 patients (RPN/RAPN: 2,814 vs. OPN: 3,189), as displayed in the forest plot of Supplementary Figure 50a. Sub-analysis of high-accuracy studies attained statistical significance, showing a 43% reduction in odds favoring RAPN (OR = 0.568, with CI 95% = [0.464; 0.697], and I 2 = 41%). Examination of PB, depicted in Supplementary Figures 50b, 50c & 50d showed notable symmetry in the funnel plot around the overall OR-estimate, with moderate deviation in Egger’s test, and limited SSEs. Supplementary Figure 51 presents the pertinent MRA plots, revealing a stable and statistically significant advantage of the robotic approach in reducing mild post-PN complications from 2012 onwards, which appears as expanding across all study quality levels. Subsequently, the SA focused on PSM rates, with the pertinent dataset comprising 18 studies with 10,094 patients (RPN/RAPN: 5,330 vs. OPN: 4,764), as shown in Supplementary Figure 52a, with the respective results showing no significant effect (OR = 0.901, with CI 95% = [0.651; 1.246], and I 2 = 50%). PB was assessed using typical funnel and radial plots, as shown in Supplementary Figures 52b & 52c, revealing rough asymmetry around the overall effect and marginal deviation in Egger’s test. The MRA plots of Supplementary Figure 53 displayed a non-significant variation in logOR between RAPN and OPN both across publication years and NOS quality levels. In the next step, the SA was directed towards IT as a secondary outcome. From 32 studies involving 17,343 patients (RPN/RAPN: 9,686 vs. OPN: 7,657), results did not reveal any difference in average ischemia duration between the two approaches in studies with enhanced accuracy (MD = 1.273 min, with CI 95% = [-1.104; 3.650], and I 2 = 98%), as depicted in Supplementary Figure 54a. PB evaluation through the relevant graphs of Supplementary Figures 54b, 54c & 54d exhibited adequate symmetry in the funnel plots, with negligible impact from SSEs, and just notable deviation in Egger’s test. The MRA plots of Supplementary Figure 55 revealed no significant divergence in IT between RAPN and OPN, neither by publication year nor by the NOS quality class. The subsequent secondary outcome investigated was ΔeGFR, with data derived from 22 analyses entailing 9,636 patients (RPN/RAPN: 5,184 vs. OPN: 4,452). The forest plot of Supplementary Figure 56a illustrates the overall effect direction. In studies with augmented accuracy, RAPN showed a marginally significant advantage in the postoperative maintenance of eGFR (MD = 2.492 ml/min/1.73m 2 , with CI 95% = [0.922; 4.063], and I 2 = 98%), with the benefit magnitude remaining around 2.5 ml/min/1.73m 2 , consistent with findings from the pooled analysis. Supplementary Figures 56b, 56c & 56d demonstrate the assessment of PB, indicating sufficient symmetry in the relevant funnel plot, limited deviation between regression lines in Egger’s test, and negligible SSEs. The MRA plot in chronological scale, presented in Supplementary Figure 57a, reveals a significant and escalating effect favoring RAPN in eGFR preservation from 2016 onwards. Additionally, the NOS-based MRA exhibited a resembling pattern among studies with 7-9 quality stars (Supplementary Figure 57b), providing qualitative reinforcement of RAPN’s apparent superiority observed in the SA. The final secondary outcome concerned ΔCr, with comparative data from 10 studies encompassing 1,778 patients (RPN/RAPN: 776 vs. OPN: 1,002). Supplementary Figure 58a shows the relevant forest plot depicting the comparative effect. In studies with improved accuracy in reported results, no substantial difference was identified between RAPN and OPN regarding the postoperative increase in serum Cr levels from baseline (MD = 0.009 mg/dl, with CI 95% = [-0.042; 0.060], and I 2 = 87%). PB was explored using typical funnel and radial plots (Supplementary Figures 58b, 58c & 58d), showing adequate symmetry around the overall effect and minimal deviation in Egger’s test, albeit with notable SSEs. The temporal and qualitative MRA plots, presented in Supplementary Figures 59a and 59b respectively, indicated insignificant disparity between RAPN and OPN for either moderator utilized. DISCUSSION Discussion of findings The current analysis aimed to compare the Trifecta outcome between robotic and open approaches in PN, with its attainment rates serving as the primary outcome. Secondary outcomes included severe (CD ≥ 3) and mild (CD ≤ 2) postoperative complications, PSM rates, absolute IT duration, postoperative eGFR reduction, and increase in serum Cr levels post-PN. The credibility of the conclusions drawn from statistical inference was ensured by treating each study set independently. Pooled data analysis revealed a 1.5-fold increase in odds for RAPN in achieving Trifecta, with the trend for providing a consistent temporal advantage over time, and across all study qualities. Studies published after 2018, along with non-matched analyses, also indicated nearly a 1.5-fold increase in odds with the adoption of RAPN. Single-center studies demonstrated a 1.8-fold increase, confirming the homogeneity of RAPN’s comparative advantage post-2018. In the subgroup of records defining Trifecta by IT, a 1.3-fold increase when employing RAPN was identified, with a trend for a chronologically and qualitatively constant comparative effect. In comparisons with enhanced accuracy in reported outcomes, the 1.5-fold increase observed in pooled data analysis in favor of RAPN was confirmed, showing a consistent trend of chronological uniformity over time. In general, the robotic approach demonstrated superiority in achieving the Trifecta outcome, with odds ranging from 1.3 to 1.8 in its favor. This finding indicates the advantageous effects of RPN/RAPN in terms of tumor excision quality and potentially surgical precision. In the analysis of CD ≥ 3 complications, pooled data demonstrated a trend of a 0.35-fold decrease in odds for RAPN, shaping a common pattern of marginally homogeneous temporal and qualitative benefits. Studies with & without patient matching exhibited similar trends, with 0.67 & 0.57 odds for RAPN, respectively. Results from multicenter studies were statistically significant, with a 0.47-fold decrease in CD ≥ 3 complications through RAPN, supporting the trend of a comparative advantage remaining temporally uniform. Serious ROB studies displayed halved odds for RAPN with a trend of stable benefits during the last decade. The SA revealed a significant OR of 0.57 favoring RAPN, indicating a bolstering pattern in its comparative advantage over OPN in the past 5-year period. Based on the above, it can be supported that RAPN demonstrates a strong tendency in reducing the odds for major postoperative complications by approximately 35-45% compared to OPN. These benefits may be of increasing magnitude over time, and especially during the last five years, potentially reflecting the effective assimilation of robotic platforms into contemporary kidney surgery. However, additional studies are needed to clarify the final trajectory of the above-described advantageous trend on the part of the robotic approach. Regarding CD ≤ 2 complications, the analysis of aggregated studies outlined that RAPN is correlated with a 0.44-fold reduction in odds compared to OPN. Additionally, the pooled MRA indicated a time-consistent comparative effect that becomes more pronounced with increasing study quality levels. Subgroups of records published after and before 2018 revealed 0.55 and 0.58 odds for RAPN respectively. Matched comparisons also displayed 0.58 odds when implementing RAPN, with broadening comparative effects both temporally and within the quality scale range. Studies with unmatched populations showed 0.53 odds in favor of RAPN with uniform temporal and qualitative effects in the MRA. Multi- and single-center analyses demonstrated odds of 0.58 and 0.56 in favor of RAPN, respectively. However, MRA variations highlighted differing patterns: a chronologically shrinking advantage for the former and a quasi-stable benefit for the latter. Concerning the ROBINS-I classification, low-, intermediate-, and high-risk records revealed odds of 0.51, 0.57, and 0.56 for RAPN, respectively. These subgroups showed progressively expanding, stable, and marginally diminishing temporal variations in the absolute logOR favoring RAPN. The SA also indicated 0.57 odds in favor of the robotic approach, with a chronologically consistent and qualitatively expanding benefit in the MRA. The overall results highlighted 40-50% lower odds for RAPN compared to open surgery for CD ≤ 2 complications, with a uniform comparative effect over time and across all study qualities. This finding is further validated by a prior study conducted by our team, which specifically concentrated on the comparative analysis of minor complications incidence [ 28 ]. The subsequent analysis of PSM rates generally indicated non-significantly lower odds for RAPN (OR ≈ 0.8-0.9) from the pooled MA and SGA, with the MRA illustrating the trend of a stabilized effect during the last 5-year period. The SA also revealed a non-significant OR for PSM when adopting RAPN over OPN. The above findings support the absence of significant divergence between robotic and open approaches in PN regarding PSM rates. Correspondingly, as for ischemia duration, no substantial differences were underlined between the robotic and open surgery groups at any level of data analysis. In terms of the secondary outcome of eGFR preservation (MD ΔeGFR ), aggregate data revealed an advantage of approximately 2.5 ml/min/1.73m 2 in favor of RAPN. The temporal MRA indicated a progressively increasing benefit over OPN, possibly due to the ongoing optimization of robotic techniques during the past decade. Although the above finding emerged as statistically significant, it was not considered to possess robust clinical implications due to the low-magnitude estimate of MD ΔeGFR . However, it remained indicative of the favorable impact of RAPN on renal function. A similar benefit from selecting RAPN over OPN emerged as a consistent trend from subgroups published pre-2018 (MD ≈ 2.6 ml/min/1.73m 2 ) and post-2018 (MD ≈ 2.5 ml/min/1.73m 2 ). Matched analyses also uncovered a trend in the comparative eGFR preservation of approximately 3 ml/min/1.73m 2 , with chronologically expanding beneficial effects by RAPN over the last 5 years. Non-matched comparisons supported the tendency of RAPN to preserve renal function by nearly 2 ml/min/1.73m 2 more than OPN, with the comparative effects being temporally uniform. Similarly, in multicenter analyses, an analogous MD ΔeGFR of approximately 1.8 ml/min/1.73m 2 was observed, with progressively shrinking MDs over the last decade. Conversely, in the subgroup of single-center studies, the advantageous impact of RAPN on eGFR preservation manifested as an MD of about 2.8 ml/min/1.73m 2 , with MRA highlighting an enlarging comparative effect during the same timeframe. In low ROB studies, a similar trend in eGFR preservation of around 3 ml/min/1.73m 2 favoring RAPN was noted, with homogenous chronological effects observed in the MRA. The respective findings were statistically significant in the subgroup of records with moderate ROB (MD ≈ 1.9 ml/min/1.73m 2 ), with the comparative effects progressively decreasing over the last decade. High-accuracy studies in the SA marginally supported the presence of a beneficial shift toward the robotic approach, with additional eGFR preservation of approximately 2.5 ml/min/1.73m 2 , accompanied by a chronological expansion of the comparative effect, confirming the findings from the pooled analysis. The above-presented results strongly support at least a tendency for RAPN to outperform OPN in preserving postoperative renal function, with declines in eGFR being at least 2-3 ml/min/1.73m 2 lower in robotic approaches, suggesting a growing benefit with the increasing integration of robotic platforms in current kidney surgery. Nevertheless, it's important to emphasize that the above findings from the SGA are generally in line with those from the pooled analysis, and thus do not possess strong clinical significance, beyond potentially underlining the more favorable dynamics of RAPN's impact on renal function. Lastly, no significant differences were detected in the comparative increase in postoperative serum Cr from baseline, as indicated by both the pooled MA and SGA, along with the SA and MRA. Collectively, RAPN demonstrated superiority over OPN in Trifecta rates (OR ≈ 1.3-1.8), with a quasi-consistent advantage observed over the past five years. Additionally, RAPN exhibited a strong trend of benefit regarding CD ≥ 3 complications (OR ≈ 0.5-0.7) and a substantial merit in terms of CD ≤ 2 complication rates (OR ≈ 0.5-0.6), showcasing time-consistent to potentially expanding comparative effects in both outcomes. Discrepancies in PSM rates and the mean IT between RPN/RAPN and OPN groups were not significant. Furthermore, regarding the comparative impact on renal function, RAPN exhibited a more favorable effect on ΔeGFR, with approximately 2-3 ml/min/1.73m 2 less decline compared to open surgery, a finding implying its protective role against postoperative nephron-loss. However, this discovery was not deemed clinically significant. Instead, it merely hinted at a modest effect, suggesting the potential suitability of the robotic approach in patients with already affected kidney function, for whom PN is primarily recommended. Furthermore, there were non-substantial differences in ΔCr between RPN/RAPN and OPN patient groups. Based on the comparative analysis of primary and secondary outcomes, it can be inferred that the more favorable profile of RAPN over OPN in Trifecta achievement rates is primarily attributed to the mitigation of postoperative complications, particularly those of mild severity (CD ≤ 2). Discussion on international literature The management of SRMs prioritizes oncological control, optimal preservation of kidney function, and minimization of postoperative morbidity. The Trifecta outcome, summarizing the triad of surgical margin status, IT duration or decline in eGFR, and the absence of complications, is essential for the qualitative assessment of excision efficacy in nephron sparing surgery. In their 2017 study, Maurice et al. aimed to compare the attainment of optimal outcomes between RPN and OPN. They utilized total GFR preservation and chronic kidney disease (CKD) upstaging as outcome measures, highlighting functional effects as crucial. The study revealed that RPN displayed a more favorable profile compared to OPN, attributed primarily to lower wound-related complications. Oncological outcomes were similar between the approaches, and RPN achieved similar long-term GFR preservation despite the predominant use of warm ischemia in OPN. The study supported previous findings indicating that RPN yields equivalent early outcomes with decreased morbidity in patients with cT1a tumors. Additionally, within the context of cT1b renal masses, RPN exhibited a higher rate of achieving optimal end-points. Acknowledging constraints such as the retrospective design and potential bias, the study concluded that RPN compares favorably with OPN, offering tangible benefits in reducing morbidity in patients with renal tumors even exceeding 7 cm in maximum diameter. According to authors, the concept of achieving optimal outcomes such as Trifecta, including functional preservation and morbidity reduction, holds significance in evaluating and comparing different surgical approaches in PN [ 29 ]. In a comparative study between OPN and RPN conducted by Acar et al. in 2015, Trifecta rates were similar, with complications being the key differentiating factor. Length of hospitalization varied based on the Trifecta outcome. Limitations of the comparison included its retrospective design, and the use of "Modification of Diet in Renal Disease" formula (MDRD) for evaluating renal function, through eGFR estimation [ 30 ]. In their 2019 study, Ghali et al. aimed to compare surgical quality and additional outcomes related to renal function between robotic and open PN for cT2a renal masses. They analyzed 150 patients (RPN: 59 vs. OPN: 91) and found that the robotic approach yielded comparable functional and oncologic outcomes to open surgery. Additionally, RPN was coupled with decreased blood loss, shorter hospitalizations, and lower incidence of major complications (CD ≥ 3). Furthermore, Trifecta attainment rates were significantly higher in the RPN patient group, indicating better overall surgical quality [ 1 ]. Another study of retrospective design by Soisrithong et al. in 2021 compared perioperative and Trifecta outcomes among patients with SRMs undergoing OPN, LPN, and RAPN. Analyzing 70 cases in total, the authors discovered that while OT was notably shorter in the open surgery group, Trifecta rates did not substantially diverge among the three approaches. However, they identified the length of stay as a factor negatively correlated with Trifecta achievement. Overall, the study indicated that the three approaches are comparable regarding Trifecta rates, with the duration of hospitalization emerging as a key determinant of success [ 3 ]. Within a similar context, Bravi et al. in 2019 conducted a multi-arm study comparing perioperative outcomes among the above three PN approaches for cT1 renal tumors. Patients submitted to minimally invasive procedures experienced fewer complications than those in the OPN group, while RPN showed the highest probability for ischemia application, and LPN demanded longer IT compared to open and robotic surgery. Acute kidney injury risk was lower in RPN and LPN arms than in open surgery. PSM rates did not vary between groups, and RPN demonstrated higher Trifecta rates in lesions of low and intermediate complexity (PADUA score < 10) [ 31 ]. Another study conducted by Hoeh et al. in 2023 contrasted RAPN and OPN in patients with localized SRMs. RAPN resulted in shorter hospital stays and fewer complications than OPN, despite similar blood loss volumes. The robotic approach showed better outcomes in multivariable models, especially regarding complications and Trifecta achievement rates [ 32 ]. Remaining within the same framework, Ingels et al. in 2022 compared perioperative outcomes between RPN and OPN. The former approach manifested advantages in early complications, transfusion rates, hospital stay lengths, and renal function preservation. Additionally, it exhibited restriction in the incidence of new-onset CKD. Stratified analysis also favored RPN concerning Trifecta attainment in large and complex tumors. The study advocated for RPN due to its superior perioperative outcomes, suggesting its appropriateness even for tumors with challenging features [ 33 ]. In an additional study by Mehra et al. in 2019, OPN, LPN, and RAPN were compared with respect to perioperative outcomes in patients with average complexity renal tumors. OPN showed higher blood loss than LPN and RAPN, with longer drain removal times. Postoperative complications and margin status were similar across the three approaches. LPN was comparable to RAPN, with the former being emphasized for its cost-effectiveness, making it an attractive option in developing countries [ 34 ]. Lastly, Motoyama et al. in 2019 evaluated RAPN utilizing the da Vinci Xi ® system against conventional OPN. The robotic approach demonstrated superior perioperative results, including reduced OT and blood loss, as well as shorter hospital stays. Trifecta achievement was significantly more frequent in the RAPN group, driven by the R.E.N.A.L. nephrometry score and the surgical modality. Robotic PN using the da Vinci Xi ® system was favored by the authors for managing patients with SRMs, pending further research on long-term outcomes [ 35 ]. In synthesis, the body of literature scrutinizing RPN/RAPN in contrast to OPN consistently delineates a plethora of advantageous effects on the part of the former. These encompass not only reduced incidences of major and minor complications, thereby mitigating overall postoperative morbidity, but also decreased blood loss volumes and transfusion requirements [ 36 ]. These findings persist in the face of an apparent increase in OT, reported to accompany RAPN in certain patient cohorts, particularly in older studies. Interestingly, despite the protracted operative durations, patients undergoing robotic PN tend to experience shorter hospital stays, an observation potentially attributable to the lower incidence of postoperative complications, and also associated with achieving higher Trifecta rates. Furthermore, the reliance of RPN on ischemia application is underscored, albeit amid the demonstration of superior renal function preservation compared to OPN. Crucially, the robotic procedure seems to consistently deliver comparable oncological and functional outcomes, alongside equivalent PSM rates, cementing its status as a viable alternative in the armamentarium of modern kidney surgery. Finally, fusing our results with respective findings from the international literature, we can also support that RAPN overall results in a combination of higher Trifecta rates, a simultaneous reduction in complications, equivalent PSM rates and IT, and a statistically but not clinically superior MD ΔeGFR compared to OPN. This complex of findings, given the central role of CD ≤ 2 complications in shaping the Trifecta outcome, may stem from a higher level of dexterity in handling the renal parenchyma during tumor resection. This connection becomes causal when considering that the precision of maneuvers has a greater impact on minor complications, while the severity of the intervention or the stage of the disease primarily affects major ones. Consequently, RAPN, through its high technological integration at the intraoperative level, seems to achieve superior surgical quality, as evidenced by Trifecta, which is interconnected with rather superior surgical precision, as demonstrated by CD ≤ 2 complications. Strengths & Limitations The study presents robust strengths and limitations, offering a comprehensive perspective on the topic. Strong-points include the rigorous methodology, employing a random effects MA with SGA at multiple levels, and MRA using two moderators. An SA based on study precision was also conducted to address heterogeneity, by similarly utilizing a modified random effects model. The comparative effects from the MRA were presented through a prototype table (Table 2), illustrating evolution patterns in both chronological and qualitative frames relative to the horizontal axis of zero impact. In this way, the optimal representation and summary of the corresponding MRA plots were achieved in a sufficiently informative manner. The present investigation explored Trifecta and its components, utilizing two primary definition-based clusters to establish appropriate subsets, while concurrently ensuring maximum data availability for each outcome. Although the processed literature was divided between studies that clearly favor RAPN in terms of Trifecta attainment and those that portray it as equivalent to open surgery, the present analysis managed through data synthesis to highlight significant advantages for RAPN. Apart from the above strengths, notable limitations also exist. The comparison between RPN/RAPN and OPN relied mainly on non-randomized studies, leading to heterogeneity and inclusion of findings from small-scale analyses. Moreover, differing Trifecta definitions posed challenges, mitigated by grouping individual records according to ΔeGFR % and IT thresholds through appropriate SGA. Another limitation concerned the number of studies in the SA for each outcome, mainly due to the high proportion of small studies with low accuracy. These limitations underscore caution in interpreting findings and highlight areas for future research and methodological refinement. Future potential The Trifecta outcome, considered as a key measure in evaluating PN, warrants thorough examination to gauge the efficacy of modern surgical robotic platforms. Analyzing its components assists in comparing achievement rates between robotic and open approaches. Future analyses should aim to maximize data inclusion to clarify differences in PSM rates and the comparative impact on renal function, with a specific focus on IT and ΔCr. Further studies could explore the correlation between therapeutic adequacy and surgical precision during tumor resection, including considerations of hemostasis and proportional IT over OT. Understanding these interconnections shall elucidate how precise maneuvers translate into superior therapeutic outcomes. CONCLUSIONS The present study compared robotic and open PN, focusing on tumor excision quality. It specifically examined the Trifecta and its key components, linking each individual outcome with specific aspects of surgical precision. The data analysis demonstrated RAPN's superiority in Trifecta achievement rates, occurrence of major and minor complications, and eGFR preservation compared to OPN. The relative benefits showed a quasi-stable to expanding magnitude over time, reflecting the effective integration of robotic technology into contemporary kidney surgery. The consistently stable comparative effect regarding minor complications was considered to stem from the inherent characteristics of RAPN as a minimally invasive modality. In particular, RAPN's advantage in postoperative complications appears to be the primary driver behind the increasing benefit in Trifecta attainment, potentially reflecting higher quality of intraoperative maneuvers and justifying its apparent preeminence in surgical precision. ABBREVIATIONS ASA: American Society of Anesthesiologists BMI: Body Mass Index CCI: Charlson Comorbidity Index CD: Clavien-Dindo classification of postoperative complications CI 95% : 95% Confidence Interval CKD: Chronic Kidney Disease cm: Centimeters Cr: Creatinine levels dl: Deciliters eGFR: estimated Glomerular Filtration Rate GFR: Glomerular Filtration Rate Hb: Hemoglobin concentration IT: Ischemia Time logOR: decimal logarithm of Odds Ratio LPN: Laparoscopic Partial Nephrectomy m: Meters MA: Meta-analysis MD: Mean Difference MDRD: Modification of Diet in Renal Disease min: Minutes ml: Milliliters MRA: Meta-regression Analysis NOS: Newcastle-Ottawa Scale OPN: Open Partial Nephrectomy OR: Odds Ratio OT: Operative Time PADUA - R.E.N.A.L.: Nephrometry scores PB: Publication Bias PN: Partial Nephrectomy PRISMA: Preferred Reporting Items for Systematic reviews and Meta-analyses PSM: Positive Surgical Margins RAPN: Robot-assisted Partial Nephrectomy ROB: Risk of Bias ROBINS-I: Risk of Bias In Non-randomized Studies of Interventions RPN: Robotic Partial Nephrectomy SA: Sensitivity Analysis SD: Standard Deviation SGA: Subgroup Analysis SRMs: Small Renal Masses SSEs: Small Study Effects ΔCr: Change (positive) from baseline in serum Creatinine levels ΔeGFR % : Percentage change in estimated Glomerular Filtration Rate ΔeGFR: Change (negative) from baseline in estimated Glomerular Filtration Rate DECLARATIONS 1. Ethics approval and consent to participate: Not applicable. 