Comparison of Perioperative Outcomes Between Transperitoneal and Retroperitoneal Approaches for Robot‐Assisted Partial Nephrectomy by Tumor Locations

ABSTRACT Introduction Robot‐assisted partial nephrectomy is a common surgical technique for the management of small renal tumors and has extended its utility to challenging cases, including large or complex tumors. However, no previous reports have compared the surgical outcomes of the retroperitoneal and transperitoneal approaches for different renal tumor sites. We aimed to compare the perioperative outcomes between these approaches in robot‐assisted partial nephrectomy based on tumor location. Methods Perioperative outcomes were systematically analyzed in 380 robot‐assisted partial nephrectomy procedures performed at our institution between February 2015 and April 2023. Transperitoneal for anterior and retroperitoneal for posterior cases were defined as typical cases, whereas transperitoneal for posterior/lateral cases and retroperitoneal for anterior/lateral cases were defined as atypical. Case and patient characteristics were recorded and used for propensity score matching. Results The overall distribution of the transperitoneal/retroperitoneal cases was 154/226. After matching, 37 anterior, 15 posterior, 26 lateral, 89 typical, and 39 atypical cases were identified. The retroperitoneal approach was superior to transperitoneal in terms of console time and trifecta achievement rate in the overall patient; retroperitoneal was superior in terms of operative time, console time, and trifecta achievement in atypical cases. In atypical cases of the retroperitoneal approach, a history of abdominal surgery and renal anatomy were the predominant determinants of approach selection. Posterior tumors located in the renal hilum, which protruded not dorsally but ventrally into the renal sinus, were a common reason to select the transperitoneal approach in atypical cases. Conclusion The retroperitoneal approach achieves shorter console times in any location except for anterior hilar tumors. Both approaches are safe and feasible.