Background: Partial nephrectomy (PN) has a non-negligible perioperative morbidity. Comparative evidence of the available surgical techniques is limited. Objective: To compare the perioperative outcomes of open, laparoscopic, and robotic PN. Methods: Data of 2331 patients treated with PN for cT1 renal tumors were extracted from the RECORd2 database, a prospective multicenter project. Multivariable regression models assessed the relationship between surgical technique and surgical margins, warm ischemia time, postoperative complications, and acute kidney injury (AKI). The probability of achieving a modified trifecta (negative margins, warm ischemia time <25 min, and no Clavien–Dindo ≥2 complications) was examined for each surgical approach. Results: Minimally invasive techniques had lower rate of Clavien–Dindo ≥2 complications than that of open surgery (odds ratio [OR] for robotic surgery: 0.27; 95% confidence interval [95% CI]: 0.15–0.47, p < 0.0001; OR for laparoscopy: 0.52; 95% CI: 0.34–0.78; p = 0.002). The probability of receiving ischemia was highest for robotic PN (p < 0.001). Among on-clamp PN, laparoscopy had longer ischemia than open (estimate: 1.09; 95% CI: –0.00 to 2.18; p = 0.050) and robotic (estimate: 1.36; 95% CI: 0.31–2.40; p = 0.011) surgery. When compared with open PN, the risk of AKI was roughly halved for patients treated by robotic and laparoscopic surgery (both p < 0.0001). Positive margins rate did not differ between the groups (all p ≥ 0.1). The likelihood to achieve a modified trifecta was not affected by surgical technique in the overall population (all p ≥ 0.075). In Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score < 10 lesions, robotic surgery had higher probability of achieving a modified trifecta than open PN (OR: 1.66; 95% CI: 1.09–2.53; p = 0.018) and laparoscopy (OR: 1.34; 95% CI: 0.94–1.90; p = 0.11). Conclusions: In PADUA < 10 renal tumors, robotic PN allows for higher rates of trifecta than open and laparoscopic surgeries. The impact of surgical technique on perioperative outcomes of PN might be limited in more complex lesions. Patient summary: We evaluated the association between surgical technique and perioperative outcomes of partial nephrectomy. In less complex (Preoperative Aspects and Dimensions Used for an Anatomical [PADUA] score < 10) lesions, robotic PN allows for higher rates of trifecta when compared with other surgical techniques.