2. Consent for publication: Not applicable. 3. Availability of data and materials: All the data utilized and statistical code developed are available at the following link: https://github.com/sotbike/NESTOR.git. 4. Competing interests: Sotirios Artsitas (S.A.), Dimitrios Artsitas (D.A.), Irene Koronaki (I.K.), Konstantinos G. Toutouzas (K.G.T.), George C. Zografos (G.C.Z.) declare that they have no conflict of interest. 5. Funding: All authors confirm that no funds, grants, or other support was received. 6. Authors' contributions: 6a. Authors' contributions (descriptively): S.A. has given substantial contributions to the conceptualization, data curation, formal analysis, data investigation, methodology implementation, project administration, acquisition of resources, software utilization, procedure validation, visualization of results, original draft formulation, as well as the final review & editing of the present study. D.A. has given substantial contributions in data curation, formal analysis, data investigation, project administration, acquisition of resources, as well as procedure validation. I.K. has given substantial contributions in conceptualization, methodology implementation, software utilization, procedure validation, as well as critical review of the final manuscript. K.G.T. has given substantial contributions in supervision, data validation, as well as critical review of the final manuscript. G.C.Z. held the position of general supervisor during the elaboration of the present study. All authors have read and approved the final manuscript. 6b. Authors' contributions (according to CREdiT): Conceptualization: [S.A., I.K.]; Data curation: [S.A., D.A.]; Formal Analysis: [S.A., D.A.]; Funding acquisition: [ - ]; Investigation: [S.A., D.A., I.K.]; Methodology: [S.A., I.K.]; Project administration: [S.A., D.A.]; Resources: [S.A., D.A., I.K.]; Software: [S.A., I.K.]; Supervision: [K.G.T., G.C.Z.]; Validation: [S.A., D.A., K.G.T.]; Visualization: [S.A.]; Writing - original draft: [S.A., D.A.]; Writing - review & editing: [S.A., D.A., I.K., K.G.T.]. All authors have read and approved the final manuscript. 7. Acknowledgments: Not applicable. 8. Authors’ information: 8a. Sotirios Artsitas (S.A.) - Corresponding author Affiliation 1 : School of Medicine, National and Kapodistrian University of Athens (NKUA), Address: Mikras Asias str. 75, Postal Code: 11527, Athens, Greece. Affiliation 2 : 1 st Propaedeutic Department of Surgery, Geniko Nosokomeio Athenon Ippokrateio, Address: Vasilisis Sofias str. 114, Postal Code: 11527, Athens, Greece. Medical Doctor (M.D.), Mechanical Engineer (Mech.Eng.), Telephone number: +30 6945824838, ORCID ID: 0000-0002-1605-5028, Personal e-mail: [email protected] , Alternative e-mail: [email protected] , Academic e-mail: [email protected] . Corresponding author. 8b. Dimitrios Artsitas (D.A.) Affiliation 3 : 2 nd Department of Orthopaedics, KAT Attica General Hospital, Address: Nikis str. 2, Kifissia, Postal Code: 14561, Athens, Greece. Medical Doctor (M.D.), ORCID ID: 0000-0002-6626-7512, Personal e-mail: [email protected] . 8c. Irene Koronaki (I.K.) Affiliation 4 : Laboratory of Applied Thermodynamics, School of Mechanical Engineering, National Technical University of Athens (NTUA), Address: Heroon Polytechniou str. 9, Zografou Campus, Postal Code: 15780, Athens, Greece. Professor (Mech.Eng., PhD), Personal e-mail: [email protected] , Academic e-mail: [email protected] . 8d. Konstantinos G. Toutouzas (K.G.T.) Affiliation 1 : School of Medicine, National and Kapodistrian University of Athens (NKUA), Address: Mikras Asias str. 75, Postal Code: 11527, Athens, Greece. Affiliation 2 : 1 st Propaedeutic Department of Surgery, Geniko Nosokomeio Athenon Ippokrateio, Address: Vasilisis Sofias str. 114, Postal Code: 11527, Athens, Greece. Professor (M.D., PhD), Personal e-mail: [email protected] , Academic e-mail: [email protected] . 8e. George C. Zografos (G.C.Z.) Affiliation 1 : School of Medicine, National and Kapodistrian University of Athens (NKUA), Address: Mikras Asias str. 75, Postal Code: 11527, Athens, Greece. Professor (M.D., PhD), Academic e-mail: [email protected] . REFERENCES F. Ghali, A. A. Elbakry, Z. A. Hamilton, K. Yim, R. Nasseri, S. Patel , et al. , "Robotic partial nephrectomy for clinical T2a renal mass is associated with improved trifecta outcome compared to open partial nephrectomy: a single surgeon comparative analysis," World journal of urology, pp. 1-10, 2019, https://doi.org/10.1007/s00345-019-02994-2. S. Ghavimi, O. Saarela, F. Pouliot, R. A. Rendon, A. Finelli, A. Kapoor , et al. , "Achieving the "trifecta" with open versus minimally invasive partial nephrectomy," World J Urol, vol. 39, pp. 1569-1575, May 2021, https://doi.org/10.1007/s00345-020-03349-y. C. Soisrithong, P. Sirisreetreerux, P. Sangkum, K. Kijvikai, W. Viseshsindh, W. Kongchareonsombat , et al. , "Comparative Outcomes and Predictive Assessment of Trifecta in Open, Laparoscopic, and Robotic-Assisted Partial Nephrectomy Cases with Renal Cell Carcinoma: A 10-Year Experience at Ramathibodi Hospital," Res Rep Urol, vol. 13, pp. 425-435, 2021, https://doi.org/10.2147/rru.s316824. L. Bianchi, R. Schiavina, M. Borghesi, F. Chessa, C. Casablanca, A. Angiolini , et al. , "Which patients with clinical localized renal mass would achieve the trifecta after partial nephrectomy? The impact of surgical technique," Minerva Urol Nefrol, vol. 72, pp. 339-349, Jun 2020, https://doi.org/10.23736/s0393-2249.19.03485-4. M. Borghesi, R. Schiavina, F. Chessa, L. Bianchi, G. La Manna, A. Porreca , et al. , "Retroperitoneal Robot-Assisted Versus Open Partial Nephrectomy for cT1 Renal Tumors: A Matched-Pair Comparison of Perioperative and Early Oncological Outcomes," Clin Genitourin Cancer, vol. 16, pp. e391-e396, Apr 2018, https://doi.org/10.1016/j.clgc.2017.09.010. Y. Benichou, F. Audenet, K. Bensalah, M. Roupret, P. Paparel, C. Lebacle , et al. , "Partial nephrectomy in solitary kidneys: comparison between open surgery and robotic-assisted laparoscopy on perioperative and functional outcomes (UroCCR-54 study)," World J Urol, Jun 20 2022, https://doi.org/10.1007/s00345-022-04026-y. F. Porpiglia, A. Mari, R. Bertolo, A. Antonelli, G. Bianchi, F. Fidanza , et al. , "Partial Nephrectomy in Clinical T1b Renal Tumors: Multicenter Comparative Study of Open, Laparoscopic and Robot-assisted Approach (the RECORd Project)," Urology, vol. 89, pp. 45-51, Mar 2016, https://doi.org/10.1016/j.urology.2015.08.049. O. O. Omidele, N. Davoudzadeh, and M. Palese, "Trifecta Outcomes to Assess Learning Curve of Robotic Partial Nephrectomy," Jsls, vol. 22, Jan-Mar 2018, https://doi.org/10.4293/jsls.2017.00064. E. Bajalia, K. Parikh, D. Haehn, A. Kahn, C. Thomas, and D. Thiel, "MP47-03 Is there a learning curve plateau for achieving Trifecta and minimizing Operative Time (OT) for Robotic-Assisted Partial Nephrectomy (RAPN)?," The Journal of Urology, vol. 203, p. e684, 04/01 2020, https://doi.org/10.1097/JU.0000000000000902.03. S. Artsitas, D. Artsitas, I. Koronaki, K. G. Toutouzas, and G. C. Zografos, "A prototype variable corresponding to the proportion of ischemia for the comparison between robotic and open partial nephrectomy: a meta-analysis accompanied by sensitivity analysis," Beni-Suef University Journal of Basic and Applied Sciences, vol. 12, p. 90, 2023/10/14 2023, https://doi.org/10.1186/s43088-023-00431-3. S. Artsitas, D. Artsitas, I. Koronaki, K. G. Toutouzas, and G. C. Zografos, "Comparing robotic and open partial nephrectomy under the prism of surgical precision: a meta-analysis of the average blood loss rate as a novel variable," Journal of Robotic Surgery, vol. 18, p. 313, 2024/08/07 2024, https://doi.org/10.1007/s11701-024-02060-z. M. J. Page, L. Shamseer, and A. C. Tricco, "Registration of systematic reviews in PROSPERO: 30,000 records and counting," Syst Rev, vol. 7, p. 32, Feb 20 2018, https://doi.org/10.1186/s13643-018-0699-4. T. Bozada, J. Borden, M. Cid, J. Malinowski, and T. Luechtefeld, "Sysrev: A FAIR platform for Data Curation and Systematic Evidence Review," 2021, https://doi.org/10.1101/2021.03.24.436697. S. Artsitas, D. Artsitas, I. Segkou, G. Tsourouflis, D. Dimitroulis, and N. Nikiteas, "Considering "Trifecta" as a Single Outcome when Comparing Robotic With Open Partial Nephrectomy: A Mathematical Model of Volume Conservation and Systematic Review," In Vivo, vol. 36, pp. 2558-2578, Nov-Dec 2022, https://doi.org/10.21873/invivo.12992. P. A. Clavien, J. Barkun, M. L. de Oliveira, J. N. Vauthey, D. Dindo, R. D. Schulick , et al. , "The Clavien-Dindo classification of surgical complications: five-year experience," Ann Surg, vol. 250, pp. 187-96, Aug 2009, https://doi.org/10.1097/SLA.0b013e3181b13ca2. X. Wan, W. Wang, J. Liu, and T. Tong, "Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range," BMC Medical Research Methodology, vol. 14, p. 135, 2014/12/19 2014, https://doi.org/10.1186/1471-2288-14-135. D.-G. Chen and K. Peace, Applied Meta-Analysis with R and Stata , 2021, ISBN: 9780429061240, https://doi.org/10.1201/9780429061240. D.-G. Chen and K. Peace, Applied Meta-Analysis with R , 2013, ISBN: 978-1-46-650599-5, https://doi.org/10.13140/2.1.3165.5368. A. Stang, "Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses," Eur J Epidemiol, vol. 25, pp. 603-5, Sep 2010, https://doi.org/10.1007/s10654-010-9491-z. J. A. Sterne, M. A. Hernán, B. C. Reeves, J. Savović, N. D. Berkman, M. Viswanathan , et al. , "ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions," BMJ, vol. 355, p. i4919, 2016, https://doi.org/10.1136/bmj.i4919. L. Smolinsky, "Odds ratios and Mantel-Haenszel quotients," Journal of Informetrics, vol. 13, 02/01 2019, https://doi.org/10.1016/j.joi.2019.02.005. B. George and I. Aban, "An application of meta-analysis based on DerSimonian and Laird method," Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology, vol. 23, 08/06 2015, https://doi.org/10.1007/s12350-015-0249-6. L. Lin, "Comparison of four heterogeneity measures for meta-analysis," Journal of Evaluation in Clinical Practice, vol. 26, pp. 376-384, 2020/02/01 2020, https://doi.org/10.1111/jep.13159. L. Lin, H. Chu, M. H. Murad, C. Hong, Z. Qu, S. Cole , et al. , "Empirical Comparison of Publication Bias Tests in Meta-Analysis," Journal of General Internal Medicine, vol. 33, 04/16 2018, https://doi.org/10.1007/s11606-018-4425-7. M. J. Page, J. E. McKenzie, P. M. Bossuyt, I. Boutron, T. C. Hoffmann, C. D. Mulrow , et al. , "The PRISMA 2020 statement: an updated guideline for reporting systematic reviews," BMJ, vol. 372, p. n71, 2021, https://doi.org/10.1136/bmj.n71. S. Wattanakriengkrai, B. Chinthanet, H. Hata, R. G. Kula, C. Treude, J. Guo , et al. , "GitHub repositories with links to academic papers: Public access, traceability, and evolution," Journal of Systems and Software, vol. 183, p. 111117, 2022/01/01/ 2022, https://doi.org/10.1016/j.jss.2021.111117. T. L. Staples, "Expansion and evolution of the R programming language," Royal Society Open Science, vol. 10, p. 221550, 2023/04/12 2023, https://doi.org/10.1098/rsos.221550. S. Artsitas, D. Artsitas, I. Segkou, I. Koronaki, K. G. Toutouzas, and G. C. Zografos, "Robotic versus open partial nephrectomy in the context of mild severity complications: a meta-analysis of comparative studies supplemented by meta-regression," Bulletin of the National Research Centre, vol. 47, p. 36, 2023/03/06 2023, https://doi.org/10.1186/s42269-023-01008-x. M. J. Maurice, D. Ramirez, Ö. Kara, E. Malkoç, R. J. Nelson, K. Fareed , et al. , "Optimum outcome achievement in partial nephrectomy for T1 renal masses: a contemporary analysis of open and robot-assisted cases," BJU Int, vol. 120, pp. 537-543, Oct 2017, https://doi.org/10.1111/bju.13888. Ö. Acar, E. Işık, T. Mut, Y. Sağlıcan, A. Onay, M. Vural , et al. , "Comparison of the trifecta outcomes of robotic and open nephron-sparing surgeries performed in the robotic era of a single institution," Springerplus, vol. 4, p. 472, 2015, https://doi.org/10.1186/s40064-015-1274-2. C. A. Bravi, A. Larcher, U. Capitanio, A. Mari, A. Antonelli, W. Artibani , et al. , "Perioperative outcomes of Open, Laparoscopic, and Robotic Partial Nephrectomy: A prospective multicenter observational study (The RECORd 2 Project)," European urology focus, 2019, https://doi.org/10.1016/j.euf.2019.10.013. B. Hoeh, M. Wenzel, O. Eckart, F. Fleisgarten, C. C. Garcia, J. Köllermann , et al. , "Comparison of peri- and intraoperative outcomes of open vs robotic-assisted partial nephrectomy for renal cell carcinoma: a propensity-matched analysis," World Journal of Surgical Oncology, vol. 21, p. 189, 2023/06/22 2023, https://doi.org/10.1186/s12957-023-03061-2. A. Ingels, K. Bensalah, J. B. Beauval, P. Paparel, M. Rouprêt, H. Lang , et al. , "Comparison of open and robotic-assisted partial nephrectomy approaches using multicentric data (UroCCR-47 study)," Scientific Reports, vol. 12, p. 18981, 2022/11/08 2022, https://doi.org/10.1038/s41598-022-22912-8. K. Mehra, R. Manikandan, L. N. Dorairajan, S. Sreerag, A. Jain, and S. H. Bokka, "Trifecta Outcomes in Open, Laparoscopy or Robotic Partial Nephrectomy: Does the Surgical Approach Matter?," Journal of kidney cancer and VHL, vol. 6, p. 8, 2019, https://doi.org/10.15586/jkcvhl.2019.115. D. Motoyama, R. Aki, Y. Matsushita, K. Tamura, T. Ito, T. Sugiyama , et al. , "Early single-center experience with robotic partial nephrectomy using the da Vinci Xi: comparative assessment with conventional open partial nephrectomy," Current urology, vol. 13, pp. 13-18, 2019, https://doi.org/10.1159/000499300. H. Qu, K. Wang, and B. Hu, "Meta-analysis of clinical outcomes of robot-assisted partial nephrectomy and classical open partial nephrectomy," Int J Surg, Apr 3 2024, https://doi.org/10.1097/js9.0000000000001324. A. Antonelli, A. Mari, A. Tafuri, R. Tellini, U. Capitanio, P. Gontero , et al. , "Prediction of significant renal function decline after open, laparoscopic, and robotic partial nephrectomy: External validation of the Martini’s nomogram on the RECORD2 project cohort," International Journal of Urology, vol. 29, pp. 525-532, 2022, https://doi.org/10.1111/iju.14831. V. Audigé, A. Baghli, J. Hubert, C. Mazeaud, S. Larré, and B. Branchu, "Clinical and oncological outcomes of open partial nephrectomy versus robot assisted partial nephrectomy over 15 years," Journal of Robotic Surgery, pp. 1-8, 2022, https://doi.org/10.1007/s11701-022-01446-1. P. Banapour, G. A. Abdelsayed, Z. Bider-Canfield, P. A. Elliott, P. S. Kilday, and G. W. Chien, "Nephrometry score matched Robotic vs. Laparoscopic vs. Open Partial Nephrectomy," Journal of robotic surgery, vol. 12, pp. 679-685, 2018, https://doi.org/10.1007/s11701-018-0801-x. C. B. Ugur Boylu, Umit Yildirim, Fikret F. Onol, Eyup Gumus, "Comparison of surgical, functional, and oncological outcomes of open and robot-assisted partial nephrectomy," Journal of Minimal Access Surgery, vol. 11, 2015, https://doi.org/10.4103/0972-9941.147699. C. A. Bravi, G. Rosiello, E. Mazzone, A. Minervini, A. Mari, F. Di Maida , et al. , "The IRON Study: Investigation of Robot-assisted Versus Open Nephron-sparing Surgery," European Urology Open Science, vol. 49, pp. 71-77, 2023/03/01/ 2023, https://doi.org/10.1016/j.euros.2022.12.017. M. Chandra, S. Wasnik, and S. Karan, "A prospective, multi-institutional study of perioperative morbidities in the patients of renal cell carcinoma undergoing either open nephron sparing surgery or robotic nephron sparing surgery in fifty cases," International Surgery Journal, vol. 6, pp. 2785-2790, 2019, https://doi.org/10.18203/2349-2902.isj20193155. K. Chang, A. Abdel Raheem, K. Kim, C. Oh, S. Park, Y. Kim , et al. , "Functional and oncologic outcomes of open, laparoscopic and robotic partial nephrectomy: A Multicenter comparative matched-pair analyses with a median 5 years follow up," BJU Int, 2018, https://doi.org/10.1111/bju.14250. S. Y. Choi, H. Jung, D. You, I. G. Jeong, C. Song, B. Hong , et al. , "Robot-assisted partial nephrectomy is associated with early recovery of renal function: Comparison of open, laparoscopic, and robot-assisted partial nephrectomy using DTPA renal scintigraphy," J Surg Oncol, vol. 119, pp. 1016-1023, Jun 2019, https://doi.org/10.1002/jso.25429. T. Esen, Ö. Acar, A. Musaoğlu, and M. Vural, "Morphometric profile of the localised renal tumors managed either by open or robot-assisted nephron-sparing surgery: the impact of scoring systems on the decision making process," BMC urology, vol. 13, pp. 1-7, 2013, https://doi.org/10.1186/1471-2490-13-63. V. Ficarra, A. Minervini, A. Antonelli, S. Bhayani, G. Guazzoni, N. Longo , et al. , "A multicentre matched-pair analysis comparing robot-assisted versus open partial nephrectomy," BJU Int, vol. 113, pp. 936-41, Jun 2014, https://doi.org/10.1111/bju.12570. C. Gandi, A. Totaro, R. Bientinesi, F. Marino, F. Pierconti, A. Russo , et al. , "Purely Off-Clamp Partial Nephrectomy: Robotic Approach Better than Open Using a Pentafecta Outcome with Propensity Score Matching," Journal of Clinical Medicine, vol. 11, 2022, https://doi.org/10.3390/jcm11216241. K. S. Han, G. H. Song, D. You, C. Song, I. G. Jeong, J. H. Hong , et al. , "Comparison of Hand-Assisted Laparoscopic vs Robot-Assisted Laparoscopic vs Open Partial Nephrectomy in Patients with T1 Renal Masses," J Endourol, vol. 31, pp. 374-379, Apr 2017, https://doi.org/10.1089/end.2014.0517. C. R. Jelley, K. A. Kurukulaarachchi, L. Forster, H. Bardgett, R. Singh, and S. K. Addla, "Comparison of open and robotic nephron sparing surgery: a single centre experience," Journal of Clinical Urology, vol. 10, pp. 28-35, 2017, https://doi.org/10.1177/2051415816668942. K. Kim, M. Choo, H. Lee, Y. Park, S. Song, and H. Kim, "Comparison of robot-assisted partial nephrectomy and open partial nephrectomy: Clinical outcome and complication analysis," European Urology Supplements, vol. 1, pp. e32, e32a, 2012, https://doi.org/10.1371/journal.pone.0210413. Z. Klaassen, R. M. Kohut, D. Patel, M. K. Terris, and R. Madi, "A single surgeon’s experience with open, laparoscopic, and robotic partial nephrectomy," International scholarly research notices, vol. 2014, 2014, https://doi.org/10.1155/2014/430914 K.-F. Kowalewski, D. Müller, M. Kirchner, R. Brinster, J. Mühlbauer, M. A. S. Abate , et al. , "Robotic-Assisted Versus Conventional Open Partial Nephrectomy (Robocop): A Propensity Score-Matched Analysis of 249 Patients," Urologia Internationalis, pp. 1-9, 2021, https://doi.org/10.1159/000513189. K.-F. Kowalewski, M. Neuberger, M. A. Sidoti Abate, M. Kirchner, C. M. Haney, F. Siegel , et al. , "Randomized Controlled Feasibility Trial of Robot-assisted Versus Conventional Open Partial Nephrectomy: The ROBOCOP II Study," European Urology Oncology, 2023/06/12/ 2023, https://doi.org/10.1016/j.euo.2023.05.011. S. Kumar and B. Nayak, "Transition From Open and Laparoscopic to Robotic Partial Nephrectomy: Learning Curve and Outcomes," Cureus, vol. 16, p. e51646, Jan 2024, https://doi.org/10.7759/cureus.51646. C. Lee, T. Kwon, S. Yoo, J. Jung, C. Lee, D. You , et al. , "Comparison of renal function between robot-assisted and open partial nephrectomy as determined by Tc 99m-DTPA renal scintigraphy," Journal of Korean Medical Science, vol. 31, pp. 743-749, 2016, https://doi.org/10.3346/jkms.2016.31.5.743. S. Lee, J. Oh, S. K. Hong, S. E. Lee, and S. S. Byun, "Open versus robot-assisted partial nephrectomy: effect on clinical outcome," J Endourol, vol. 25, pp. 1181-5, Jul 2011, https://doi.org/10.1089/end.2010.0670. S. Lee, H. Ryu, and J. W. Lee, "Open Partial Nephrectomy vs. Robot-assisted Partial Nephrectomy for a Renal Tumor Larger than 4 cm: a Propensity Score Matching Analysis," J Korean Med Sci, vol. 36, p. e135, May 24 2021, https://doi.org/10.3346/jkms.2021.36.e135. S. M. Lucas, M. J. Mellon, L. Erntsberger, and C. P. Sundaram, "A comparison of robotic, laparoscopic and open partial nephrectomy," JSLS: Journal of the Society of Laparoendoscopic Surgeons, vol. 16, p. 581, 2012, https://doi.org/10.4293/108680812X13462882737177. L. G. Luciani, S. Chiodini, D. Mattevi, T. Cai, M. Puglisi, W. Mantovani , et al. , "Robotic-assisted partial nephrectomy provides better operative outcomes as compared to the laparoscopic and open approaches: results from a prospective cohort study," Journal of robotic surgery, vol. 11, pp. 333-339, 2017, https://doi.org/10.1007/s11701-016-0660-2. E. Malkoc, D. Ramirez, O. Kara, M. J. Maurice, R. J. Nelson, P. A. Caputo , et al. , "Robotic and open partial nephrectomy for localized renal tumors larger than 7 cm: a single-center experience," World journal of urology, vol. 35, pp. 781-787, 2017, https://doi.org/10.1007/s00345-016-1937-9. K. Masoumi-Ravandi, R. J. Mason, and R. A. Rendon, "Robotic-assisted laparoscopic partial nephrectomy vs. laparoscopic and open partial nephrectomy: A single-site, two-surgeon, retrospective cohort study," Can Urol Assoc J, Apr 2 2024, https://doi.org/10.5489/cuaj.8585. A. Masson-Lecomte, D. R. Yates, V. Hupertan, A. Haertig, E. Chartier-Kastler, M. O. Bitker , et al. , "A prospective comparison of the pathologic and surgical outcomes obtained after elective treatment of renal cell carcinoma by open or robot-assisted partial nephrectomy," Urol Oncol, vol. 31, pp. 924-9, Aug 2013, https://doi.org/10.1016/j.urolonc.2011.08.004. L. Mearini, E. Nunzi, A. Vianello, M. Di Biase, and M. Porena, "Margin and complication rates in clampless partial nephrectomy: a comparison of open, laparoscopic and robotic surgeries," Journal of robotic surgery, vol. 10, pp. 135-144, 2016, https://doi.org/10.1007/s11701-016-0584-x. J. J. Oh, S. Byun, S. K. Hong, C. W. Jeong, and S. E. Lee, "Comparison of robotic and open partial nephrectomy: Single-surgeon matched cohort study," Canadian Urological Association Journal, vol. 8, p. E471, 2014, https://doi.org/10.5489/cuaj.1679. J. J. Oh, J. K. Lee, K. Kim, S.