However, the comparative value of these strategies becomes more difficult to interpret when tumor complexity increases. Anatomical complexity, commonly assessed using nephrometry systems such as the RENAL and PADUA scores, may influence technical feasibility, complication risk, local tumor control, and functional outcomes.4,5 Despite the growing use of both RAPN and PTA in contemporary practice, evidence directly comparing these approaches according to tumor complexity has remained limited.
In our systematic review and meta-analysis, we included 17 comparative studies comprising 2,516 patients treated with either PTA or RAPN for localized RCC.1 A distinctive feature of our analysis was the attempt to stratify outcomes according to anatomical tumor complexity, thereby addressing a clinically relevant question: does increasing complexity modify the relative performance of ablative and robotic nephron-sparing approaches?
The principal finding of our study was that RAPN provides superior local tumor control compared with PTA. Patients treated with PTA experienced a significantly higher risk of local recurrence, and this signal persisted in the subgroup of intermediate- to high-complexity renal masses.1 This observation is clinically and technically plausible. While PTA relies on accurate imaging-based targeting and adequate thermal coverage of the tumor and its margins, RAPN allows direct tumor excision, pathological assessment, and more precise management of complex anatomical relationships.
At the same time, despite the higher rate of local recurrence, we did not observe significant differences between PTA and RAPN in metastatic progression, cancer-specific survival, overall survival, major complications, or long-term renal functional outcomes.1 This distinction is clinically relevant. Local recurrence and survival are not synonymous endpoints, particularly in the setting of small renal masses, where competing mortality risks, surveillance intensity, and salvage treatment options may substantially influence long-term outcomes.
This is particularly relevant for patients with advanced age, relevant comorbidity burden, solitary kidneys, chronic kidney disease, or limited surgical fitness. In such patients, PTA may still represent an appropriate and rational treatment strategy, provided that the higher risk of local recurrence is clearly discussed and that structured post-treatment surveillance is ensured. In other words, PTA should not be viewed simply as an inferior alternative, but rather as a treatment whose value depends strongly on patient selection and clinical context.
Another relevant message from our analysis is that the presumed functional and morbidity advantage of PTA over RAPN may be less pronounced than traditionally expected. Although PTA is less invasive and avoids renal ischemia, pooled data did not demonstrate significant differences in major complications or renal functional preservation.1 This likely reflects the maturity of robotic surgery, improved perioperative care, and increasing experience in the management of complex renal masses using minimally invasive nephron-sparing techniques.6
Nevertheless, several limitations must be acknowledged. Most available evidence derives from retrospective comparative studies, with inherent selection bias. Patients undergoing PTA were generally older and more comorbid than those treated with RAPN. Moreover, definitions of technical success, recurrence, follow-up schedules, and reporting of complications varied across studies. These limitations reinforce the need for prospective comparative datasets, standardized outcome definitions, and more robust adjustment for patient frailty, renal functional reserve, and operator experience.
Future research should move beyond binary comparisons between surgery and ablation. The optimal management of localized RCC will increasingly depend on individualized risk prediction models integrating anatomical complexity, tumor biology, patient frailty, renal function, life expectancy, and patient preference. Advanced imaging, artificial intelligence-based decision tools, and multidisciplinary tumor boards may further refine patient selection and improve shared decision-making.
In conclusion, RAPN remains the treatment associated with the most reliable local oncological control for localized RCC, including anatomically complex renal masses. However, PTA retains an important role in carefully selected patients, particularly when procedural invasiveness and competing clinical risks outweigh the incremental benefit of maximal local control. The central challenge is therefore not to identify a universally superior treatment, but to select the most appropriate treatment for the right patient, at the right time, within a transparent and evidence-based shared decision-making framework.
Written by: Federico Zorzi,1 Antonio Amodeo,2 Angelo Porreca,3 and Francesco Claps2
- Department of Urology, Tenon Hôpital, Paris (France)
- Oncological Urology, Veneto Institute of Oncology IRCCS, Padua (Italy)
- Department of Urology, Humanitas Gavazzeni, Bergamo (Italy)
- Zorzi F, Amodeo A, Moretto S, et al. Percutaneous thermal ablation versus robot-assisted partial nephrectomy for localized renal cell carcinoma: a systematic review and meta-analysis stratified by tumor complexity. J Robot Surg. 2026;20:569. doi:10.1007/s11701-026-03442-1. PMID: 42223755.
- Ljungberg B, Albiges L, Abu-Ghanem Y, et al. European Association of Urology Guidelines on Renal Cell Carcinoma: The 2022 Update. Eur Urol. 2022;82(4):399-410.
- Campbell S, Uzzo RG, Allaf ME, et al. Renal mass and localized renal cancer: AUA guideline. J Urol. 2017;198(3):520-529.
- Kutikov A, Uzzo RG. The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth. J Urol. 2009;182(3):844-853.
- Ficarra V, Novara G, Secco S, et al. Preoperative aspects and dimensions used for an anatomical classification of renal tumours in patients who are candidates for nephron-sparing surgery. Eur Urol. 2009;56(5):786-793.
- Leow JJ, Heah NH, Chang SL, Chong YL, Png KS. Outcomes of robotic versus laparoscopic partial nephrectomy: an updated meta-analysis of 4,919 patients. J Urol. 2016;196(5):1371-1377.