Background: With increasing acceptance of robotic partial nephrectomy over the last decade, there is an ongoing discussion about the transperitoneal versus retroperitoneal access.

Objective: To report outcomes after transperitoneal (TRPN) versus retroperitoneal (RRPN) robotic partial nephrectomy.

Design, setting, and participants: A total of 754 patients were identified from the databases of three high-volume centers who underwent either TRPN (n = 551) or RRPN (n = 203).

Outcome measurements and statistical analysis: Perioperative data were evaluated retrospectively. A propensity score matched-pair analysis was performed with the following variables: grade of renal insufficiency, age, body mass index, tumor diameter, and preoperative aspects and dimensions used for an anatomical (PADUA) score with a subsequent subgroup analysis for tumor location. For quality outcomes, the margin, ischemia, and complications (MIC) criteria were used (negative margins, ischemia time <20 min, and no major complications). Statistical analyses included chi-square and Mann-Whitney U tests.

Results and limitations: In all, 176 patients could be matched in each group. The median tumor diameter was 28 mm with a PADUA score of 9. In 11% of RRPN versus 44% of TRPN cases, an anterior tumor location was found, and in 55% versus 30%, a posterior lesion was found (p < 0.001). Operative time (119 vs 139 min, p < 0.001) and warm ischemia time (9 vs 10 min, p = 0.003) were significantly shorter for RRPN. No significant differences were observed between intra- and postoperative complication rates, with 8% major complications in TRPN versus 3% in RRPN (p = 0.06). The MIC criteria were achieved in 90% in the RRPN versus 88% in the TRPN group, without differences for tumor location.

Conclusions: Significant differences between TRPN and RRPN could be found for intraoperative time, while complication rates and quality outcomes were comparable. RRPN can also be a considerable alternative for anterior tumors.

Patient summary: In this study, we demonstrate that robotic partial nephrectomy is feasible with either a transperitoneal or a retroperitoneal surgical access. The posterior approach can also be used for anterior renal tumors and may result in shorter operative time.