-S. Byun, S. E. Lee, and S. K. Hong, "Comparison of the width of peritumoral surgical margin in open and robotic partial nephrectomy: a propensity score matched analysis," PloS one, vol. 11, p. e0158027, 2016, https://doi.org/10.1371/journal.pone.0158027. R. Saoud, A. El Hajj, M. Shahait, M. Bulbul, R. Nasr, W. Wazzan , et al. , "Comparative Analysis of Robotic-Assisted Partial Nephrectomy Versus Open Partial Nephrectomy During the Initial Robotic Learning Curve: Does the End Justify the Means?," World Journal of Nephrology and Urology, vol. 5, pp. 79-82, 2017, https://doi.org/10.14740/wjnu286w. A. Sawada, T. Kobayashi, T. Takahashi, J. Kono, K. Masui, T. Sato , et al. , "Comparative analysis of perioperative outcomes between robot-assisted partial nephrectomy and open partial nephrectomy: a propensity-matched study," Mini-invasive Surgery, vol. 5, p. 6, 02/03 2021, https://doi.org/10.20517/2574-1225.2020.100. H. Tachibana, T. Kondo, K. Yoshida, T. Takagi, and K. Tanabe, "Lower Incidence of Postoperative Acute Kidney Injury in Robot-Assisted Partial Nephrectomy Than in Open Partial Nephrectomy: A Propensity Score-Matched Study," J Endourol, vol. 34, pp. 754-762, Jul 2020, https://doi.org/10.1089/end.2019.0622. T. Takagi, T. Kondo, H. Tachibana, J. Iizuka, K. Omae, H. Kobayashi , et al. , "A propensity score-matched comparison of surgical precision obtained by using volumetric analysis between robot-assisted laparoscopic and open partial nephrectomy for T1 renal cell carcinoma: a retrospective non-randomized observational study of initial outcomes," Int Urol Nephrol, vol. 48, pp. 1585-91, Oct 2016, https://doi.org/10.1007/s11255-016-1323-y. K. Takahara, K. Fukaya, T. Nukaya, M. Takenaka, K. Zennami, M. Ichino , et al. , "Perioperative and long-term functional outcomes of robot-assisted versus open partial nephrectomy: A single-center retrospective study of a Japanese cohort," Ann Med Surg (Lond), vol. 75, p. 103482, Mar 2022, https://doi.org/10.1016/j.amsu.2022.103482. J. L. Tan, M. Frydenberg, J. Grummet, U. Hanegbi, R. Snow, S. Mann , et al. , "Comparison of perioperative, renal and oncologic outcomes in robotic‐assisted versus open partial nephrectomy," ANZ journal of surgery, vol. 88, pp. E194-E199, 2018, https://doi.org/10.1111/ans.14154. G. Vittori, "Open versus robotic-assisted partial nephrectomy: a multicenter comparison study of perioperative results and complications," World journal of urology, vol. 32, pp. 287-293, 2014, https://doi.org/10.1007/s00345-013-1136-x. Z. Wu, M. Li, L. Qu, H. Ye, B. Liu, Q. Yang , et al. , "A propensity-score matched comparison of perioperative and early renal functional outcomes of robotic versus open partial nephrectomy," PloS one, vol. 9, p. e94195, 2014, https://doi.org/10.1371/journal.pone.0094195. Y. D. Yu, N. H. Nguyen, H. Y. Ryu, S. K. Hong, S. S. Byun, and S. Lee, "Predictors of renal function after open and robot‐assisted partial nephrectomy: A propensity score‐matched study," International Journal of Urology, vol. 26, pp. 377-384, 2019, https://doi.org/10.1111/iju.13879. P. Zeuschner, L. Greguletz, I. Meyer, J. Linxweiler, M. Janssen, G. Wagenpfeil , et al. , "Open versus robot-assisted partial nephrectomy: A longitudinal comparison of 880 patients over 10 years," Int J Med Robot, vol. 17, pp. 1-8, Feb 2021, https://doi.org/10.1002/rcs.2167. Tables Tables 1 to 3 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files SupplementaryFigures.docx SupplementaryPRISMA2020Checklist.docx SupplementaryROBINSIforms.docx Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-5174620","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":382979159,"identity":"cf4bf939-11c9-454a-b868-978d4a6b8cff","order_by":0,"name":"Sotirios Artsitas","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYHACNoaEAwxyBmC2gQUxOpjBWowNGJhBWiSI1MJwgCFxA1gLAxFa5Nv7jz14cMYmfTt7/9ENPwokGPjbuxPwajE4c5jdIOFGWu7OnsNsN3uADpM4c3YDfi0SyWwSCR8O5264kcx2gweoxUAiF78W+RlgLf/TDYBabv4hRgvDDZCWGwcSQFpuE2UL0C/mBglnkg03nDlsdlvGQIKHoF/k2xufPfxxzE7e4Hjjs5tv/tjI8bf3EnAYOuAhTfkoGAWjYBSMAqwAAE1+SX0Dw8cqAAAAAElFTkSuQmCC","orcid":"","institution":"National and Kapodistrian University of Athens (NKUA)","correspondingAuthor":true,"prefix":"","firstName":"Sotirios","middleName":"","lastName":"Artsitas","suffix":""},{"id":382979160,"identity":"9e554024-799c-4b75-850d-65bbc0901879","order_by":1,"name":"Dimitrios Artsitas","email":"","orcid":"","institution":"KAT Attica General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dimitrios","middleName":"","lastName":"Artsitas","suffix":""},{"id":382979161,"identity":"144d34a0-92c1-43e6-b8c1-daa819ebbb68","order_by":2,"name":"Irene Koronaki","email":"","orcid":"","institution":"National Technical University of Athens (NTUA)","correspondingAuthor":false,"prefix":"","firstName":"Irene","middleName":"","lastName":"Koronaki","suffix":""},{"id":382979162,"identity":"421ad962-daf1-4fba-8aca-84ee68845f8f","order_by":3,"name":"Konstantinos G. Toutouzas","email":"","orcid":"","institution":"National and Kapodistrian University of Athens (NKUA)","correspondingAuthor":false,"prefix":"","firstName":"Konstantinos","middleName":"G.","lastName":"Toutouzas","suffix":""},{"id":382979163,"identity":"0848b3c7-b893-4163-8ac6-851079e5aa81","order_by":4,"name":"George C. Zografos","email":"","orcid":"","institution":"National and Kapodistrian University of Athens (NKUA)","correspondingAuthor":false,"prefix":"","firstName":"George","middleName":"C.","lastName":"Zografos","suffix":""}],"badges":[],"createdAt":"2024-09-29 11:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5174620/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5174620/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":70129407,"identity":"3657ba80-315f-4fd2-bcbe-c60a25d204a9","added_by":"auto","created_at":"2024-11-28 15:43:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":74651,"visible":true,"origin":"","legend":"\u003cp\u003eFlow-chart of studies according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/ba44fe00f8e099af74568688.png"},{"id":70128194,"identity":"c648b08b-b293-430b-b681-f08b812c8bb5","added_by":"auto","created_at":"2024-11-28 15:35:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":339301,"visible":true,"origin":"","legend":"\u003cp\u003ePie charts depicting the percentages of studies and patients corresponding to each country of origin (a). Map charts illustrating the geographical distributions of studies and patients by percentage (b).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/01450281c9190a328a56f32c.png"},{"id":70128192,"identity":"f6fe718e-d0d2-4010-ac1e-636866f0e2eb","added_by":"auto","created_at":"2024-11-28 15:35:43","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":68374,"visible":true,"origin":"","legend":"\u003cp\u003eHistogram illustrating the percentage distribution of studies based on the NOS grading (a). Horizontal stacked bar chart displaying the percentage distribution of studies across each domain of the ROBINS-I tool (b). Abbreviations: NOS: Newcastle-Ottawa Scale, ROBINS-I: Risk of Bias In Non-randomized Studies of Interventions.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/69a25d93db8c8cc1aa21e36a.png"},{"id":70129929,"identity":"a15c1653-115c-48bc-a4d9-474ebe79c510","added_by":"auto","created_at":"2024-11-28 15:51:43","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":201542,"visible":true,"origin":"","legend":"\u003cp\u003ePooled MA forest plot pertaining to the OR of Trifecta rates (a). Funnel plot for assessing PB with contours of distinct significance levels (b). Pooled MRA plot depicting the evolution of logOR\u003csub\u003eTrifecta\u003c/sub\u003e in chronological scale (c). Pooled MRA plot depicting the variation of logOR\u003csub\u003eTrifecta\u003c/sub\u003e in the NOS qualitative scale (d). Abbreviations: MA: Meta-analysis, OR: Odds Ratio, PB: Publication Bias, MRA: Meta-regression Analysis, logOR: decimal logarithm of Odds Ratio, NOS: Newcastle-Ottawa Scale.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/4f9ba5630943c36a817d5efa.png"},{"id":70128196,"identity":"bcdd9445-8e6a-46ca-93f0-afd0ff7bc4c5","added_by":"auto","created_at":"2024-11-28 15:35:43","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":204318,"visible":true,"origin":"","legend":"\u003cp\u003ePooled MA forest plot pertaining to the OR of major (CD ≥ 3) complication rates (a). Funnel plot for assessing PB with contours of distinct significance levels (b). Pooled MRA plot depicting the evolution of logOR\u003csub\u003eCD≥3\u003c/sub\u003e in chronological scale (c). Pooled MRA plot depicting the variation of logOR\u003csub\u003eCD≥3\u003c/sub\u003e in the NOS qualitative scale (d). Abbreviations: MA: Meta-analysis, OR: Odds Ratio, CD: Clavien-Dindo classification of postoperative complications, PB: Publication Bias, MRA: Meta-regression Analysis, logOR: decimal logarithm of Odds Ratio, NOS: Newcastle-Ottawa Scale.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/3fd2cdd79ff130fbf9589571.png"},{"id":70128195,"identity":"5b023667-897c-4e3b-8b63-cf427f1cd090","added_by":"auto","created_at":"2024-11-28 15:35:43","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":210380,"visible":true,"origin":"","legend":"\u003cp\u003ePooled MA forest plot pertaining to the OR of minor (CD ≤ 2) complication rates (a). Funnel plot for assessing PB with contours of distinct significance levels (b). Pooled MRA plot depicting the evolution of logOR\u003csub\u003eCD≤2\u003c/sub\u003e in chronological scale (c). Pooled MRA plot depicting the variation of logOR\u003csub\u003eCD≤2\u003c/sub\u003e in the NOS qualitative scale (d). Abbreviations: MA: Meta-analysis, OR: Odds Ratio, CD: Clavien-Dindo classification of postoperative complications, PB: Publication Bias, MRA: Meta-regression Analysis, logOR: decimal logarithm of Odds Ratio, NOS: Newcastle-Ottawa Scale.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/083606dfc35e52310e7ef9c2.png"},{"id":70128201,"identity":"cea59ce9-1089-466b-985a-a788d0d73b4c","added_by":"auto","created_at":"2024-11-28 15:35:43","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":219088,"visible":true,"origin":"","legend":"\u003cp\u003ePooled MA forest plot pertaining to the OR of PSM rates (a). Funnel plot assessing PB with contours of distinct significance levels (b). Pooled MRA plot depicting the evolution of logOR\u003csub\u003ePSM\u003c/sub\u003e in chronological scale (c). Pooled MRA plot depicting the variation of logOR\u003csub\u003ePSM\u003c/sub\u003e in the NOS qualitative scale (d). Abbreviations: MA: Meta-analysis, OR: Odds Ratio, PSM: Positive Surgical Margins, PB: Publication Bias, MRA: Meta-regression Analysis, logOR: decimal logarithm of Odds Ratio, NOS: Newcastle-Ottawa Scale\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/228a4c39078bd3055adad97a.png"},{"id":70129408,"identity":"0f44aea9-0b67-48f3-af65-128936d4a838","added_by":"auto","created_at":"2024-11-28 15:43:43","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":252116,"visible":true,"origin":"","legend":"\u003cp\u003ePooled MA forest plot pertaining to the MD of IT (a). Funnel plot assessing PB with contours of distinct significance levels (b). Pooled MRA plot depicting the evolution of MD\u003csub\u003eIT\u003c/sub\u003e in chronological scale (c). Pooled MRA plot depicting the variation of MD\u003csub\u003eIT\u003c/sub\u003e in the NOS qualitative scale (d). Abbreviations: MA: Meta-analysis, MD: Mean Difference, IT: Ischemia Time, PB: Publication Bias, MRA: Meta-regression Analysis, NOS: Newcastle-Ottawa Scale.\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/2e26acf70b9cd77aa450b193.png"},{"id":70128204,"identity":"82bb8abb-43dd-46c0-876e-0f591a72589a","added_by":"auto","created_at":"2024-11-28 15:35:43","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":249446,"visible":true,"origin":"","legend":"\u003cp\u003ePooled MA forest plot pertaining to the MD of ΔeGFR (a). Funnel plot assessing PB with contours of distinct significance levels (b). Pooled MRA plot depicting the evolution of MD\u003csub\u003eΔeGFR\u003c/sub\u003e in chronological scale (c). Pooled MRA plot depicting the variation of MD\u003csub\u003eΔeGFR\u003c/sub\u003e in the NOS qualitative scale (d). Abbreviations: MA: Meta-analysis, MD: Mean Difference, ΔeGFR: Change (negative) from baseline in estimated Glomerular Filtration Rate, PB: Publication Bias, MRA: Meta-regression Analysis, NOS: Newcastle-Ottawa Scale.\u003c/p\u003e","description":"","filename":"9.png","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/cfebbc279b3280ad64d781ef.png"},{"id":70128199,"identity":"19792397-2b7a-48b9-b64e-78eb668c2a91","added_by":"auto","created_at":"2024-11-28 15:35:43","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":165814,"visible":true,"origin":"","legend":"\u003cp\u003ePooled MA forest plot pertaining to the MD of ΔCr (a). Funnel plot assessing PB with contours of distinct significance levels (b). Pooled MRA plot depicting the evolution of MD\u003csub\u003eΔCr\u003c/sub\u003e in chronological scale (c). Pooled MRA plot depicting the variation of MD\u003csub\u003eΔCr\u003c/sub\u003e in the NOS qualitative scale (d). Abbreviations: MA: Meta-analysis, MD: Mean Difference, ΔCr: Change (positive) from baseline in serum Creatinine levels, PB: Publication Bias, MRA: Meta-regression Analysis, NOS: Newcastle-Ottawa Scale.\u003c/p\u003e","description":"","filename":"10.png","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/7daa1e7e7da10fa9e4af5b11.png"},{"id":70131117,"identity":"61939b1a-7077-4107-bb2b-aba2e36b0d5d","added_by":"auto","created_at":"2024-11-28 15:59:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2296996,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/9059e7aa-32bb-4633-8426-83b9ef89ecdc.pdf"},{"id":70128205,"identity":"93d95209-fd7a-4ad9-ba17-6e07275239ae","added_by":"auto","created_at":"2024-11-28 15:35:43","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":32687641,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigures.docx","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/d4086dd5cf2adfc68ae40819.docx"},{"id":70128197,"identity":"2d012fe9-431c-4009-9cac-900ffcb2d364","added_by":"auto","created_at":"2024-11-28 15:35:43","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":33504,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryPRISMA2020Checklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/91cff61bbfe4bb3f2c1399f2.docx"},{"id":70129409,"identity":"e25fc110-f02b-4e00-82a6-fc2304578396","added_by":"auto","created_at":"2024-11-28 15:43:43","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":553044,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryROBINSIforms.docx","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/f2d18c24c68705c6ae3191c7.docx"},{"id":70129410,"identity":"0c5fa3cb-7cd0-4553-8618-225c1f3cee62","added_by":"auto","created_at":"2024-11-28 15:43:43","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":132168,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-5174620/v1/172f97a3d3b3b96e729a25fa.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative investigation of therapeutic efficacy in tumor resection between robotic and open partial nephrectomy: A meta-analysis supplemented by time-series and quality-based meta-regression","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003ePrior research indicates that partial nephrectomy (PN) practically equals radical surgery in terms of oncological outcomes, concurrently providing additional functional advantages in patients with small renal masses (SRMs), typically ranging from 4 to 7 cm in size. Limited data exists as for tumors of larger sizes, particularly of maximum diameters greater than 7 cm [1]. In contemporary kidney surgery practice, SRMs are commonly managed through active surveillance or PN. Minimally invasive procedures conventionally involve laparoscopic PN (LPN) and robotic PN (RPN). This study was conducted with the aim to primarily compare Trifecta rates between robotic / robot-assisted PN (RPN/ RAPN) and open partial nephrectomy (OPN). The Trifecta outcome, originally formulated for the qualitative evaluation of radical prostatectomy procedures, also standardizes the quantification of therapeutic efficacy in PN [2]. Trifecta encompasses the combined avoidance of positive surgical margins (PSM), severe complications, as well as substantial ischemic impact or decline in renal function [3]. Within the Trifecta framework, PN essentially targets resections with negative margins, minimal strain on renal function, and mitigation of severe postoperative morbidity. OPN is still considered as the standard approach, albeit RAPN provides similar oncological outcomes, reduced morbidity, and faster recovery times. In general, PN is primarily recommended in patients with cT1 renal tumors, with an extending spectrum during the last decade in managing hilar or multifocal lesions [4-6]. In this concept, minimally invasive surgery, including LPN, RPN, and RAPN, is preferably adopted in cases of SRMs, with RPN/RAPN addressing LPN's technical challenges [7]. The focal point of this study involves the comparison between RPN/RAPN and open surgery, specifically examining the overall quality of tumor excision as a component of precision in surgical tissue handling. Therefore, an in-depth evaluation of both the Trifecta outcome and its individual components will be performed. Fundamentally, the objective was to juxtapose robotic and open approaches in PN within the broader context of surgical precision from a therapeutic perspective. The latter covers the spectrum of surgical safety through postoperative complications, oncological control through recurrence risk, and functional recovery through the intraoperative ischemic impact and postoperative decrease in glomerular filtration rate (GFR). The selection of Trifecta as a measure of surgical precision is based on its strong correlation with the surgeon's technical expertise and level of experience [8]. Building upon this association, a causal link is established, connecting surgical capacity to an increased likelihood of achieving Trifecta, while simultaneously resulting in reduced operative time (OT) in RAPN [9]. Limiting OT to levels comparable with OPN facilitates a synchronous comparison (within the same operative timeframe) of quantitative variables such as blood loss and ischemia time (IT), both of which are integral to defining surgical precision in PN [10, 11].\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e\u003cu\u003eLiterature search\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe literature search covered the period from August 15, 2022, to August 15, 2024, targeting all studies investigating the comparison: RPN/RAPN vs. OPN, using the keywords: \u0026quot;robot-assisted\u0026quot;, \u0026quot;robotic\u0026quot;, \u0026quot;open\u0026quot;, and \u0026quot;partial nephrectomy\u0026quot;. A title-centered method was chosen due to the abundance of pertinent studies. The databases consulted included: \u0026quot;MEDLINE\u0026quot;, \u0026quot;CENTRAL\u0026quot;, \u0026quot;Scopus\u0026quot;, \u0026quot;Google Scholar\u0026quot; and \u0026quot;ScienceDirect\u0026quot;, with monthly alerts for updates. The study protocol (ID: CRD42023483593) was developed on PROSPERO online platform, where the applicable search strategy is accessible in PDF format (https://www.crd.york.ac.uk/prospero) [12].\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStudy selection\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe research strategy yielded an initial study set imported into the Sysrev platform in \u0026quot;.ris\u0026quot; format for inclusion assessment [13]. The primary criteria comprised English language, non-duplicated records, availability of full-text articles, and comparative data between RPN/RAPN and OPN. Non-comparative or single-arm analyses were excluded, along with studies with special patient populations such as pediatric, single-kidney, or multiple prior abdominal surgery cases. No upper age or tumor size thresholds were set due to the increasing adoption of robotic surgery during the last decade. The primary aim was to initially gather diverse studies reflecting current comparative literature for RPN/RAPN vs. OPN. Thereafter, secondary criteria for inclusion were applied, considering field of interest and reported outcomes, with the goal of standardizing the final dataset for analysis. The primary inclusion criteria project is accessible on Sysrev (https://sysrev.com/p/119881). The inclusion process comprised two stages: binary suitability criteria application and outcome-based labeling, conducted by an individual author ([S.A.]). Three investigators ([S.A.], [D.A.], and [I.K.]) applied the secondary criteria, isolating studies for final analysis. For each outcome, distinct \u0026quot;.xlsx\u0026quot; tables were generated. Every study had to provide comparative data for at least one outcome to be incorporated. The finalized dataset was tabulated in a \u0026quot;.csv\u0026quot; file containing individual outcome data and metadata, including the author\u0026rsquo;s name, year of first publication, number of involved centers, matching application in patient groups, risk of bias (ROB) assessment, and baseline differences between patient subpopulations.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eOutcomes\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAs previously delineated, the principal aim of this investigation revolves around the RPN/RAPN vs. OPN comparison, with specific attention directed towards Trifecta achievement. Typically, the Trifecta concept can be summarized by two distinct definitions commonly observed in the pertinent international literature. On one hand, the triple criterion involves achieving negative surgical margins, avoiding significant complications, and maintaining a percentage reduction in estimated GFR (\u0026Delta;eGFR\u003csub\u003e%\u003c/sub\u003e) below 10%. On the other hand, the second set of combined requirements replaces the \u0026Delta;eGFR\u003csub\u003e%\u003c/sub\u003e threshold with an upper limit of 20-25 minutes for absolute ischemia time (IT). These definitions converge in evaluating PN\u0026apos;s impact on renal function decline [14]. Secondary outcomes explored Trifecta parameters individually. Postoperative complications were dichotomized into severe (major) or mild (minor) based on the Clavien-Dindo (CD) classification scale, with \u0026quot;CD \u0026ge; 3\u0026quot; indicating the former and \u0026quot;CD \u0026le; 2\u0026quot; representing the latter [15]. The comparative analysis of PSM rates contrasts RAPN and OPN in terms of oncological effectiveness, indicating local recurrence risk. Renal function analysis included absolute ischemia duration, eGFR change from baseline, and the corresponding change in serum creatinine (Cr) levels.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eEvidence acquisition\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eAfter formulating the final study set, data extraction for primary and secondary outcomes was conducted. Each variable was linked with a corresponding \u0026quot;.csv\u0026quot; file, containing study metadata as well as numerical outcome-oriented data. Three investigators ([S.A.], [D.A.], and [I.K.]) independently conducted the procedure outlined above. Frequencies of nominal variables in RPN/RAPN vs. OPN cases were systematically documented. Continuous variables that followed a normal distribution were characterized by their mean and standard deviation (SD). In instances where only medians and interquartile ranges were available, they were appropriately converted to means and SDs as required [16]. The expressions (1) and (2) detailed below were employed to obtain the required summary statistics for changes in eGFR and serum Cr from baseline [17, 18].\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003c/p\u003e\n\u003cp\u003eIn the aforementioned expressions, \u0026quot;\u0026Delta;\u0026quot; denotes the change from baseline levels (\u0026Delta;eGFR or \u0026Delta;Cr), while \u0026quot;X̄\u0026quot; refers to the average of the random variable corresponding to eGFR or Cr. Similarly, \u0026quot;S\u0026quot; pertains to the respective standard deviations. The indices \u0026quot;post\u0026quot; and \u0026quot;pre\u0026quot; describe the postoperative and preoperative measurements respectively, with \u0026quot;n\u003csub\u003epost\u003c/sub\u003e\u0026quot; and \u0026quot;n\u003csub\u003epre\u003c/sub\u003e\u0026quot; denoting the corresponding patient populations. As evident, the aim was to estimate the expected values and standard errors of \u0026Delta;eGFR and \u0026Delta;Cr, denoted as EV\u003csub\u003e\u0026Delta;\u003c/sub\u003e and SE\u003csub\u003e\u0026Delta;\u003c/sub\u003e in the expressions above, respectively. In the next step, missing values were identified and used to estimate the standard errors per comparison arm. Metadata included author, publication year, patient matching, referral center count, Trifecta definition, timeframe of activity, qualitative status, and baseline differences between patient groups. These metadata were combined into a final \u0026quot;.csv\u0026quot; file along with the frequentist or quantitative data for each outcome in the RPN/RAPN vs. OPN comparison arms.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eQuality assessment\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNumerical data from each comparison arm were meticulously tabulated, followed by a two-tiered qualitative assessment of study design and methodology. The Newcastle-Ottawa Scale (NOS) was initially implemented to assess patient selection, comparability, and outcome ascertainment by two team members ([S.A.] and [I.K.]) [19]. In sequence, the ROBINS-I tool was collectively employed by three investigators ([S.A.], [D.A.], and [I.K.]) to assess the ROB classification of each study across its 7 domains [20]. Integrating these frameworks aimed to inform the subgroup analysis (SGA) and establish appropriate moderators in the subsequent meta-regression analysis (MRA). More specifically, the joint application of NOS and ROBINS-I assisted in eliminating confounding issues in appraising study quality.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStatistical analysis\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe data analysis aimed to compare RAPN and OPN as for their effectiveness in achieving the Trifecta outcome, and further investigate individual parameters such as complications incidence, PSM rates, IT, as well as eGFR and serum Cr changes from baseline. These comparisons were derived from separate datasets within Sysrev to ensure objectivity. Two random effects models were employed for the analysis, utilizing odds ratios (OR) regarding nominal variables and mean differences (MD) as for continuous outcomes. These measures were uniformly applied as effect size indicators [21, 22]. Heterogeneity was probed and quantified using Higgins I\u003csup\u003e2\u003c/sup\u003e [23]. Assessment of publication bias (PB) involved the use of suitable funnel and radial plots. In the latter, Egger\u0026apos;s test was visually depicted by evaluating the deviation trend of the dashed regression line representing reported results with the solid line corresponding to the threshold of no relative bias [24]. The impact of small-scale studies was modeled by fitting a regression curve onto appropriately configured funnel plots. In these diagrams, the magnitude of relative bias was assessed through the geometric deviation of the curve from the vertical line that indicates the absence of small-study effects (SSEs). Study groups were analyzed based on various criteria including publication year, matching of patient subpopulations, analysis type according to referral centers, ROB class, and Trifecta definition cluster. Forest plots and multilevel MRA plots were used to represent the dynamics of the effects, with circles representing individual studies and their radii being inversely proportional to the 95% confidence interval (CI\u003csub\u003e95%\u003c/sub\u003e) of the reported results. In these plots, the evolution of each comparative effect corresponds to a regression line geometrically related to the horizontal line of neutrality, with its direction indicated by appropriate labels. A subsequent sensitivity analysis (SA) focused on more accurate analyses by considering only those results with a CI\u003csub\u003e95%\u003c/sub\u003e width not exceeding a threshold of 2 standard deviations (SDs) of the respective widths in the pooled data. Ultimately, the SA ensured statistical robustness, while the SGA confirmed methodological reliability based on patient matching and referral center count.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eReporting of results \u0026amp; Data availability\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe present systematic review adheres to the PRISMA 2020 guidelines [25]. Results are presented as: \u0026quot;OR - CI\u003csub\u003e95%\u003c/sub\u003e\u0026quot; or \u0026quot;MD - CI\u003csub\u003e95%\u003c/sub\u003e\u0026quot;, at a confidence level of \u0026alpha; = 0.05. All primary and secondary outcome-related datasets, along with the analytic code, are publicly available on GitHub (https://github.com/sotbike/NESTOR.git). Data files are made available in \u0026quot;.csv\u0026quot; format, while the computational code is appropriately rendered in \u0026quot;.txt\u0026quot; format [26]. Additional details regarding the subject under investigation for each code file, along with specifications ensuring result reproducibility, are also included. The code implementation for results extraction and graph generation was performed using the R programming language, version 4.4.0 [27].\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cu\u003eStudy retrieval\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1 outlines the inclusion and exclusion process from the initially isolated dataset. Specifically, 604 studies were retrieved from the databases investigated. Following the removal of records in languages other than English, duplicated references, and entries with ineligible titles and/or abstracts, 191 analyses with available manuscripts and appropriately formatted comparative data were screened. Subsequently, 155 studies providing statistically utilizable data were evaluated, leading to the exclusion of systematic reviews \u0026amp; meta-analyses, non-comparative analyses, investigations lacking relevant comparative data, and presentation supplements. The above procedure yielded a dataset of 77 records, which were further evaluated to obtain the most homogeneous study set possible for analysis. For this reason, comparisons involving specific patient populations were excluded, resulting in a final set of 51 studies encompassing 20,844 patients in total (RPN/RAPN: 10,996 vs. OPN: 9,848). Comparative data included Trifecta rates, major and minor complication occurrences, PSM incidences, absolute IT durations, ΔeGFR, and ΔCr. There were 15 RPN vs. OPN and 36 RAPN vs. OPN comparisons. Regarding the missing data, they involved a total of 87 patients as for major complications (RPN/RAPN: 43 vs. OPN: 44), one case in the OPN group for minor complications, 240 individuals concerning PSM rates (RPN/RAPN: 127 vs. OPN: 113), and 1,679 cases in the IT dataset (RPN/RAPN: 350 vs. OPN: 1,329). Finally, there were no missing data in the datasets for Trifecta rates, ΔeGFR, and ΔCr. Table 1 displays the selected studies included in the analysis, showcasing their methodological and qualitative features, along with baseline differences between the compared arms.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStudy demographics\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis subsection details the individual characteristics of records regarding the collected metadata. Study features included title, author, country of origin, publication year, implementation of patient matching, type of analysis based on referral center count, ROB class, NOS-based quality star rating, time period of activity, and baseline differences between patient groups. The stratification of data origin by country was conducted at both the study level and the patient population level. Figure 2a depicts the geographical distribution of studies in a pie chart, whereas Figure 2b presents a map chart illustrating the above distribution at both the study- \u0026amp; patient-level data. The majority of analyzed records originated from the United States, followed by Eastern countries (South Korea and Japan), and the broader European region (Italy, Germany, and France). Roughly 55% of the data emerged from comparative studies published during the last five years, representing about 77% of the total patient population. Furthermore, around 45% of the study-level data, comprising a nearly equivalent proportion of the total patient population, stemmed from analyses employing patient matching protocols. Multicenter comparisons contributed to 25.5% of study-level \u0026amp; 60.4% of patient-level data. Regarding the ROB clustering, 35.3% of study-level \u0026amp; 48% of patient-level data were classified as of low risk. Conversely, moderate \u0026amp; serious ROB records accounted for 39.2% \u0026amp; 25.5% of studies, and 40% \u0026amp; 12% of patients, respectively. This favorable profile in terms of the proportion of studies with optimum ROB, may be attributed to the homogenization of the included dataset through the exclusion of comparative analyses involving specific patient populations. Supplementary Figure 1 contains the pertinent diagrams illustrating the above distributions. Supplementary Figure 2a displays active timeframes of included studies stratified by patient matching, showing uniform coverage from 2008 to 2018. In Supplementary Figure 2b, a similar diagram driven by referral center count, indicates data predominantly originating from single-center studies during this period. Supplementary Figure 2c illustrates activity periods based on the ROB cluster of each study, aligning with the previously described distributions as per ROBINS-I category during the above decade.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eQualitative profiles\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eFigure 3a displays a histogram illustrating the distribution of percentages across the entire study set for each NOS quality level, as indicated by the overall star count. The distribution appears nearly normal, centered around studies rated with 7 stars and ranging from 5 to 9 quality stars. Supplementary Figure 3 illustrates the corresponding distributions at the subgroup level. Notably, comparative population matching emerges as a crucial parameter directly linked to study quality (Supplementary Figure 3b). Additionally, a similar qualitative profile emerged for studies conducted across multiple centers (Supplementary Figure 3c). The above observations underscore the consistency of results obtained from matched and multicenter analyses in reporting the primary and secondary outcomes in the present investigation. Complementarily, Figure 3b depicts the percentage distribution of studies across the individual components of the ROBINS-I tool. Minimal ROB is observed in domains such as \"Deviations from intended interventions\" and \"Missing data\", while the fields of \"Confounding\", \"Selection of participants\", \"Selection of reported results\", and \"Classification of interventions\" indicate evident ROB. Supplementary Figure 4a presents the ROBINS-I clusterization for subgroups based on publication year, revealing limited overall ROB in studies from the last 5-year period, with \"ROBINS-I: Low\" records approaching 40%, compared to older publications (approximately 30%). Supplementary Figure 4b illustrates the above distribution based on the application of patient matching, confirming a connection between protocol application and minimization of ROB. Matched comparisons include approximately 60% of low-ROB analyses, contrasting with a respective proportion of about 15% in those without matching. Lastly, supplementary Figure 4c depicts subgroups based on single- or multicenter types of analysis, indicating a more favorable ROB profile in multicenter studies, particularly in areas like \"Confounding\", \"Selection of participants\", \"Selection of reported results\", and \"Classification of interventions\". Low-ROB records accounted for 60% in multicenter studies, while in single-center comparisons the corresponding percentage was below 30%. Supplementary Figures 5-11 provide the respective traffic light plots for aggregated data and subgroups, specifying the ROB class for each study across all seven ROBINS-I domains.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMeta-analysis of primary outcomes (Trifecta outcome)\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eIn the current subsection, we illustrate the meta-analysis (MA) findings on Trifecta rates. The initially derived study set consisted of 15 studies involving 4,913 patients (RPN/RAPN: 2,139 vs. OPN: 2,774). Figure 4a displays the forest plot for the entire study set, showing 50% increased odds for RAPN compared to OPN in achieving the Trifecta outcome (OR = 1.505, with CI\u003csub\u003e95%\u003c/sub\u003e = [1.122; 2.018], and I\u003csup\u003e2\u003c/sup\u003e = 77%). Figure 4b shows the funnel plot assessing PB, demonstrating rough symmetry. Supplementary Figure 12a captures the radial plot with the regression line from Egger’s test, showing notable geometric divergence between the two lines. Additionally, Supplementary Figure 12b depicts the funnel plot for small-scale analyses, where the respective effects appear as marginally significant. In Supplementary Figure 13a, results by publication year reveal RAPN's significant superiority in recent (post-2018) studies (OR = 1.471, with CI\u003csub\u003e95%\u003c/sub\u003e = [1.042; 2.077], and I\u003csup\u003e2\u003c/sup\u003e = 74%). However, older publications (pre-2018) showed only a trend towards superior Trifecta achievement with RAPN (OR = 1.656, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.885; 3.100], and I\u003csup\u003e2\u003c/sup\u003e = 75%). Supplementary Figure 13b highlights subsets based on patient matching, marginally indicating 63% higher odds for RAPN in matched comparisons (OR = 1.631, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.903; 2.948], and I\u003csup\u003e2\u003c/sup\u003e = 76%). On the other hand, non-matched analyses showed 46% higher odds for RAPN in Trifecta rates (OR = 1.459, with CI\u003csub\u003e95%\u003c/sub\u003e = [1.025; 2.075], and I\u003csup\u003e2\u003c/sup\u003e = 81%). In Supplementary Figure 14a, no statistically significant odds ratio emerged from multicenter studies (OR = 0.998, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.747; 1.334], and I\u003csup\u003e2\u003c/sup\u003e = 45%). On the contrary, single-center studies showed 81% higher odds for Trifecta achievement with RAPN (OR = 1.814, with CI\u003csub\u003e95%\u003c/sub\u003e = [1.270; 2.592], and I\u003csup\u003e2\u003c/sup\u003e = 73%). Despite its qualitative limitations, this discovery underscores noteworthy advantages for the robotic approach, suggesting an added margin of benefit compared to the findings of the pooled analysis. Supplementary Figure 14b presents results stratified by the ROBINS-I tool, marginally advocating for nearly double odds for Trifecta achievement in studies with optimal ROB (OR = 2.090, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.968; 4.514], and I\u003csup\u003e2\u003c/sup\u003e = 79%). Furthermore, studies with intermediate ROB displayed a trend for a 23% increase in Trifecta attainment rates with RAPN (OR = 1.231, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.923; 1.643], and I\u003csup\u003e2\u003c/sup\u003e = 66%), while those with the highest ROB also marginally implied doubled odds (OR = 2.111, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.956; 4.663], and I\u003csup\u003e2\u003c/sup\u003e = 54%). In Supplementary Figure 14c, studies utilizing postoperative eGFR change in the Trifecta definition (ΔeGFR\u003csub\u003e%\u003c/sub\u003e ≤ 10%) showed a strong tendency favoring RAPN (OR = 1.797, with CI\u003csub\u003e95%\u003c/sub\u003e = [1.009; 3.202], and I\u003csup\u003e2\u003c/sup\u003e = 88%). Conversely, studies defining Trifecta by ischemic impact (IT ≤ 20-25 min) showed an additional \u003csup\u003e1\u003c/sup\u003e/\u003csub\u003e3\u003c/sub\u003e increase in the odds of achieving the Trifecta (OR = 1.326, with CI\u003csub\u003e95%\u003c/sub\u003e = [1.021; 1.723], and I\u003csup\u003e2\u003c/sup\u003e = 57%), adequately reaching statistical significance. The above results are descriptively summarized in Table 2.\u003c/p\u003e\n\u003cp\u003eIn the context of MRA, Figure 4c illustrates the variation of logOR for Trifecta rates per year of publication, revealing a marginally significant and consistent superiority of RAPN from 2018 onwards. In Figure 4d, analyses with 6 to 8-star quality, which are predominant in the definitive study set, exhibited a similar trend towards higher Trifecta achievement rates through RAPN. Supplementary Figure 15a presents the MRA results for subgroups by publication year, focusing on population matching. Studies without matching protocols after 2016 reported a trend for higher odds for Trifecta with RAPN, with a gradual contraction of the comparative advantage over open surgery. In Supplementary Figure 15b, multicenter comparisons displayed a neutral effect, while single-center studies after 2018 consistently reported higher Trifecta odds with RAPN. Supplementary Figure 16a provides results per ROBINS-I stratum. Low ROB studies after 2019 supported a trend of progressively higher logOR in favor of RAPN, reflecting a potentially successful robotic integration over the years. Supplementary Figure 16b presents the MRA plots based on Trifecta definition. Studies using the eGFR criterion indicated a non-significant effect, while those defining Trifecta through IT revealed an almost consistently marginal advantage of RAPN over OPN during the last five years. In Supplementary Figure 17a, the MRA plots for NOS quality star groups based on patient matching revealed only a limited trend of advantage for RAPN, which diminishes between 6- and 7-star ratings in the unmatched comparisons. Supplementary Figure 17b illustrates the variation in comparative effect across the qualitative scale based on the number of referral centers. Single-center analyses exhibited an expanding advantage for RAPN as quality stars increased from 7 to 9. Lastly, in Supplementary Figure 17c, subgroup diagrams based on Trifecta definition demonstrated non-significant trends from records adopting the ΔeGFR-based criterion across all NOS quality levels. Conversely, in studies defining Trifecta through the ischemia duration threshold, RAPN's advantage appeared homogenous and marginally significant among records with 7 to 8 quality stars.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eMeta-analysis of secondary outcomes (Trifecta components)\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eIn the present subsection, we provide a thorough examination of secondary outcomes, furnishing their summarized MA results in Table 2 and detailed findings from the 2-modal MRA in Table 3.\u003c/p\u003e\n\u003cp\u003eIn terms of the RPN/RAPN vs. OPN comparison for major complications (CD ≥ 3), the source dataset consisted of 38 studies with 12,717 patients (RPN/RAPN: 6,701 vs. OPN: 6,016). Figure 5a illustrates a trend of a 35% reduction in pooled odds with the adoption of RAPN (OR = 0.648, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.468; 0.898], and I\u003csup\u003e2\u003c/sup\u003e = 66%). The relevant funnel plot of Figure 5b and the additional radial and funnel plots of Supplementary Figure 18 indicate symmetrical reporting of effects with minimal PB. In Supplementary Figure 19a, a non-significant reduction of the same magnitude (35%) emerged concerning the odds for CD ≥ 3 complications from post-2018 studies (OR = 0.650, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.417; 1.013], and I\u003csup\u003e2\u003c/sup\u003e = 76%). Studies published pre-2018 reported a marginally significant 34% reduction (OR = 0.660, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.434; 1.004], and I\u003csup\u003e2\u003c/sup\u003e = 21%). Supplementary Figure 19b highlights a trend for 33% (OR = 0.674, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.473; 0.961], and I\u003csup\u003e2\u003c/sup\u003e = 38%) and 43% (OR = 0.567, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.326; 0.987], and I\u003csup\u003e2\u003c/sup\u003e = 78%) reduction in odds for matched and non-matched analyses, respectively. Supplementary Figure 20a depicts SGA based on referral centers, showing a significant 47% reduction in odds for multicenter studies (OR = 0.534, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.318; 0.896], and I\u003csup\u003e2\u003c/sup\u003e = 51%). Conversely, single-center analyses reported a non-significant 29% reduction (OR = 0.707, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.480; 1.039], and I\u003csup\u003e2\u003c/sup\u003e = 69%). In Supplementary Figure 20b, studies of low ROB showed a non-significant 21% reduction in odds for severe complications with RAPN (OR = 0.793, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.596; 1.056], and I\u003csup\u003e2\u003c/sup\u003e = 4%). Intermediate ROB studies also exhibited an insignificant reduction in odds (OR = 0.546, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.294; 1.016], and I\u003csup\u003e2\u003c/sup\u003e = 84%). Lastly, the dataset of high ROB studies demonstrated a significant 46% reduction in odds for major complications within the RAPN patient group (OR = 0.539, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.359; 0.808], and I\u003csup\u003e2\u003c/sup\u003e ≈ 0%). The combination of strong trends favoring robotic access in substantial portions of the investigated subgroups, along with the significant 47% reduction in odds for CD ≥ 3 complications from multicenter analyses, underscores the need for further studies to accurately determine the additional benefits of selecting RAPN over OPN. Figure 5c presents the pooled MRA by publication year, demonstrating a steady trend of advantage for the robotic approach in severe complications from 2016 to 2022. Supplementary Figure 21a supports the presence of a widening benefit from RAPN after 2019 in matched analyses, likely reflecting the increasingly effective adoption of robotic PN and the refinement of relevant surgical practices. Conversely, non-matched analyses showed a stable effect with only a marginal benefit from RAPN between 2015 and 2019. Supplementary Figure 21b illustrates similar trends in multi- \u0026amp; single-center studies, with logORs supporting RAPN’s superiority from 2017 onwards. Supplementary Figure 21c displays MRA plots for ROB clusters, also showing a trend of stable effects in favor of RAPN in low ROB studies from 2019 onwards. Intermediate and high ROB comparisons showed marginally significant results, respectively indicating expanding and homogeneous benefits of RAPN from 2015 and 2019 onwards. Figure 5d depicts the pooled MRA for CD ≥ 3 complications across the NOS quality levels, showing a consistent trend favoring RAPN in studies rated with 6-8 quality stars. Supplementary Figures 22a \u0026amp; 22b detail the MRA plots by patient matching and referral center count, respectively. Matched analyses showed a slight contraction in RAPN's advantage at 6-7 NOS stars, while non-matched studies demonstrated an increasing benefit in the 7-9 quality-star ratings interval. In single-center analyses, a marginally significant and homogeneous logOR favoring RAPN was observed within the 6-7 quality-star range.\u003c/p\u003e\n\u003cp\u003eRegarding minor postoperative complications (CD ≤ 2), the study set comprised 27 studies incorporating 6,950 patients (RPN/RAPN: 3,179 vs. OPN: 3,771). The pooled analysis forest plot in Figure 6a illustrates a 44% decrease in odds for minor complications with RAPN vs. OPN (OR = 0.565, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.467; 0.684], and I\u003csup\u003e2\u003c/sup\u003e = 35%). The funnel plot in Figure 6b examines PB, demonstrating sustained symmetry despite a noticeable deviation between the regression lines derived from Egger’s test, as depicted in the radial plot of Supplementary Figure 23a. SSEs were considered marginal in this case, as demonstrated in Supplementary Figure 23b. Supplementary Figure 24a shows a 45% reduction in odds for mild complications with the adoption of RAPN post-2018 (OR = 0.546, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.413; 0.722], and I\u003csup\u003e2\u003c/sup\u003e = 48%). Similarly, previous publications demonstrated a 42% reduction in odds for CD ≤ 2 complications (OR = 0.577, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.435; 0.765], and I\u003csup\u003e2\u003c/sup\u003e = 19%). Matched analyses in Supplementary Figure 24b also report a 42% reduction (OR = 0.584, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.409; 0.834], and I\u003csup\u003e2\u003c/sup\u003e = 56%), contrasting with a 47% reduction in non-matched comparisons (OR = 0.531, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.424; 0.667], and I\u003csup\u003e2\u003c/sup\u003e ≈ 0%). Supplementary Figure 24c indicates a 42% reduction in odds from multicenter studies (OR = 0.578, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.372; 0.897], and I\u003csup\u003e2\u003c/sup\u003e = 17%), not substantially different from that of 44% from single-center analyses (OR = 0.562, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.452; 0.700], and I\u003csup\u003e2\u003c/sup\u003e = 40%). Supplementary Figure 24d shows almost halved odds (approximately 49%) from RAPN in \"ROBINS-I: Low\" studies (OR = 0.511, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.322; 0.811], and I\u003csup\u003e2\u003c/sup\u003e = 45%). On the other hand, moderate and serious ROB studies exhibited reductions of 43% (OR = 0.570, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.430; 0.756], and I\u003csup\u003e2\u003c/sup\u003e = 45%) and 44% (OR = 0.563, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.390; 0.814], and I\u003csup\u003e2\u003c/sup\u003e ≈ 0%), respectively. Figure 6c presents the pooled MRA results regarding publication year, showing a temporally consistent and significant reduction in minor complication rates with RAPN from 2012 onwards. The MRA plots of Supplementary Figure 25a reveal a time-expanding benefit from RAPN in studies with patient matching post-2017, possibly reflecting the successful robotic integration in SRMs management. On the contrary, a quasi-stable pattern of RAPN’s beneficial effect was observed in non-matched analyses, with the statistical significance beginning in 2012 through 2024. Supplementary Figure 25b displays MRA plots by referral center count, showing a progressively diminishing advantage on the part of RAPN from 2014 until 2019. On the other hand, single-center analyses indicated a nearly homogeneous advantage for RAPN from 2015 onwards. Supplementary Figure 25c illustrates the MRA for each ROBINS-I class, highlighting an expanding benefit from RAPN in reducing minor complications, starting from 2016 in low ROB studies. Comparative analyses of intermediate ROB demonstrated a stable benefit through RAPN after 2017, while those of high ROB only supported a trend of progressively diminishing reduction in absolute logOR between 2015 and 2018. Figure 6d illustrates the quality-based MRA in pooled data, showing a mild augmentation of RAPN's advantage with increasing NOS ratings from 6 to 9 quality stars. Supplementary Figure 26a shows a broadening relative benefit from RAPN in matched comparisons from 7 to 9 stars, while non-matched analyses illustrated a quasi-stable advantage across all quality ratings. Supplementary Figure 26b depicts the MRA in multicenter comparisons, displaying an expanding advantage with RAPN, significant in studies with quality ratings between 8 and 9 stars. Conversely, single-center studies exhibited a stable comparative effect favoring RAPN across studies with 6 to 8 quality-star ratings.\u003c/p\u003e\n\u003cp\u003eThe subsequently investigated secondary outcome concerns PSM rates. The pertinent study set included 37 studies involving 12,735 patients (RPN/RAPN: 6,562 vs. OPN: 6,173). From the MA comparing RAPN and OPN in aggregated data, the forest plot of Figure 7a indicates a non-significant reduction (approximately 10%) in odds for PSM via RAPN (OR = 0.903, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.682; 1.195], and I\u003csup\u003e2\u003c/sup\u003e = 30%). The funnel and radial plots presented in Figure 7b and Supplementary Figure 27, respectively, were used to evaluate PB, showing no substantial asymmetry or deviation. The SGA based on publication year, as shown in Supplementary Figure 28a, also revealed a non-significant reduction in odds for PSM with RAPN, estimated at approximately 13% for post-2018 studies (OR = 0.873, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.555; 1.375], and I\u003csup\u003e2\u003c/sup\u003e = 54%) and 9% for those published prior to 2018 (OR = 0.911, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.617; 1.344], and I\u003csup\u003e2\u003c/sup\u003e ≈ 0%). In terms of patient matching application, as shown in Supplementary Figure 28b, studies with matching protocols showed a non-significant 10% reduction in odds for PSM with the adoption of RAPN (OR = 0.896, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.707; 1.134], and I\u003csup\u003e2\u003c/sup\u003e = 1%), while non-matched comparisons also indicated a non-significant reduction of approximately 17% (OR = 0.826, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.508; 1.345], and I\u003csup\u003e2\u003c/sup\u003e = 46%). The SGA according to center count, as presented in Supplementary Figure 29a, indicated no significant differences in multicenter studies (OR = 0.928, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.587; 1.469], and I\u003csup\u003e2\u003c/sup\u003e = 58%), as well as single-center analyses (OR = 0.877, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.606; 1.267], and I\u003csup\u003e2\u003c/sup\u003e = 18%). The forest plot of Supplementary Figure 29b contains the individual comparative effects per ROBINS-I cluster. Among studies with low ROB, a non-significant 20% reduction in odds for PSM with RAPN compared to OPN was observed (OR = 0.805, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.607; 1.068], and I\u003csup\u003e2\u003c/sup\u003e ≈ 0%). Results from studies with intermediate ROB also supported an insignificant advantage from RAPN, with approximately 19% odds reduction (OR = 0.815, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.483; 1.377], and I\u003csup\u003e2\u003c/sup\u003e = 54%), while no significant difference emerged from studies with serious ROB as well (OR = 1.197, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.715; 2.004], and I\u003csup\u003e2\u003c/sup\u003e = 6%). The temporal MRA depicting the relevant variation of the comparative effect is illustrated in Figure 7c, showing non-significantly reduced odds for PSM rates via RAPN. The MRA for subgroups according to patient matching (Supplementary Figure 30a), and number of centers (Supplementary Figure 30b) revealed comparative effects without statistical significance. Similarly, the MRA plots for subgroups based on ROB clusters (Supplementary Figure 30c) showed non-significant comparative impacts of RAPN and OPN on PSM rates, except for the studies with low ROB which indicated a trend of stable benefit from the robotic approach during the last 5-year period. The NOS-based MRA on the qualitative spectrum, presented in Figure 7d, also demonstrated a non-significant variation in the logOR. The overall qualitative MRA for subgroups is outlined in Supplementary Figure 31, where no significant disparities between RAPN and open surgery were observed at any quality level. An exception was noted in single-center comparisons (Supplementary Figure 31b) where a trend of bolstering in the apparent benefit from RAPN was discerned in studies with 7-9 NOS quality-star count.\u003c/p\u003e\n\u003cp\u003eAt this point, the results emerging from the RPN/RAPN vs. OPN comparison within the context of IT are presented. The derived dataset encapsulated 47 studies with 18,767 patients (RPN/RAPN: 10,450 vs. OPN: 8,317). Figure 8a shows the MA results across the pooled set of studies. Aggregated data analysis indicated a non-significant difference between the two approaches (MD = 0.477 min, with CI\u003csub\u003e95%\u003c/sub\u003e = [-1.516; 2.469], and I\u003csup\u003e2\u003c/sup\u003e = 97%). Figure 8b and Supplementary Figure 32 contain the relevant diagrams for PB assessment, indicating robust symmetry in funnel plots and minimal deviation in the radial plot. However, substantial SSEs were noted in the relevant funnel plot of Supplementary Figure 32b. The SGA by publication year (Supplementary Figure 33a) revealed a non-significant difference in IT from studies published post-2018 (MD = -0.227 min, with CI\u003csub\u003e95%\u003c/sub\u003e = [-2.971; 2.516], and I\u003csup\u003e2\u003c/sup\u003e = 97%). Similarly, pre-2018 studies also showed no significant difference (MD = 1.342 min, with CI\u003csub\u003e95%\u003c/sub\u003e = [-1.772; 4.457], and I\u003csup\u003e2\u003c/sup\u003e = 97%). Additionally, in terms of the patient-matching-based SGA (Supplementary Figure 33b), no substantial difference in IT emerged from matched analyses (MD = -0.595 min, with CI\u003csub\u003e95%\u003c/sub\u003e = [-4.793; 3.603], and I\u003csup\u003e2\u003c/sup\u003e = 98%), while in non-matched comparisons, this difference appeared as marginally significant in favor of OPN (MD = 1.317 min, with CI\u003csub\u003e95%\u003c/sub\u003e = [-0.233; 2.867], and I\u003csup\u003e2\u003c/sup\u003e = 95%). Supplementary Figure 34a contrasts multicenter and single-center analyses. Non-significant differences were observed in multicenter studies (MD = -1.356 min, with CI\u003csub\u003e95%\u003c/sub\u003e = [-5.976; 3.265], and I\u003csup\u003e2\u003c/sup\u003e = 98%). Similarly, single-center analyses showed no difference in IT between robotic and open approaches (MD = 1.220 min, with CI\u003csub\u003e95%\u003c/sub\u003e = [-1.010; 3.450], and I\u003csup\u003e2\u003c/sup\u003e = 97%). The SGA forest plots concerning the distinction of studies based on the ROBINS-I tool application are presented in Supplementary Figure 34b, where a non-significant benefit from RAPN was also observed in low ROB (MD = -2.014 min, with CI\u003csub\u003e95%\u003c/sub\u003e = [-6.277; 2.248], and I\u003csup\u003e2\u003c/sup\u003e = 98%) and high ROB comparisons (MD = 2.351 min, with CI\u003csub\u003e95%\u003c/sub\u003e = [-2.393; 7.096], and I\u003csup\u003e2\u003c/sup\u003e = 98%). Studies of moderate ROB on the other hand, revealed a trend favoring OPN in terms of IT limitation (MD = 1.605 min, with CI\u003csub\u003e95%\u003c/sub\u003e = [-0.300; 3.511], and I\u003csup\u003e2\u003c/sup\u003e = 94%). The pooled MRA by publication year, presented in Figure 8c, suggests an insignificant difference in the mean IT between the robotic and open approaches. Supplementary Figure 35 illustrates the MRA plots categorized by feature matching, referral center count, and qualitative clustering based on ROBINS-I. These plots indicate insignificant temporal variations around the horizontal axis of neutrality in general. Exceptions include the unmatched comparisons (Supplementary Figure 35a) and the intermediate ROB studies (Supplementary Figure 35c), which reveal stable trends favoring OPN between 2016-2021 and 2015-2019, respectively. A similar non-significant pattern is observed in Figure 8d illustrating the NOS-based pooled MRA. Subgroup MRA plots, depicted in Supplementary Figure 36, for matched studies and multi- or single-center comparisons, also reveal non-significant disparities between the two approaches. In this case as well, an exception derives from non-matched analyses, indicating a tendency towards a homogeneous advantage for OPN within the narrow range of 6-7 quality stars (Supplementary Figure 36a).\u003c/p\u003e\n\u003cp\u003eThe comparison of robotic and open PN at this point focuses on the postprocedural reduction in eGFR, denoted as: ΔeGFR. The derived study set consisted of 24 comparisons encompassing 9,797 patients (RPN/RAPN: 5,245 vs. OPN: 4,552). Due to the typical postoperative pattern of eGFR reduction, positive overall estimates (MD\u003csub\u003eΔeGFR\u003c/sub\u003e) favored RPN/RAPN, while negative ones leaned toward OPN. Pooled data analysis favored RAPN by approximately 2.5 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e (MD = 2.545 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, with CI\u003csub\u003e95%\u003c/sub\u003e = [1.035; 4.054], and I\u003csup\u003e2\u003c/sup\u003e = 98%), as shown in Figure 9a. The relevant diagrams for PB assessment, presented in Figure 9b and Supplementary Figure 37, indicated insignificant impact, with adequately symmetric funnel plots, a minimally deviated radial plot, and negligible SSEs. The SGA according to publication year (Supplementary Figure 38a) demonstrated a trend of RAPN's consistent advantage. More specifically, the results obtained from records published in the past 5 years (MD = 2.478 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.226; 4.730], and I\u003csup\u003e2\u003c/sup\u003e = 98%), and those from earlier publications (MD = 2.632 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.317; 4.948], and I\u003csup\u003e2\u003c/sup\u003e = 92%) were marginally significant. Studies with patient matching (Supplementary Figure 38b) also supported the aforementioned trend of RAPN's superiority (MD = 2.951 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.564; 5.339], and I\u003csup\u003e2\u003c/sup\u003e = 99%), in line with non-matched analyses (MD = 2.000 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.026; 3.974], and I\u003csup\u003e2\u003c/sup\u003e = 70%). In multicenter studies (Supplementary Figure 38c), a similar tendency was observed (MD = 1.806 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, with CI\u003csub\u003e95%\u003c/sub\u003e = [-0.537; 4.148], and I\u003csup\u003e2\u003c/sup\u003e = 98%), consistent with findings from single-center analyses (MD = 2.822 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.800; 4.843], and I\u003csup\u003e2\u003c/sup\u003e = 96%). Findings based on the ROBINS-I levels, presented in Supplementary Figure 38d, also showed a trend of superior eGFR preservation with RAPN in \"ROBINS-I: Low\" studies (MD = 3.075 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.577; 5.572], and I\u003csup\u003e2\u003c/sup\u003e = 99%). The previous trend emerged as a statistically significant finding from the \"ROBINS-I: Moderate\" subgroup of studies (MD = 1.860 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, with CI\u003csub\u003e95%\u003c/sub\u003e = [1.018; 2.701], and I\u003csup\u003e2\u003c/sup\u003e ≈ 0%). In contrast, studies clustered as \"ROBINS-I: Serious\" did not yield significant results (MD = 1.704 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, with CI\u003csub\u003e95%\u003c/sub\u003e = [-3.248; 6.657], and I\u003csup\u003e2\u003c/sup\u003e = 77%). The temporal MRA on pooled studies, contained in Figure 9c, indicated an enlarging benefit from RAPN since 2016, possibly due to improved techniques and wider availability of robotic platforms, essentially suggesting an inherent advantage in preserving postoperative eGFR. The MRA according to patient matching, displayed in Supplementary Figure 39a, revealed a significant advantage for RAPN in renal function preservation, particularly in studies applying relevant protocols and from 2018 onwards, aligning with recent advancements in surgical robotics. Conversely, non-matched analyses indicated only a stable trend favoring RAPN over OPN between 2015 and 2019. Supplementary Figure 39b depicts the subgroup MRA plots based on the number of referral centers, showing a declining benefit from RAPN between 2016 and 2021 in multicenter comparisons, against an expanding comparative advantage in a wider timeframe (between 2016 and 2023) from the perspective of single-center analyses. Supplementary Figure 39c presents stacked temporal MRA plots for the different ROB levels. More specifically, studies with low ROB showed a consistently favorable comparative effect for RAPN, significant between 2018 and 2021. Intermediate ROB records indicated a contraction of this benefit between 2015 and 2019, while those of high ROB showed a relative amplification in the same timeframe. Figure 9d presents the MRA results on the qualitative scale, reflecting a growing benefit on the part of RAPN across studies with NOS ratings of 7 to 9 stars. Additionally, Supplementary Figure 40a reveals a similar finding in both matched and non-matched analyses, with more favorable outcomes concerning the robotic approaches. Lastly, Supplementary Figure 40b indicates non-significant variation in the comparative effect across different quality levels in studies conducted by multiple referral centers. On the contrary, single-center comparisons illustrated a widening pattern of significant benefit from RAPN among quality ratings of 7 to 9 stars according to the NOS.\u003c/p\u003e\n\u003cp\u003eThe final secondary outcome refers to the postoperative increase in plasma Cr concentrations from baseline, denoted as: ΔCr. The corresponding study set consisted of 11 analyses involving 1,817 patients (RPN/RAPN: 789 vs. OPN: 1,028). In this case, negative overall estimates (MD\u003csub\u003eΔCr\u003c/sub\u003e) favored RPN/RAPN, while positive mean differences favored OPN. The relevant pooled MA findings in Figure 10a revealed no difference between RAPN and OPN regarding ΔCr (MD = 0.009 mg/dl, with CI\u003csub\u003e95%\u003c/sub\u003e = [-0.039; 0.056], and I\u003csup\u003e2\u003c/sup\u003e = 86%). Figure 10b and Supplementary Figure 41 provide the respective funnel and radial plots for PB assessment. In the above, the absence of substantial bias was observed, although SSEs impacted the overall MD between RAPN and open surgery. Supplementary Figure 42a displays the SGA forest plots by publication year. Studies published in the last 5 years (MD = 0.040 mg/dl, with CI\u003csub\u003e95%\u003c/sub\u003e = [-0.135; 0.215], and I\u003csup\u003e2\u003c/sup\u003e = 85%), as well as earlier publications (MD = -0.002 mg/dl, with CI\u003csub\u003e95%\u003c/sub\u003e = [-0.051; 0.048], and I\u003csup\u003e2\u003c/sup\u003e = 88%), did not indicate statistically significant findings. Similarly, the SGA according to patient matching, presented in Supplementary Figure 42b, did not uncover significant deviations in ΔCr between RAPN and OPN in either matched (MD = 0.011 mg/dl, with CI\u003csub\u003e95%\u003c/sub\u003e = [-0.020; 0.041], and I\u003csup\u003e2\u003c/sup\u003e ≈ 0%) or non-matched comparisons (MD = 0.010 mg/dl, with CI\u003csub\u003e95%\u003c/sub\u003e = [-0.059; 0.079], and I\u003csup\u003e2\u003c/sup\u003e = 89%). Supplementary Figure 42c presents the SGA forest plots based on single- or multicenter analyses. The subset of studies conducted by multiple centers consisted of a singular record and indicated a significant benefit favoring OPN in limiting postoperative ΔCr (MD = 0.100 mg/dl, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.054; 0.146]). On the other hand, the single-center comparisons did not reveal significant findings (MD = -0.002 mg/dl, with CI\u003csub\u003e95%\u003c/sub\u003e = [-0.048; 0.044], and I\u003csup\u003e2\u003c/sup\u003e = 82%). Supplementary Figure 42d encapsulates the SGA forest plots originating from the ROBINS-I clustering, without any statistically significant disparities in ΔCr between the two compared approaches in low ROB (MD = 0.057 mg/dl, with CI\u003csub\u003e95%\u003c/sub\u003e = [-0.450; 0.564], and I\u003csup\u003e2\u003c/sup\u003e = 90%), and high ROB studies (MD = 0.006 mg/dl, with CI\u003csub\u003e95%\u003c/sub\u003e = [-0.085; 0.096], and I\u003csup\u003e2\u003c/sup\u003e = 88%). Conversely, the subgroup of records with intermediate ROB demonstrated a trend of superiority on the part of the robotic approach (MD = -0.023 mg/dl, with CI\u003csub\u003e95%\u003c/sub\u003e = [-0.040; -0.006], and I\u003csup\u003e2\u003c/sup\u003e ≈ 0%). The pooled MRA plots in chronological and qualitative scales, presented in Figures 10c \u0026amp; 10d respectively, show no discernible superiority between robotic and open PN. Supplementary Figures 43a \u0026amp; 43b depict the MRA by patient matching, in relation to publication year and NOS quality-star rating, respectively, revealing no significant deviations from neutrality lines across the entire time series or quality ranges examined. Similarly, Supplementary Figure 44 includes the MRA plots for single-center studies, presented on chronological and qualitative scales, without indicating statistical significance. Finally, Supplementary Figure 45 displays the temporal MRA for studies with moderate and serious ROB, also without notable findings within the respective ranges of the examined time series.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eSensitivity analysis\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eIn this subsection, we present the findings of the SA focused on isolating specific outcome-based study sets to achieve maximum accuracy in their reported results. The latter was determined using the inverse variance method. Firstly, we calculated the average range of the individual 95% confidence intervals (CI\u003csub\u003e95%\u003c/sub\u003e) in the initially retrieved study set, along with its SD. Subsequently, inclusion criteria were set at the threshold of 2 SDs for each CI\u003csub\u003e95%\u003c/sub\u003e range to ensure the desired accuracy in the reported effect from every comparative investigation. The results of individual pooled sub-analyses for both primary and secondary outcomes at the MA level are summarized in Table 2, while Table 3 encapsulates the respective findings at the MRA level.\u003c/p\u003e\n\u003cp\u003eThe primary outcome of Trifecta rates was analyzed across 10 studies, involving a total of 4,558 patients (RPN/RAPN: 1,964 vs. OPN: 2,594). The corresponding forest plot is detailed in Supplementary Figure 46a. Specifically, the pooled analysis demonstrated a significant effect favoring RAPN, with an additional 54% of odds in achieving Trifecta compared to OPN (OR = 1.536, with CI\u003csub\u003e95%\u003c/sub\u003e = [1.100; 2.144], and I\u003csup\u003e2\u003c/sup\u003e = 83%). Supplementary Figures 46b, 46c, and 46d summarize the PB assessment, with the funnel plots showing marginal symmetry and notable interference from SSEs, while the radial plot suggests substantial deviation based on Egger’s test. Supplementary Figures 47a \u0026amp; 47b contain the relevant graphs from the MRA, revealing a chronologically stable advantage of RAPN in achieving Trifecta from 2018 onwards. A similar trend emerged concerning the qualitative moderator and between 6-8 NOS ratings. These findings underscore the need for more large-scale comparative studies focusing on Trifecta rates as primary objectives. In the analysis of CD ≥ 3 postoperative complication rates, 18 studies comprising 9,929 patients (RPN/RAPN: 5,545 vs. OPN: 4,384) were included, as detailed in Supplementary Figure 48a. The analysis revealed a significant OR favoring RAPN, suggesting approximately 43% lower odds compared to OPN (OR = 0.574, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.367; 0.898], and I\u003csup\u003e2\u003c/sup\u003e = 81%). Supplementary Figures 48b, 48c \u0026amp; 48d contain the relevant PB assessment, demonstrating adequate symmetry around the overall effect estimate, acceptable deviation in Egger’s test, and notable impact from SSEs. Moreover, the MRA plots in Supplementary Figure 49 highlighted a trend of increasing advantage for RAPN in reducing CD ≥ 3 complications from 2018 onwards, while the magnitude of this apparent benefit diminished among studies with 6-7 NOS rating levels. The SA of CD ≤ 2 complication rates followed, including 20 records with 6,003 patients (RPN/RAPN: 2,814 vs. OPN: 3,189), as displayed in the forest plot of Supplementary Figure 50a. Sub-analysis of high-accuracy studies attained statistical significance, showing a 43% reduction in odds favoring RAPN (OR = 0.568, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.464; 0.697], and I\u003csup\u003e2\u003c/sup\u003e = 41%). Examination of PB, depicted in Supplementary Figures 50b, 50c \u0026amp; 50d showed notable symmetry in the funnel plot around the overall OR-estimate, with moderate deviation in Egger’s test, and limited SSEs. Supplementary Figure 51 presents the pertinent MRA plots, revealing a stable and statistically significant advantage of the robotic approach in reducing mild post-PN complications from 2012 onwards, which appears as expanding across all study quality levels. Subsequently, the SA focused on PSM rates, with the pertinent dataset comprising 18 studies with 10,094 patients (RPN/RAPN: 5,330 vs. OPN: 4,764), as shown in Supplementary Figure 52a, with the respective results showing no significant effect (OR = 0.901, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.651; 1.246], and I\u003csup\u003e2\u003c/sup\u003e = 50%). PB was assessed using typical funnel and radial plots, as shown in Supplementary Figures 52b \u0026amp; 52c, revealing rough asymmetry around the overall effect and marginal deviation in Egger’s test. The MRA plots of Supplementary Figure 53 displayed a non-significant variation in logOR between RAPN and OPN both across publication years and NOS quality levels. In the next step, the SA was directed towards IT as a secondary outcome. From 32 studies involving 17,343 patients (RPN/RAPN: 9,686 vs. OPN: 7,657), results did not reveal any difference in average ischemia duration between the two approaches in studies with enhanced accuracy (MD = 1.273 min, with CI\u003csub\u003e95%\u003c/sub\u003e = [-1.104; 3.650], and I\u003csup\u003e2\u003c/sup\u003e = 98%), as depicted in Supplementary Figure 54a. PB evaluation through the relevant graphs of Supplementary Figures 54b, 54c \u0026amp; 54d exhibited adequate symmetry in the funnel plots, with negligible impact from SSEs, and just notable deviation in Egger’s test. The MRA plots of Supplementary Figure 55 revealed no significant divergence in IT between RAPN and OPN, neither by publication year nor by the NOS quality class. The subsequent secondary outcome investigated was ΔeGFR, with data derived from 22 analyses entailing 9,636 patients (RPN/RAPN: 5,184 vs. OPN: 4,452). The forest plot of Supplementary Figure 56a illustrates the overall effect direction. In studies with augmented accuracy, RAPN showed a marginally significant advantage in the postoperative maintenance of eGFR (MD = 2.492 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, with CI\u003csub\u003e95%\u003c/sub\u003e = [0.922; 4.063], and I\u003csup\u003e2\u003c/sup\u003e = 98%), with the benefit magnitude remaining around 2.5 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, consistent with findings from the pooled analysis. Supplementary Figures 56b, 56c \u0026amp; 56d demonstrate the assessment of PB, indicating sufficient symmetry in the relevant funnel plot, limited deviation between regression lines in Egger’s test, and negligible SSEs. The MRA plot in chronological scale, presented in Supplementary Figure 57a, reveals a significant and escalating effect favoring RAPN in eGFR preservation from 2016 onwards. Additionally, the NOS-based MRA exhibited a resembling pattern among studies with 7-9 quality stars (Supplementary Figure 57b), providing qualitative reinforcement of RAPN’s apparent superiority observed in the SA. The final secondary outcome concerned ΔCr, with comparative data from 10 studies encompassing 1,778 patients (RPN/RAPN: 776 vs. OPN: 1,002). Supplementary Figure 58a shows the relevant forest plot depicting the comparative effect. In studies with improved accuracy in reported results, no substantial difference was identified between RAPN and OPN regarding the postoperative increase in serum Cr levels from baseline (MD = 0.009 mg/dl, with CI\u003csub\u003e95%\u003c/sub\u003e = [-0.042; 0.060], and I\u003csup\u003e2\u003c/sup\u003e = 87%). PB was explored using typical funnel and radial plots (Supplementary Figures 58b, 58c \u0026amp; 58d), showing adequate symmetry around the overall effect and minimal deviation in Egger’s test, albeit with notable SSEs. The temporal and qualitative MRA plots, presented in Supplementary Figures 59a and 59b respectively, indicated insignificant disparity between RAPN and OPN for either moderator utilized.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e\u003cu\u003eDiscussion of findings\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe current analysis aimed to compare the Trifecta outcome between robotic and open approaches in PN, with its attainment rates serving as the primary outcome. Secondary outcomes included severe (CD ≥ 3) and mild (CD ≤ 2) postoperative complications, PSM rates, absolute IT duration, postoperative eGFR reduction, and increase in serum Cr levels post-PN. The credibility of the conclusions drawn from statistical inference was ensured by treating each study set independently. Pooled data analysis revealed a 1.5-fold increase in odds for RAPN in achieving Trifecta, with the trend for providing a consistent temporal advantage over time, and across all study qualities. Studies published after 2018, along with non-matched analyses, also indicated nearly a 1.5-fold increase in odds with the adoption of RAPN. Single-center studies demonstrated a 1.8-fold increase, confirming the homogeneity of RAPN’s comparative advantage post-2018. In the subgroup of records defining Trifecta by IT, a 1.3-fold increase when employing RAPN was identified, with a trend for a chronologically and qualitatively constant comparative effect. In comparisons with enhanced accuracy in reported outcomes, the 1.5-fold increase observed in pooled data analysis in favor of RAPN was confirmed, showing a consistent trend of chronological uniformity over time. In general, the robotic approach demonstrated superiority in achieving the Trifecta outcome, with odds ranging from 1.3 to 1.8 in its favor. This finding indicates the advantageous effects of RPN/RAPN in terms of tumor excision quality and potentially surgical precision. In the analysis of CD ≥ 3 complications, pooled data demonstrated a trend of a 0.35-fold decrease in odds for RAPN, shaping a common pattern of marginally homogeneous temporal and qualitative benefits. Studies with \u0026amp; without patient matching exhibited similar trends, with 0.67 \u0026amp; 0.57 odds for RAPN, respectively. Results from multicenter studies were statistically significant, with a 0.47-fold decrease in CD ≥ 3 complications through RAPN, supporting the trend of a comparative advantage remaining temporally uniform. Serious ROB studies displayed halved odds for RAPN with a trend of stable benefits during the last decade. The SA revealed a significant OR of 0.57 favoring RAPN, indicating a bolstering pattern in its comparative advantage over OPN in the past 5-year period. Based on the above, it can be supported that RAPN demonstrates a strong tendency in reducing the odds for major postoperative complications by approximately 35-45% compared to OPN. These benefits may be of increasing magnitude over time, and especially during the last five years, potentially reflecting the effective assimilation of robotic platforms into contemporary kidney surgery. However, additional studies are needed to clarify the final trajectory of the above-described advantageous trend on the part of the robotic approach. Regarding CD ≤ 2 complications, the analysis of aggregated studies outlined that RAPN is correlated with a 0.44-fold reduction in odds compared to OPN. Additionally, the pooled MRA indicated a time-consistent comparative effect that becomes more pronounced with increasing study quality levels. Subgroups of records published after and before 2018 revealed 0.55 and 0.58 odds for RAPN respectively. Matched comparisons also displayed 0.58 odds when implementing RAPN, with broadening comparative effects both temporally and within the quality scale range. Studies with unmatched populations showed 0.53 odds in favor of RAPN with uniform temporal and qualitative effects in the MRA. Multi- and single-center analyses demonstrated odds of 0.58 and 0.56 in favor of RAPN, respectively. However, MRA variations highlighted differing patterns: a chronologically shrinking advantage for the former and a quasi-stable benefit for the latter. Concerning the ROBINS-I classification, low-, intermediate-, and high-risk records revealed odds of 0.51, 0.57, and 0.56 for RAPN, respectively. These subgroups showed progressively expanding, stable, and marginally diminishing temporal variations in the absolute logOR favoring RAPN. The SA also indicated 0.57 odds in favor of the robotic approach, with a chronologically consistent and qualitatively expanding benefit in the MRA. The overall results highlighted 40-50% lower odds for RAPN compared to open surgery for CD ≤ 2 complications, with a uniform comparative effect over time and across all study qualities. This finding is further validated by a prior study conducted by our team, which specifically concentrated on the comparative analysis of minor complications incidence\u0026nbsp;[\u003ca href=\"#_ENREF_28\" title=\"Artsitas, 2023 #928\"\u003e28\u003c/a\u003e]. The subsequent analysis of PSM rates generally indicated non-significantly lower odds for RAPN (OR ≈ 0.8-0.9) from the pooled MA and SGA, with the MRA illustrating the trend of a stabilized effect during the last 5-year period. The SA also revealed a non-significant OR for PSM when adopting RAPN over OPN. The above findings support the absence of significant divergence between robotic and open approaches in PN regarding PSM rates. Correspondingly, as for ischemia duration, no substantial differences were underlined between the robotic and open surgery groups at any level of data analysis. In terms of the secondary outcome of eGFR preservation (MD\u003csub\u003eΔeGFR\u003c/sub\u003e), aggregate data revealed an advantage of approximately 2.5 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e in favor of RAPN. The temporal MRA indicated a progressively increasing benefit over OPN, possibly due to the ongoing optimization of robotic techniques during the past decade. Although the above finding emerged as statistically significant, it was not considered to possess robust clinical implications due to the low-magnitude estimate of MD\u003csub\u003eΔeGFR\u003c/sub\u003e. However, it remained indicative of the favorable impact of RAPN on renal function. A similar benefit from selecting RAPN over OPN emerged as a consistent trend from subgroups published pre-2018 (MD ≈ 2.6 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e) and post-2018 (MD ≈ 2.5 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e). Matched analyses also uncovered a trend in the comparative eGFR preservation of approximately 3 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, with chronologically expanding beneficial effects by RAPN over the last 5 years. Non-matched comparisons supported the tendency of RAPN to preserve renal function by nearly 2 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e more than OPN, with the comparative effects being temporally uniform. Similarly, in multicenter analyses, an analogous MD\u003csub\u003eΔeGFR\u003c/sub\u003e of approximately 1.8 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e was observed, with progressively shrinking MDs over the last decade. Conversely, in the subgroup of single-center studies, the advantageous impact of RAPN on eGFR preservation manifested as an MD of about 2.8 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, with MRA highlighting an enlarging comparative effect during the same timeframe. In low ROB studies, a similar trend in eGFR preservation of around 3 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e favoring RAPN was noted, with homogenous chronological effects observed in the MRA. The respective findings were statistically significant in the subgroup of records with moderate ROB (MD ≈ 1.9 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e), with the comparative effects progressively decreasing over the last decade. High-accuracy studies in the SA marginally supported the presence of a beneficial shift toward the robotic approach, with additional eGFR preservation of approximately 2.5 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e, accompanied by a chronological expansion of the comparative effect, confirming the findings from the pooled analysis. The above-presented results strongly support at least a tendency for RAPN to outperform OPN in preserving postoperative renal function, with declines in eGFR being at least 2-3 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e lower in robotic approaches, suggesting a growing benefit with the increasing integration of robotic platforms in current kidney surgery. Nevertheless, it's important to emphasize that the above findings from the SGA are generally in line with those from the pooled analysis, and thus do not possess strong clinical significance, beyond potentially underlining the more favorable dynamics of RAPN's impact on renal function. Lastly, no significant differences were detected in the comparative increase in postoperative serum Cr from baseline, as indicated by both the pooled MA and SGA, along with the SA and MRA.\u003c/p\u003e\n\u003cp\u003eCollectively, RAPN demonstrated superiority over OPN in Trifecta rates (OR ≈ 1.3-1.8), with a quasi-consistent advantage observed over the past five years. Additionally, RAPN exhibited a strong trend of benefit regarding CD ≥ 3 complications (OR ≈ 0.5-0.7) and a substantial merit in terms of CD ≤ 2 complication rates (OR ≈ 0.5-0.6), showcasing time-consistent to potentially expanding comparative effects in both outcomes. Discrepancies in PSM rates and the mean IT between RPN/RAPN and OPN groups were not significant. Furthermore, regarding the comparative impact on renal function, RAPN exhibited a more favorable effect on ΔeGFR, with approximately 2-3 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e less decline compared to open surgery, a finding implying its protective role against postoperative nephron-loss. However, this discovery was not deemed clinically significant. Instead, it merely hinted at a modest effect, suggesting the potential suitability of the robotic approach in patients with already affected kidney function, for whom PN is primarily recommended. Furthermore, there were non-substantial differences in ΔCr between RPN/RAPN and OPN patient groups. Based on the comparative analysis of primary and secondary outcomes, it can be inferred that the more favorable profile of RAPN over OPN in Trifecta achievement rates is primarily attributed to the mitigation of postoperative complications, particularly those of mild severity (CD ≤ 2).\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eDiscussion on international literature\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe management of SRMs prioritizes oncological control, optimal preservation of kidney function, and minimization of postoperative morbidity. The Trifecta outcome, summarizing the triad of surgical margin status, IT duration or decline in eGFR, and the absence of complications, is essential for the qualitative assessment of excision efficacy in nephron sparing surgery. In their 2017 study, Maurice et al. aimed to compare the attainment of optimal outcomes between RPN and OPN. They utilized total GFR preservation and chronic kidney disease (CKD) upstaging as outcome measures, highlighting functional effects as crucial. The study revealed that RPN displayed a more favorable profile compared to OPN, attributed primarily to lower wound-related complications. Oncological outcomes were similar between the approaches, and RPN achieved similar long-term GFR preservation despite the predominant use of warm ischemia in OPN. The study supported previous findings indicating that RPN yields equivalent early outcomes with decreased morbidity in patients with cT1a tumors. Additionally, within the context of cT1b renal masses, RPN exhibited a higher rate of achieving optimal end-points. Acknowledging constraints such as the retrospective design and potential bias, the study concluded that RPN compares favorably with OPN, offering tangible benefits in reducing morbidity in patients with renal tumors even exceeding 7 cm in maximum diameter. According to authors, the concept of achieving optimal outcomes such as Trifecta, including functional preservation and morbidity reduction, holds significance in evaluating and comparing different surgical approaches in PN\u0026nbsp;[\u003ca href=\"#_ENREF_29\" title=\"Maurice, 2017 #705\"\u003e29\u003c/a\u003e]. In a comparative study between OPN and RPN conducted by Acar et al. in 2015, Trifecta rates were similar, with complications being the key differentiating factor. Length of hospitalization varied based on the Trifecta outcome. Limitations of the comparison included its retrospective design, and the use of \"Modification of Diet in Renal Disease\" formula (MDRD) for evaluating renal function, through eGFR estimation\u0026nbsp;[\u003ca href=\"#_ENREF_30\" title=\"Acar, 2015 #579\"\u003e30\u003c/a\u003e]. In their 2019 study, Ghali et al. aimed to compare surgical quality and additional outcomes related to renal function between robotic and open PN for cT2a renal masses. They analyzed 150 patients (RPN: 59 vs. OPN: 91) and found that the robotic approach yielded comparable functional and oncologic outcomes to open surgery. Additionally, RPN was coupled with decreased blood loss, shorter hospitalizations, and lower incidence of major complications (CD ≥ 3). Furthermore, Trifecta attainment rates were significantly higher in the RPN patient group, indicating better overall surgical quality\u0026nbsp;[\u003ca href=\"#_ENREF_1\" title=\"Ghali, 2019 #263\"\u003e1\u003c/a\u003e]. Another study of retrospective design by Soisrithong et al. in 2021 compared perioperative and Trifecta outcomes among patients with SRMs undergoing OPN, LPN, and RAPN. Analyzing 70 cases in total, the authors discovered that while OT was notably shorter in the open surgery group, Trifecta rates did not substantially diverge among the three approaches. However, they identified the length of stay as a factor negatively correlated with Trifecta achievement. Overall, the study indicated that the three approaches are comparable regarding Trifecta rates, with the duration of hospitalization emerging as a key determinant of success\u0026nbsp;[\u003ca href=\"#_ENREF_3\" title=\"Soisrithong, 2021 #767\"\u003e3\u003c/a\u003e]. Within a similar context, Bravi et al. in 2019 conducted a multi-arm study comparing perioperative outcomes among the above three PN approaches for cT1 renal tumors. Patients submitted to minimally invasive procedures experienced fewer complications than those in the OPN group, while RPN showed the highest probability for ischemia application, and LPN demanded longer IT compared to open and robotic surgery. Acute kidney injury risk was lower in RPN and LPN arms than in open surgery. PSM rates did not vary between groups, and RPN demonstrated higher Trifecta rates in lesions of low and intermediate complexity (PADUA score \u0026lt; 10)\u0026nbsp;[\u003ca href=\"#_ENREF_31\" title=\"Bravi, 2019 #66\"\u003e31\u003c/a\u003e]. Another study conducted by Hoeh et al. in 2023 contrasted RAPN and OPN in patients with localized SRMs. RAPN resulted in shorter hospital stays and fewer complications than OPN, despite similar blood loss volumes. The robotic approach showed better outcomes in multivariable models, especially regarding complications and Trifecta achievement rates\u0026nbsp;[\u003ca href=\"#_ENREF_32\" title=\"Hoeh, 2023 #1008\"\u003e32\u003c/a\u003e]. Remaining within the same framework, Ingels et al. in 2022 compared perioperative outcomes between RPN and OPN. The former approach manifested advantages in early complications, transfusion rates, hospital stay lengths, and renal function preservation. Additionally, it exhibited restriction in the incidence of new-onset CKD. Stratified analysis also favored RPN concerning Trifecta attainment in large and complex tumors. The study advocated for RPN due to its superior perioperative outcomes, suggesting its appropriateness even for tumors with challenging features\u0026nbsp;[\u003ca href=\"#_ENREF_33\" title=\"Ingels, 2022 #933\"\u003e33\u003c/a\u003e]. In an additional study by Mehra et al. in 2019, OPN, LPN, and RAPN were compared with respect to perioperative outcomes in patients with average complexity renal tumors. OPN showed higher blood loss than LPN and RAPN, with longer drain removal times. Postoperative complications and margin status were similar across the three approaches. LPN was comparable to RAPN, with the former being emphasized for its cost-effectiveness, making it an attractive option in developing countries\u0026nbsp;[\u003ca href=\"#_ENREF_34\" title=\"Mehra, 2019 #78\"\u003e34\u003c/a\u003e]. Lastly, Motoyama et al. in 2019 evaluated RAPN utilizing the da Vinci Xi\u003csup\u003e®\u003c/sup\u003e system against conventional OPN. The robotic approach demonstrated superior perioperative results, including reduced OT and blood loss, as well as shorter hospital stays. Trifecta achievement was significantly more frequent in the RAPN group, driven by the R.E.N.A.L. nephrometry score and the surgical modality. Robotic PN using the da Vinci Xi\u003csup\u003e®\u003c/sup\u003e system was favored by the authors for managing patients with SRMs, pending further research on long-term outcomes\u0026nbsp;[\u003ca href=\"#_ENREF_35\" title=\"Motoyama, 2019 #86\"\u003e35\u003c/a\u003e].\u003c/p\u003e\n\u003cp\u003eIn synthesis, the body of literature scrutinizing RPN/RAPN in contrast to OPN consistently delineates a plethora of advantageous effects on the part of the former. These encompass not only reduced incidences of major and minor complications, thereby mitigating overall postoperative morbidity, but also decreased blood loss volumes and transfusion requirements\u0026nbsp;[\u003ca href=\"#_ENREF_36\" title=\"Qu, 2024 #1044\"\u003e36\u003c/a\u003e]. These findings persist in the face of an apparent increase in OT, reported to accompany RAPN in certain patient cohorts, particularly in older studies. Interestingly, despite the protracted operative durations, patients undergoing robotic PN tend to experience shorter hospital stays, an observation potentially attributable to the lower incidence of postoperative complications, and also associated with achieving higher Trifecta rates. Furthermore, the reliance of RPN on ischemia application is underscored, albeit amid the demonstration of superior renal function preservation compared to OPN. Crucially, the robotic procedure seems to consistently deliver comparable oncological and functional outcomes, alongside equivalent PSM rates, cementing its status as a viable alternative in the armamentarium of modern kidney surgery. Finally, fusing our results with respective findings from the international literature, we can also support that RAPN overall results in a combination of higher Trifecta rates, a simultaneous reduction in complications, equivalent PSM rates and IT, and a statistically but not clinically superior MD\u003csub\u003eΔeGFR\u003c/sub\u003e compared to OPN. This complex of findings, given the central role of CD ≤ 2 complications in shaping the Trifecta outcome, may stem from a higher level of dexterity in handling the renal parenchyma during tumor resection. This connection becomes causal when considering that the precision of maneuvers has a greater impact on minor complications, while the severity of the intervention or the stage of the disease primarily affects major ones. Consequently, RAPN, through its high technological integration at the intraoperative level, seems to achieve superior surgical quality, as evidenced by Trifecta, which is interconnected with rather superior surgical precision, as demonstrated by CD ≤ 2 complications.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eStrengths \u0026amp; Limitations\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe study presents robust strengths and limitations, offering a comprehensive perspective on the topic. Strong-points include the rigorous methodology, employing a random effects MA with SGA at multiple levels, and MRA using two moderators. An SA based on study precision was also conducted to address heterogeneity, by similarly utilizing a modified random effects model. The comparative effects from the MRA were presented through a prototype table (Table 2), illustrating evolution patterns in both chronological and qualitative frames relative to the horizontal axis of zero impact. In this way, the optimal representation and summary of the corresponding MRA plots were achieved in a sufficiently informative manner. The present investigation explored Trifecta and its components, utilizing two primary definition-based clusters to establish appropriate subsets, while concurrently ensuring maximum data availability for each outcome. Although the processed literature was divided between studies that clearly favor RAPN in terms of Trifecta attainment and those that portray it as equivalent to open surgery, the present analysis managed through data synthesis to highlight significant advantages for RAPN. Apart from the above strengths, notable limitations also exist. The comparison between RPN/RAPN and OPN relied mainly on non-randomized studies, leading to heterogeneity and inclusion of findings from small-scale analyses. Moreover, differing Trifecta definitions posed challenges, mitigated by grouping individual records according to\u0026nbsp;ΔeGFR\u003csub\u003e%\u003c/sub\u003e and IT thresholds through appropriate SGA. Another limitation concerned the number of studies in the SA for each outcome, mainly due to the high proportion of small studies with low accuracy. These limitations underscore caution in interpreting findings and highlight areas for future research and methodological refinement.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFuture potential\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe Trifecta outcome, considered as a key measure in evaluating PN, warrants thorough examination to gauge the efficacy of modern surgical robotic platforms. Analyzing its components assists in comparing achievement rates between robotic and open approaches. Future analyses should aim to maximize data inclusion to clarify differences in PSM rates and the comparative impact on renal function, with a specific focus on IT and ΔCr. Further studies could explore the correlation between therapeutic adequacy and surgical precision during tumor resection, including considerations of hemostasis and proportional IT over OT. Understanding these interconnections shall elucidate how precise maneuvers translate into superior therapeutic outcomes.\u0026nbsp;\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThe present study compared robotic and open PN, focusing on tumor excision quality. It specifically examined the Trifecta and its key components, linking each individual outcome with specific aspects of surgical precision. The data analysis demonstrated RAPN's superiority in Trifecta achievement rates, occurrence of major and minor complications, and eGFR preservation compared to OPN. The relative benefits showed a quasi-stable to expanding magnitude over time, reflecting the effective integration of robotic technology into contemporary kidney surgery. The consistently stable comparative effect regarding minor complications was considered to stem from the inherent characteristics of RAPN as a minimally invasive modality. In particular, RAPN's advantage in postoperative complications appears to be the primary driver behind the increasing benefit in Trifecta attainment, potentially reflecting higher quality of intraoperative maneuvers and justifying its apparent preeminence in surgical precision.\u003c/p\u003e"},{"header":"ABBREVIATIONS ","content":"\u003cp\u003eASA: American Society of Anesthesiologists\u003c/p\u003e\n\u003cp\u003eBMI: Body Mass Index\u003c/p\u003e\n\u003cp\u003eCCI: Charlson Comorbidity Index\u003c/p\u003e\n\u003cp\u003eCD: Clavien-Dindo classification of postoperative complications\u003c/p\u003e\n\u003cp\u003eCI\u003csub\u003e95%\u003c/sub\u003e: 95% Confidence Interval\u003c/p\u003e\n\u003cp\u003eCKD: Chronic Kidney Disease\u003c/p\u003e\n\u003cp\u003ecm: Centimeters\u003c/p\u003e\n\u003cp\u003eCr: Creatinine levels\u003c/p\u003e\n\u003cp\u003edl: Deciliters\u003c/p\u003e\n\u003cp\u003eeGFR: estimated Glomerular Filtration Rate\u003c/p\u003e\n\u003cp\u003eGFR: Glomerular Filtration Rate\u003c/p\u003e\n\u003cp\u003eHb: Hemoglobin concentration\u003c/p\u003e\n\u003cp\u003eIT: Ischemia Time\u003c/p\u003e\n\u003cp\u003elogOR: decimal logarithm of Odds Ratio\u003c/p\u003e\n\u003cp\u003eLPN: Laparoscopic Partial Nephrectomy\u003c/p\u003e\n\u003cp\u003em: Meters\u003c/p\u003e\n\u003cp\u003eMA: Meta-analysis\u003c/p\u003e\n\u003cp\u003eMD: Mean Difference\u003c/p\u003e\n\u003cp\u003eMDRD: Modification of Diet in Renal Disease\u003c/p\u003e\n\u003cp\u003emin: Minutes\u003c/p\u003e\n\u003cp\u003eml: Milliliters\u003c/p\u003e\n\u003cp\u003eMRA: Meta-regression Analysis\u003c/p\u003e\n\u003cp\u003eNOS: Newcastle-Ottawa Scale\u003c/p\u003e\n\u003cp\u003eOPN: Open Partial Nephrectomy\u003c/p\u003e\n\u003cp\u003eOR: Odds Ratio\u003c/p\u003e\n\u003cp\u003eOT: Operative Time\u003c/p\u003e\n\u003cp\u003ePADUA - R.E.N.A.L.: Nephrometry scores\u003c/p\u003e\n\u003cp\u003ePB: Publication Bias\u003c/p\u003e\n\u003cp\u003ePN: Partial Nephrectomy\u003c/p\u003e\n\u003cp\u003ePRISMA: Preferred Reporting Items for Systematic reviews and Meta-analyses\u003c/p\u003e\n\u003cp\u003ePSM: Positive Surgical Margins\u003c/p\u003e\n\u003cp\u003eRAPN: Robot-assisted Partial Nephrectomy\u003c/p\u003e\n\u003cp\u003eROB: Risk of Bias\u003c/p\u003e\n\u003cp\u003eROBINS-I: Risk of Bias In Non-randomized Studies of Interventions\u003c/p\u003e\n\u003cp\u003eRPN: Robotic Partial Nephrectomy\u003c/p\u003e\n\u003cp\u003eSA: Sensitivity Analysis\u003c/p\u003e\n\u003cp\u003eSD: Standard Deviation\u003c/p\u003e\n\u003cp\u003eSGA: Subgroup Analysis\u003c/p\u003e\n\u003cp\u003eSRMs: Small Renal Masses\u003c/p\u003e\n\u003cp\u003eSSEs: Small Study Effects\u003c/p\u003e\n\u003cp\u003eΔCr: Change (positive) from baseline in serum Creatinine levels\u003c/p\u003e\n\u003cp\u003eΔeGFR\u003csub\u003e%\u003c/sub\u003e: Percentage change in estimated Glomerular Filtration Rate\u003c/p\u003e\n\u003cp\u003eΔeGFR: Change (negative) from baseline in estimated Glomerular Filtration Rate\u003c/p\u003e"},{"header":"DECLARATIONS","content":"\u003cp\u003e1. Ethics approval and consent to participate:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. Consent for publication:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e3. Availability of data and materials:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll the data utilized and statistical code developed are available at the following link: https://github.com/sotbike/NESTOR.git.\u003c/p\u003e\n\u003cp\u003e4. Competing interests:\u003c/p\u003e\n\u003cp\u003eSotirios Artsitas (S.A.), Dimitrios Artsitas (D.A.), Irene Koronaki (I.K.), Konstantinos G. Toutouzas (K.G.T.), George C. Zografos (G.C.Z.) declare that they have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e5. Funding:\u003c/p\u003e\n\u003cp\u003eAll authors confirm that no funds, grants, or other support was received.\u003c/p\u003e\n\u003cp\u003e6. Authors' contributions:\u003c/p\u003e\n\u003cp\u003e6a. Authors' contributions (descriptively):\u003c/p\u003e\n\u003cp\u003eS.A. has given substantial contributions to the conceptualization, data curation, formal analysis, data investigation, methodology implementation, project administration, acquisition of resources, software utilization, procedure validation, visualization of results, original draft formulation, as well as the final review \u0026amp; editing of the present study. D.A. has given substantial contributions in data curation, formal analysis, data investigation, project administration, acquisition of resources, as well as procedure validation. I.K. has given substantial contributions in conceptualization, methodology implementation, software utilization, procedure validation, as well as critical review of the final manuscript. K.G.T. has given substantial contributions in supervision, data validation, as well as critical review of the final manuscript. G.C.Z. held the position of general supervisor during the elaboration of the present study. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e6b. Authors' contributions (according to CREdiT):\u003c/p\u003e\n\u003cp\u003eConceptualization: [S.A., I.K.]; Data curation: [S.A., D.A.]; Formal Analysis: [S.A., D.A.]; Funding acquisition: [ - ]; Investigation: [S.A., D.A., I.K.]; Methodology: [S.A., I.K.]; Project administration: [S.A., D.A.]; Resources: [S.A., D.A., I.K.]; Software: [S.A., I.K.]; Supervision: [K.G.T., G.C.Z.]; Validation: [S.A., D.A., K.G.T.]; Visualization: [S.A.]; Writing - original draft: [S.A., D.A.]; Writing - review \u0026amp; editing: [S.A., D.A., I.K., K.G.T.]. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e7. Acknowledgments:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e8. Authors’ information:\u003c/p\u003e\n\u003cp\u003e8a. Sotirios Artsitas (S.A.) - Corresponding author\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAffiliation 1\u003c/u\u003e: School of Medicine, National and Kapodistrian University of Athens (NKUA), Address: Mikras Asias str. 75, Postal Code: 11527, Athens, Greece.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAffiliation 2\u003c/u\u003e: 1\u003csup\u003est\u003c/sup\u003e Propaedeutic Department of Surgery, Geniko Nosokomeio Athenon Ippokrateio, Address: Vasilisis Sofias str. 114, Postal Code: 11527, Athens, Greece.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMedical Doctor (M.D.), Mechanical Engineer (Mech.Eng.), Telephone number: +30 6945824838, ORCID ID: 0000-0002-1605-5028, Personal e-mail: [email protected], Alternative e-mail: [email protected], Academic e-mail: [email protected].\u003c/p\u003e\n\u003cp\u003eCorresponding author.\u003c/p\u003e\n\u003cp\u003e8b. Dimitrios Artsitas (D.A.)\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAffiliation 3\u003c/u\u003e: 2\u003csup\u003end\u003c/sup\u003e Department of Orthopaedics, KAT Attica General Hospital, Address: Nikis str. 2, Kifissia, Postal Code: 14561, Athens, Greece.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMedical Doctor (M.D.), ORCID ID: 0000-0002-6626-7512, Personal e-mail: [email protected].\u003c/p\u003e\n\u003cp\u003e8c. Irene Koronaki (I.K.)\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAffiliation 4\u003c/u\u003e: Laboratory of Applied Thermodynamics, School of Mechanical Engineering, National Technical University of Athens (NTUA), Address: Heroon Polytechniou str. 9, Zografou Campus, Postal Code: 15780, Athens, Greece.\u003c/p\u003e\n\u003cp\u003eProfessor (Mech.Eng., PhD), Personal e-mail: [email protected], Academic e-mail: [email protected].\u003c/p\u003e\n\u003cp\u003e8d. Konstantinos G. Toutouzas (K.G.T.)\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAffiliation 1\u003c/u\u003e: School of Medicine, National and Kapodistrian University of Athens (NKUA), Address: Mikras Asias str. 75, Postal Code: 11527, Athens, Greece.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAffiliation 2\u003c/u\u003e: 1\u003csup\u003est\u003c/sup\u003e Propaedeutic Department of Surgery, Geniko Nosokomeio Athenon Ippokrateio, Address: Vasilisis Sofias str. 114, Postal Code: 11527, Athens, Greece.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProfessor (M.D., PhD), Personal e-mail: [email protected], Academic e-mail: [email protected].\u003c/p\u003e\n\u003cp\u003e8e. George C. Zografos (G.C.Z.)\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAffiliation 1\u003c/u\u003e: School of Medicine, National and Kapodistrian University of Athens (NKUA), Address: Mikras Asias str. 75, Postal Code: 11527, Athens, Greece.\u003c/p\u003e\n\u003cp\u003eProfessor (M.D., PhD), Academic e-mail: [email protected].\u003c/p\u003e"},{"header":"REFERENCES","content":"\u003col\u003e\n\u003cli\u003eF. Ghali, A. A. Elbakry, Z. A. Hamilton, K. Yim, R. Nasseri, S. Patel\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Robotic partial nephrectomy for clinical T2a renal mass is associated with improved trifecta outcome compared to open partial nephrectomy: a single surgeon comparative analysis,\u0026quot; \u003cem\u003eWorld journal of urology, \u003c/em\u003epp. 1-10, 2019, https://doi.org/10.1007/s00345-019-02994-2.\u003c/li\u003e\n\u003cli\u003eS. Ghavimi, O. Saarela, F. Pouliot, R. A. Rendon, A. Finelli, A. Kapoor\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Achieving the \u0026quot;trifecta\u0026quot; with open versus minimally invasive partial nephrectomy,\u0026quot; \u003cem\u003eWorld J Urol, \u003c/em\u003evol. 39, pp. 1569-1575, May 2021, https://doi.org/10.1007/s00345-020-03349-y.\u003c/li\u003e\n\u003cli\u003eC. Soisrithong, P. Sirisreetreerux, P. Sangkum, K. Kijvikai, W. Viseshsindh, W. Kongchareonsombat\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Comparative Outcomes and Predictive Assessment of Trifecta in Open, Laparoscopic, and Robotic-Assisted Partial Nephrectomy Cases with Renal Cell Carcinoma: A 10-Year Experience at Ramathibodi Hospital,\u0026quot; \u003cem\u003eRes Rep Urol, \u003c/em\u003evol. 13, pp. 425-435, 2021, https://doi.org/10.2147/rru.s316824.\u003c/li\u003e\n\u003cli\u003eL. Bianchi, R. Schiavina, M. Borghesi, F. Chessa, C. Casablanca, A. Angiolini\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Which patients with clinical localized renal mass would achieve the trifecta after partial nephrectomy? The impact of surgical technique,\u0026quot; \u003cem\u003eMinerva Urol Nefrol, \u003c/em\u003evol. 72, pp. 339-349, Jun 2020, https://doi.org/10.23736/s0393-2249.19.03485-4.\u003c/li\u003e\n\u003cli\u003eM. Borghesi, R. Schiavina, F. Chessa, L. Bianchi, G. La Manna, A. Porreca\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Retroperitoneal Robot-Assisted Versus Open Partial Nephrectomy for cT1 Renal Tumors: A Matched-Pair Comparison of Perioperative and Early Oncological Outcomes,\u0026quot; \u003cem\u003eClin Genitourin Cancer, \u003c/em\u003evol. 16, pp. e391-e396, Apr 2018, https://doi.org/10.1016/j.clgc.2017.09.010.\u003c/li\u003e\n\u003cli\u003eY. Benichou, F. Audenet, K. Bensalah, M. Roupret, P. Paparel, C. Lebacle\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Partial nephrectomy in solitary kidneys: comparison between open surgery and robotic-assisted laparoscopy on perioperative and functional outcomes (UroCCR-54 study),\u0026quot; \u003cem\u003eWorld J Urol, \u003c/em\u003eJun 20 2022, https://doi.org/10.1007/s00345-022-04026-y.\u003c/li\u003e\n\u003cli\u003eF. Porpiglia, A. Mari, R. Bertolo, A. Antonelli, G. Bianchi, F. Fidanza\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Partial Nephrectomy in Clinical T1b Renal Tumors: Multicenter Comparative Study of Open, Laparoscopic and Robot-assisted Approach (the RECORd Project),\u0026quot; \u003cem\u003eUrology, \u003c/em\u003evol. 89, pp. 45-51, Mar 2016, https://doi.org/10.1016/j.urology.2015.08.049.\u003c/li\u003e\n\u003cli\u003eO. O. Omidele, N. Davoudzadeh, and M. Palese, \u0026quot;Trifecta Outcomes to Assess Learning Curve of Robotic Partial Nephrectomy,\u0026quot; \u003cem\u003eJsls, \u003c/em\u003evol. 22, Jan-Mar 2018, https://doi.org/10.4293/jsls.2017.00064.\u003c/li\u003e\n\u003cli\u003eE. Bajalia, K. Parikh, D. Haehn, A. Kahn, C. Thomas, and D. Thiel, \u0026quot;MP47-03 Is there a learning curve plateau for achieving Trifecta and minimizing Operative Time (OT) for Robotic-Assisted Partial Nephrectomy (RAPN)?,\u0026quot; \u003cem\u003eThe Journal of Urology, \u003c/em\u003evol. 203, p. e684, 04/01 2020, https://doi.org/10.1097/JU.0000000000000902.03.\u003c/li\u003e\n\u003cli\u003eS. Artsitas, D. Artsitas, I. Koronaki, K. G. Toutouzas, and G. C. Zografos, \u0026quot;A prototype variable corresponding to the proportion of ischemia for the comparison between robotic and open partial nephrectomy: a meta-analysis accompanied by sensitivity analysis,\u0026quot; \u003cem\u003eBeni-Suef University Journal of Basic and Applied Sciences, \u003c/em\u003evol. 12, p. 90, 2023/10/14 2023, https://doi.org/10.1186/s43088-023-00431-3.\u003c/li\u003e\n\u003cli\u003eS. Artsitas, D. Artsitas, I. Koronaki, K. G. Toutouzas, and G. C. Zografos, \u0026quot;Comparing robotic and open partial nephrectomy under the prism of surgical precision: a meta-analysis of the average blood loss rate as a novel variable,\u0026quot; \u003cem\u003eJournal of Robotic Surgery, \u003c/em\u003evol. 18, p. 313, 2024/08/07 2024, https://doi.org/10.1007/s11701-024-02060-z.\u003c/li\u003e\n\u003cli\u003eM. J. Page, L. Shamseer, and A. C. Tricco, \u0026quot;Registration of systematic reviews in PROSPERO: 30,000 records and counting,\u0026quot; \u003cem\u003eSyst Rev, \u003c/em\u003evol. 7, p. 32, Feb 20 2018, https://doi.org/10.1186/s13643-018-0699-4.\u003c/li\u003e\n\u003cli\u003eT. Bozada, J. Borden, M. Cid, J. Malinowski, and T. Luechtefeld, \u0026quot;Sysrev: A FAIR platform for Data Curation and Systematic Evidence Review,\u0026quot; 2021, https://doi.org/10.1101/2021.03.24.436697.\u003c/li\u003e\n\u003cli\u003eS. Artsitas, D. Artsitas, I. Segkou, G. Tsourouflis, D. Dimitroulis, and N. Nikiteas, \u0026quot;Considering \u0026quot;Trifecta\u0026quot; as a Single Outcome when Comparing Robotic With Open Partial Nephrectomy: A Mathematical Model of Volume Conservation and Systematic Review,\u0026quot; \u003cem\u003eIn Vivo, \u003c/em\u003evol. 36, pp. 2558-2578, Nov-Dec 2022, https://doi.org/10.21873/invivo.12992.\u003c/li\u003e\n\u003cli\u003eP. A. Clavien, J. Barkun, M. L. de Oliveira, J. N. Vauthey, D. Dindo, R. D. Schulick\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;The Clavien-Dindo classification of surgical complications: five-year experience,\u0026quot; \u003cem\u003eAnn Surg, \u003c/em\u003evol. 250, pp. 187-96, Aug 2009, https://doi.org/10.1097/SLA.0b013e3181b13ca2.\u003c/li\u003e\n\u003cli\u003eX. Wan, W. Wang, J. Liu, and T. Tong, \u0026quot;Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range,\u0026quot; \u003cem\u003eBMC Medical Research Methodology, \u003c/em\u003evol. 14, p. 135, 2014/12/19 2014, https://doi.org/10.1186/1471-2288-14-135.\u003c/li\u003e\n\u003cli\u003eD.-G. Chen and K. Peace, \u003cem\u003eApplied Meta-Analysis with R and Stata\u003c/em\u003e, 2021, ISBN: 9780429061240, https://doi.org/10.1201/9780429061240.\u003c/li\u003e\n\u003cli\u003eD.-G. Chen and K. Peace, \u003cem\u003eApplied Meta-Analysis with R\u003c/em\u003e, 2013, ISBN: 978-1-46-650599-5, https://doi.org/10.13140/2.1.3165.5368.\u003c/li\u003e\n\u003cli\u003eA. Stang, \u0026quot;Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses,\u0026quot; \u003cem\u003eEur J Epidemiol, \u003c/em\u003evol. 25, pp. 603-5, Sep 2010, https://doi.org/10.1007/s10654-010-9491-z.\u003c/li\u003e\n\u003cli\u003eJ. A. Sterne, M. A. Hern\u0026aacute;n, B. C. Reeves, J. Savović, N. D. Berkman, M. Viswanathan\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions,\u0026quot; \u003cem\u003eBMJ, \u003c/em\u003evol. 355, p. i4919, 2016, https://doi.org/10.1136/bmj.i4919.\u003c/li\u003e\n\u003cli\u003eL. Smolinsky, \u0026quot;Odds ratios and Mantel-Haenszel quotients,\u0026quot; \u003cem\u003eJournal of Informetrics, \u003c/em\u003evol. 13, 02/01 2019, https://doi.org/10.1016/j.joi.2019.02.005.\u003c/li\u003e\n\u003cli\u003eB. George and I. Aban, \u0026quot;An application of meta-analysis based on DerSimonian and Laird method,\u0026quot; \u003cem\u003eJournal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology, \u003c/em\u003evol. 23, 08/06 2015, https://doi.org/10.1007/s12350-015-0249-6.\u003c/li\u003e\n\u003cli\u003eL. Lin, \u0026quot;Comparison of four heterogeneity measures for meta-analysis,\u0026quot; \u003cem\u003eJournal of Evaluation in Clinical Practice, \u003c/em\u003evol. 26, pp. 376-384, 2020/02/01 2020, https://doi.org/10.1111/jep.13159.\u003c/li\u003e\n\u003cli\u003eL. Lin, H. Chu, M. H. Murad, C. Hong, Z. Qu, S. Cole\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Empirical Comparison of Publication Bias Tests in Meta-Analysis,\u0026quot; \u003cem\u003eJournal of General Internal Medicine, \u003c/em\u003evol. 33, 04/16 2018, https://doi.org/10.1007/s11606-018-4425-7.\u003c/li\u003e\n\u003cli\u003eM. J. Page, J. E. McKenzie, P. M. Bossuyt, I. Boutron, T. C. Hoffmann, C. D. Mulrow\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;The PRISMA 2020 statement: an updated guideline for reporting systematic reviews,\u0026quot; \u003cem\u003eBMJ, \u003c/em\u003evol. 372, p. n71, 2021, https://doi.org/10.1136/bmj.n71.\u003c/li\u003e\n\u003cli\u003eS. Wattanakriengkrai, B. Chinthanet, H. Hata, R. G. Kula, C. Treude, J. Guo\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;GitHub repositories with links to academic papers: Public access, traceability, and evolution,\u0026quot; \u003cem\u003eJournal of Systems and Software, \u003c/em\u003evol. 183, p. 111117, 2022/01/01/ 2022, https://doi.org/10.1016/j.jss.2021.111117.\u003c/li\u003e\n\u003cli\u003eT. L. Staples, \u0026quot;Expansion and evolution of the R programming language,\u0026quot; \u003cem\u003eRoyal Society Open Science, \u003c/em\u003evol. 10, p. 221550, 2023/04/12 2023, https://doi.org/10.1098/rsos.221550.\u003c/li\u003e\n\u003cli\u003eS. Artsitas, D. Artsitas, I. Segkou, I. Koronaki, K. G. Toutouzas, and G. C. Zografos, \u0026quot;Robotic versus open partial nephrectomy in the context of mild severity complications: a meta-analysis of comparative studies supplemented by meta-regression,\u0026quot; \u003cem\u003eBulletin of the National Research Centre, \u003c/em\u003evol. 47, p. 36, 2023/03/06 2023, https://doi.org/10.1186/s42269-023-01008-x.\u003c/li\u003e\n\u003cli\u003eM. J. Maurice, D. Ramirez, \u0026Ouml;. Kara, E. Malko\u0026ccedil;, R. J. Nelson, K. Fareed\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Optimum outcome achievement in partial nephrectomy for T1 renal masses: a contemporary analysis of open and robot-assisted cases,\u0026quot; \u003cem\u003eBJU Int, \u003c/em\u003evol. 120, pp. 537-543, Oct 2017, https://doi.org/10.1111/bju.13888.\u003c/li\u003e\n\u003cli\u003e\u0026Ouml;. Acar, E. Işık, T. Mut, Y. Sağlıcan, A. Onay, M. Vural\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Comparison of the trifecta outcomes of robotic and open nephron-sparing surgeries performed in the robotic era of a single institution,\u0026quot; \u003cem\u003eSpringerplus, \u003c/em\u003evol. 4, p. 472, 2015, https://doi.org/10.1186/s40064-015-1274-2.\u003c/li\u003e\n\u003cli\u003eC. A. Bravi, A. Larcher, U. Capitanio, A. Mari, A. Antonelli, W. Artibani\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Perioperative outcomes of Open, Laparoscopic, and Robotic Partial Nephrectomy: A prospective multicenter observational study (The RECORd 2 Project),\u0026quot; \u003cem\u003eEuropean urology focus, \u003c/em\u003e2019, https://doi.org/10.1016/j.euf.2019.10.013.\u003c/li\u003e\n\u003cli\u003eB. Hoeh, M. Wenzel, O. Eckart, F. Fleisgarten, C. C. Garcia, J. K\u0026ouml;llermann\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Comparison of peri- and intraoperative outcomes of open vs robotic-assisted partial nephrectomy for renal cell carcinoma: a propensity-matched analysis,\u0026quot; \u003cem\u003eWorld Journal of Surgical Oncology, \u003c/em\u003evol. 21, p. 189, 2023/06/22 2023, https://doi.org/10.1186/s12957-023-03061-2.\u003c/li\u003e\n\u003cli\u003eA. Ingels, K. Bensalah, J. B. Beauval, P. Paparel, M. Roupr\u0026ecirc;t, H. Lang\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Comparison of open and robotic-assisted partial nephrectomy approaches using multicentric data (UroCCR-47 study),\u0026quot; \u003cem\u003eScientific Reports, \u003c/em\u003evol. 12, p. 18981, 2022/11/08 2022, https://doi.org/10.1038/s41598-022-22912-8.\u003c/li\u003e\n\u003cli\u003eK. Mehra, R. Manikandan, L. N. Dorairajan, S. Sreerag, A. Jain, and S. H. Bokka, \u0026quot;Trifecta Outcomes in Open, Laparoscopy or Robotic Partial Nephrectomy: Does the Surgical Approach Matter?,\u0026quot; \u003cem\u003eJournal of kidney cancer and VHL, \u003c/em\u003evol. 6, p. 8, 2019, https://doi.org/10.15586/jkcvhl.2019.115.\u003c/li\u003e\n\u003cli\u003eD. Motoyama, R. Aki, Y. Matsushita, K. Tamura, T. Ito, T. Sugiyama\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Early single-center experience with robotic partial nephrectomy using the da Vinci Xi: comparative assessment with conventional open partial nephrectomy,\u0026quot; \u003cem\u003eCurrent urology, \u003c/em\u003evol. 13, pp. 13-18, 2019, https://doi.org/10.1159/000499300.\u003c/li\u003e\n\u003cli\u003eH. Qu, K. Wang, and B. Hu, \u0026quot;Meta-analysis of clinical outcomes of robot-assisted partial nephrectomy and classical open partial nephrectomy,\u0026quot; \u003cem\u003eInt J Surg, \u003c/em\u003eApr 3 2024, https://doi.org/10.1097/js9.0000000000001324.\u003c/li\u003e\n\u003cli\u003eA. Antonelli, A. Mari, A. Tafuri, R. Tellini, U. Capitanio, P. Gontero\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Prediction of significant renal function decline after open, laparoscopic, and robotic partial nephrectomy: External validation of the Martini\u0026rsquo;s nomogram on the RECORD2 project cohort,\u0026quot; \u003cem\u003eInternational Journal of Urology, \u003c/em\u003evol. 29, pp. 525-532, 2022, https://doi.org/10.1111/iju.14831.\u003c/li\u003e\n\u003cli\u003eV. Audig\u0026eacute;, A. Baghli, J. Hubert, C. Mazeaud, S. Larr\u0026eacute;, and B. Branchu, \u0026quot;Clinical and oncological outcomes of open partial nephrectomy versus robot assisted partial nephrectomy over 15 years,\u0026quot; \u003cem\u003eJournal of Robotic Surgery, \u003c/em\u003epp. 1-8, 2022, https://doi.org/10.1007/s11701-022-01446-1.\u003c/li\u003e\n\u003cli\u003eP. Banapour, G. A. Abdelsayed, Z. Bider-Canfield, P. A. Elliott, P. S. Kilday, and G. W. Chien, \u0026quot;Nephrometry score matched Robotic vs. Laparoscopic vs. Open Partial Nephrectomy,\u0026quot; \u003cem\u003eJournal of robotic surgery, \u003c/em\u003evol. 12, pp. 679-685, 2018, https://doi.org/10.1007/s11701-018-0801-x.\u003c/li\u003e\n\u003cli\u003eC. B. Ugur Boylu, Umit Yildirim, Fikret F. Onol, Eyup Gumus, \u0026quot;Comparison of surgical, functional, and oncological outcomes of open and robot-assisted partial nephrectomy,\u0026quot; \u003cem\u003eJournal of Minimal Access Surgery, \u003c/em\u003evol. 11, 2015, https://doi.org/10.4103/0972-9941.147699.\u003c/li\u003e\n\u003cli\u003eC. A. Bravi, G. Rosiello, E. Mazzone, A. Minervini, A. Mari, F. Di Maida\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;The IRON Study: Investigation of Robot-assisted Versus Open Nephron-sparing Surgery,\u0026quot; \u003cem\u003eEuropean Urology Open Science, \u003c/em\u003evol. 49, pp. 71-77, 2023/03/01/ 2023, https://doi.org/10.1016/j.euros.2022.12.017.\u003c/li\u003e\n\u003cli\u003eM. Chandra, S. Wasnik, and S. Karan, \u0026quot;A prospective, multi-institutional study of perioperative morbidities in the patients of renal cell carcinoma undergoing either open nephron sparing surgery or robotic nephron sparing surgery in fifty cases,\u0026quot; \u003cem\u003eInternational Surgery Journal, \u003c/em\u003evol. 6, pp. 2785-2790, 2019, https://doi.org/10.18203/2349-2902.isj20193155.\u003c/li\u003e\n\u003cli\u003eK. Chang, A. Abdel Raheem, K. Kim, C. Oh, S. Park, Y. Kim\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Functional and oncologic outcomes of open, laparoscopic and robotic partial nephrectomy: A Multicenter comparative matched-pair analyses with a median 5 years follow up,\u0026quot; \u003cem\u003eBJU Int, \u003c/em\u003e2018, https://doi.org/10.1111/bju.14250.\u003c/li\u003e\n\u003cli\u003eS. Y. Choi, H. Jung, D. You, I. G. Jeong, C. Song, B. Hong\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Robot-assisted partial nephrectomy is associated with early recovery of renal function: Comparison of open, laparoscopic, and robot-assisted partial nephrectomy using DTPA renal scintigraphy,\u0026quot; \u003cem\u003eJ Surg Oncol, \u003c/em\u003evol. 119, pp. 1016-1023, Jun 2019, https://doi.org/10.1002/jso.25429.\u003c/li\u003e\n\u003cli\u003eT. Esen, \u0026Ouml;. Acar, A. Musaoğlu, and M. Vural, \u0026quot;Morphometric profile of the localised renal tumors managed either by open or robot-assisted nephron-sparing surgery: the impact of scoring systems on the decision making process,\u0026quot; \u003cem\u003eBMC urology, \u003c/em\u003evol. 13, pp. 1-7, 2013, https://doi.org/10.1186/1471-2490-13-63.\u003c/li\u003e\n\u003cli\u003eV. Ficarra, A. Minervini, A. Antonelli, S. Bhayani, G. Guazzoni, N. Longo\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;A multicentre matched-pair analysis comparing robot-assisted versus open partial nephrectomy,\u0026quot; \u003cem\u003eBJU Int, \u003c/em\u003evol. 113, pp. 936-41, Jun 2014, https://doi.org/10.1111/bju.12570.\u003c/li\u003e\n\u003cli\u003eC. Gandi, A. Totaro, R. Bientinesi, F. Marino, F. Pierconti, A. Russo\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Purely Off-Clamp Partial Nephrectomy: Robotic Approach Better than Open Using a Pentafecta Outcome with Propensity Score Matching,\u0026quot; \u003cem\u003eJournal of Clinical Medicine, \u003c/em\u003evol. 11, 2022, https://doi.org/10.3390/jcm11216241.\u003c/li\u003e\n\u003cli\u003eK. S. Han, G. H. Song, D. You, C. Song, I. G. Jeong, J. H. Hong\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Comparison of Hand-Assisted Laparoscopic vs Robot-Assisted Laparoscopic vs Open Partial Nephrectomy in Patients with T1 Renal Masses,\u0026quot; \u003cem\u003eJ Endourol, \u003c/em\u003evol. 31, pp. 374-379, Apr 2017, https://doi.org/10.1089/end.2014.0517.\u003c/li\u003e\n\u003cli\u003eC. R. Jelley, K. A. Kurukulaarachchi, L. Forster, H. Bardgett, R. Singh, and S. K. Addla, \u0026quot;Comparison of open and robotic nephron sparing surgery: a single centre experience,\u0026quot; \u003cem\u003eJournal of Clinical Urology, \u003c/em\u003evol. 10, pp. 28-35, 2017, https://doi.org/10.1177/2051415816668942.\u003c/li\u003e\n\u003cli\u003eK. Kim, M. Choo, H. Lee, Y. Park, S. Song, and H. Kim, \u0026quot;Comparison of robot-assisted partial nephrectomy and open partial nephrectomy: Clinical outcome and complication analysis,\u0026quot; \u003cem\u003eEuropean Urology Supplements, \u003c/em\u003evol. 1, pp. e32, e32a, 2012, https://doi.org/10.1371/journal.pone.0210413.\u003c/li\u003e\n\u003cli\u003eZ. Klaassen, R. M. Kohut, D. Patel, M. K. Terris, and R. Madi, \u0026quot;A single surgeon\u0026rsquo;s experience with open, laparoscopic, and robotic partial nephrectomy,\u0026quot; \u003cem\u003eInternational scholarly research notices, \u003c/em\u003evol. 2014, 2014, https://doi.org/10.1155/2014/430914\u003c/li\u003e\n\u003cli\u003eK.-F. Kowalewski, D. M\u0026uuml;ller, M. Kirchner, R. Brinster, J. M\u0026uuml;hlbauer, M. A. S. Abate\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Robotic-Assisted Versus Conventional Open Partial Nephrectomy (Robocop): A Propensity Score-Matched Analysis of 249 Patients,\u0026quot; \u003cem\u003eUrologia Internationalis, \u003c/em\u003epp. 1-9, 2021, https://doi.org/10.1159/000513189.\u003c/li\u003e\n\u003cli\u003eK.-F. Kowalewski, M. Neuberger, M. A. Sidoti Abate, M. Kirchner, C. M. Haney, F. Siegel\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Randomized Controlled Feasibility Trial of Robot-assisted Versus Conventional Open Partial Nephrectomy: The ROBOCOP II Study,\u0026quot; \u003cem\u003eEuropean Urology Oncology, \u003c/em\u003e2023/06/12/ 2023, https://doi.org/10.1016/j.euo.2023.05.011.\u003c/li\u003e\n\u003cli\u003eS. Kumar and B. Nayak, \u0026quot;Transition From Open and Laparoscopic to Robotic Partial Nephrectomy: Learning Curve and Outcomes,\u0026quot; \u003cem\u003eCureus, \u003c/em\u003evol. 16, p. e51646, Jan 2024, https://doi.org/10.7759/cureus.51646.\u003c/li\u003e\n\u003cli\u003eC. Lee, T. Kwon, S. Yoo, J. Jung, C. Lee, D. You\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Comparison of renal function between robot-assisted and open partial nephrectomy as determined by Tc 99m-DTPA renal scintigraphy,\u0026quot; \u003cem\u003eJournal of Korean Medical Science, \u003c/em\u003evol. 31, pp. 743-749, 2016, https://doi.org/10.3346/jkms.2016.31.5.743.\u003c/li\u003e\n\u003cli\u003eS. Lee, J. Oh, S. K. Hong, S. E. Lee, and S. S. Byun, \u0026quot;Open versus robot-assisted partial nephrectomy: effect on clinical outcome,\u0026quot; \u003cem\u003eJ Endourol, \u003c/em\u003evol. 25, pp. 1181-5, Jul 2011, https://doi.org/10.1089/end.2010.0670.\u003c/li\u003e\n\u003cli\u003eS. Lee, H. Ryu, and J. W. Lee, \u0026quot;Open Partial Nephrectomy vs. Robot-assisted Partial Nephrectomy for a Renal Tumor Larger than 4 cm: a Propensity Score Matching Analysis,\u0026quot; \u003cem\u003eJ Korean Med Sci, \u003c/em\u003evol. 36, p. e135, May 24 2021, https://doi.org/10.3346/jkms.2021.36.e135.\u003c/li\u003e\n\u003cli\u003eS. M. Lucas, M. J. Mellon, L. Erntsberger, and C. P. Sundaram, \u0026quot;A comparison of robotic, laparoscopic and open partial nephrectomy,\u0026quot; \u003cem\u003eJSLS: Journal of the Society of Laparoendoscopic Surgeons, \u003c/em\u003evol. 16, p. 581, 2012, https://doi.org/10.4293/108680812X13462882737177.\u003c/li\u003e\n\u003cli\u003eL. G. Luciani, S. Chiodini, D. Mattevi, T. Cai, M. Puglisi, W. Mantovani\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Robotic-assisted partial nephrectomy provides better operative outcomes as compared to the laparoscopic and open approaches: results from a prospective cohort study,\u0026quot; \u003cem\u003eJournal of robotic surgery, \u003c/em\u003evol. 11, pp. 333-339, 2017, https://doi.org/10.1007/s11701-016-0660-2.\u003c/li\u003e\n\u003cli\u003eE. Malkoc, D. Ramirez, O. Kara, M. J. Maurice, R. J. Nelson, P. A. Caputo\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Robotic and open partial nephrectomy for localized renal tumors larger than 7 cm: a single-center experience,\u0026quot; \u003cem\u003eWorld journal of urology, \u003c/em\u003evol. 35, pp. 781-787, 2017, https://doi.org/10.1007/s00345-016-1937-9.\u003c/li\u003e\n\u003cli\u003eK. Masoumi-Ravandi, R. J. Mason, and R. A. Rendon, \u0026quot;Robotic-assisted laparoscopic partial nephrectomy vs. laparoscopic and open partial nephrectomy: A single-site, two-surgeon, retrospective cohort study,\u0026quot; \u003cem\u003eCan Urol Assoc J, \u003c/em\u003eApr 2 2024, https://doi.org/10.5489/cuaj.8585.\u003c/li\u003e\n\u003cli\u003eA. Masson-Lecomte, D. R. Yates, V. Hupertan, A. Haertig, E. Chartier-Kastler, M. O. Bitker\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;A prospective comparison of the pathologic and surgical outcomes obtained after elective treatment of renal cell carcinoma by open or robot-assisted partial nephrectomy,\u0026quot; \u003cem\u003eUrol Oncol, \u003c/em\u003evol. 31, pp. 924-9, Aug 2013, https://doi.org/10.1016/j.urolonc.2011.08.004.\u003c/li\u003e\n\u003cli\u003eL. Mearini, E. Nunzi, A. Vianello, M. Di Biase, and M. Porena, \u0026quot;Margin and complication rates in clampless partial nephrectomy: a comparison of open, laparoscopic and robotic surgeries,\u0026quot; \u003cem\u003eJournal of robotic surgery, \u003c/em\u003evol. 10, pp. 135-144, 2016, https://doi.org/10.1007/s11701-016-0584-x.\u003c/li\u003e\n\u003cli\u003eJ. J. Oh, S. Byun, S. K. Hong, C. W. Jeong, and S. E. Lee, \u0026quot;Comparison of robotic and open partial nephrectomy: Single-surgeon matched cohort study,\u0026quot; \u003cem\u003eCanadian Urological Association Journal, \u003c/em\u003evol. 8, p. E471, 2014, https://doi.org/10.5489/cuaj.1679.\u003c/li\u003e\n\u003cli\u003eJ. J. Oh, J. K. Lee, K. Kim, S.-S. Byun, S. E. Lee, and S. K. Hong, \u0026quot;Comparison of the width of peritumoral surgical margin in open and robotic partial nephrectomy: a propensity score matched analysis,\u0026quot; \u003cem\u003ePloS one, \u003c/em\u003evol. 11, p. e0158027, 2016, https://doi.org/10.1371/journal.pone.0158027.\u003c/li\u003e\n\u003cli\u003eR. Saoud, A. El Hajj, M. Shahait, M. Bulbul, R. Nasr, W. Wazzan\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Comparative Analysis of Robotic-Assisted Partial Nephrectomy Versus Open Partial Nephrectomy During the Initial Robotic Learning Curve: Does the End Justify the Means?,\u0026quot; \u003cem\u003eWorld Journal of Nephrology and Urology, \u003c/em\u003evol. 5, pp. 79-82, 2017, https://doi.org/10.14740/wjnu286w.\u003c/li\u003e\n\u003cli\u003eA. Sawada, T. Kobayashi, T. Takahashi, J. Kono, K. Masui, T. Sato\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Comparative analysis of perioperative outcomes between robot-assisted partial nephrectomy and open partial nephrectomy: a propensity-matched study,\u0026quot; \u003cem\u003eMini-invasive Surgery, \u003c/em\u003evol. 5, p. 6, 02/03 2021, https://doi.org/10.20517/2574-1225.2020.100.\u003c/li\u003e\n\u003cli\u003eH. Tachibana, T. Kondo, K. Yoshida, T. Takagi, and K. Tanabe, \u0026quot;Lower Incidence of Postoperative Acute Kidney Injury in Robot-Assisted Partial Nephrectomy Than in Open Partial Nephrectomy: A Propensity Score-Matched Study,\u0026quot; \u003cem\u003eJ Endourol, \u003c/em\u003evol. 34, pp. 754-762, Jul 2020, https://doi.org/10.1089/end.2019.0622.\u003c/li\u003e\n\u003cli\u003eT. Takagi, T. Kondo, H. Tachibana, J. Iizuka, K. Omae, H. Kobayashi\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;A propensity score-matched comparison of surgical precision obtained by using volumetric analysis between robot-assisted laparoscopic and open partial nephrectomy for T1 renal cell carcinoma: a retrospective non-randomized observational study of initial outcomes,\u0026quot; \u003cem\u003eInt Urol Nephrol, \u003c/em\u003evol. 48, pp. 1585-91, Oct 2016, https://doi.org/10.1007/s11255-016-1323-y.\u003c/li\u003e\n\u003cli\u003eK. Takahara, K. Fukaya, T. Nukaya, M. Takenaka, K. Zennami, M. Ichino\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Perioperative and long-term functional outcomes of robot-assisted versus open partial nephrectomy: A single-center retrospective study of a Japanese cohort,\u0026quot; \u003cem\u003eAnn Med Surg (Lond), \u003c/em\u003evol. 75, p. 103482, Mar 2022, https://doi.org/10.1016/j.amsu.2022.103482.\u003c/li\u003e\n\u003cli\u003eJ. L. Tan, M. Frydenberg, J. Grummet, U. Hanegbi, R. Snow, S. Mann\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Comparison of perioperative, renal and oncologic outcomes in robotic‐assisted versus open partial nephrectomy,\u0026quot; \u003cem\u003eANZ journal of surgery, \u003c/em\u003evol. 88, pp. E194-E199, 2018, https://doi.org/10.1111/ans.14154.\u003c/li\u003e\n\u003cli\u003eG. Vittori, \u0026quot;Open versus robotic-assisted partial nephrectomy: a multicenter comparison study of perioperative results and complications,\u0026quot; \u003cem\u003eWorld journal of urology, \u003c/em\u003evol. 32, pp. 287-293, 2014, https://doi.org/10.1007/s00345-013-1136-x.\u003c/li\u003e\n\u003cli\u003eZ. Wu, M. Li, L. Qu, H. Ye, B. Liu, Q. Yang\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;A propensity-score matched comparison of perioperative and early renal functional outcomes of robotic versus open partial nephrectomy,\u0026quot; \u003cem\u003ePloS one, \u003c/em\u003evol. 9, p. e94195, 2014, https://doi.org/10.1371/journal.pone.0094195.\u003c/li\u003e\n\u003cli\u003eY. D. Yu, N. H. Nguyen, H. Y. Ryu, S. K. Hong, S. S. Byun, and S. Lee, \u0026quot;Predictors of renal function after open and robot‐assisted partial nephrectomy: A propensity score‐matched study,\u0026quot; \u003cem\u003eInternational Journal of Urology, \u003c/em\u003evol. 26, pp. 377-384, 2019, https://doi.org/10.1111/iju.13879.\u003c/li\u003e\n\u003cli\u003eP. Zeuschner, L. Greguletz, I. Meyer, J. Linxweiler, M. Janssen, G. Wagenpfeil\u003cem\u003e, et al.\u003c/em\u003e, \u0026quot;Open versus robot-assisted partial nephrectomy: A longitudinal comparison of 880 patients over 10 years,\u0026quot; \u003cem\u003eInt J Med Robot, \u003c/em\u003evol. 17, pp. 1-8, Feb 2021, https://doi.org/10.1002/rcs.2167.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Robot-assisted partial nephrectomy, open partial nephrectomy, surgical precision, Trifecta, complications, surgical margins, ischemia time, renal function, meta-analysis.","lastPublishedDoi":"10.21203/rs.3.rs-5174620/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5174620/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Differential tumor resection efficacy between robotic and open partial nephrectomy has been extensively explored. This study comparatively evaluates the above nephron-sparing approaches focusing on the Trifecta outcome, along with its individual components, as a metric for surgical quality assessment.\u003c/p\u003e\n\u003cp\u003eMethods: A literature review from August 2022 to August 2024 yielded 51 relevant studies. Trifecta attainment served as the primary outcome, while secondary end-points included the incidence of major and minor postoperative complications, positive surgical margin rates, the absolute ischemia duration, as well as the corresponding postoperative alterations in estimated glomerular filtration rate and plasma creatinine levels. Analyses were conducted using random-effects meta-analysis models, with subgroup analyses performed to manage heterogeneity. Additionally, meta-regression was implemented on a temporal and qualitative basis, and sensitivity analysis was carried out on the most statistically robust studies.\u003c/p\u003e\n\u003cp\u003eResults: The robotic approach exhibited clear superiority in overall Trifecta achievement, with odds ratios ranging between 1.3-1.8 and indicating a quasi-constant comparative effect over time. Major and minor complication rates, as defined by the Clavien-Dindo classification, favored robotic surgery, demonstrating odds ratios of 0.5-0.7 and 0.5-0.6, respectively. Specifically, a consistent to increasing trend of advantage was observed for severe complications over time and across qualitative measures. Conversely, a stable and significant benefit was noted for mild complications on the chronological scale. The robotic intervention also significantly impacted the estimated glomerular filtration rate, preserving an additional 2-3 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e postoperatively compared to open surgery. However, this finding was considered of limited clinical importance due to the low magnitude of the effect. Ischemic times and positive surgical margin rates did not significantly differ between the two approaches. Finally, the findings regarding the postoperative increase in serum creatinine levels from baseline were inconclusive, with neither modality demonstrating superiority over the other.\u003c/p\u003e\n\u003cp\u003eConclusion: Robotic partial nephrectomy surpasses open surgery in Trifecta attainment and in mitigating major and minor complications. However, the clinical significance of renal function preservation is marginal and requires further prospective investigation.\u003c/p\u003e","manuscriptTitle":"Comparative investigation of therapeutic efficacy in tumor resection between robotic and open partial nephrectomy: A meta-analysis supplemented by time-series and quality-based meta-regression","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-28 15:35:38","doi":"10.21203/rs.3.rs-5174620/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ccb0e16e-415f-48dc-be2a-b1634574b187","owner":[],"postedDate":"November 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-28T15:35:38+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-28 15:35:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5174620","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5174620","identity":"rs-5174620","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}