Percutaneous thermal ablation versus robot-assisted partial nephrectomy for localized renal cell carcinoma: a systematic review and meta-analysis stratified by tumor complexity.

Robot-assisted partial nephrectomy (RAPN) and percutaneous thermal ablation (PTA) are established treatment options for localized renal tumors. While RAPN remains the standard-of-care, PTA is increasingly adopted, particularly in patients unfit for surgery. Evidence on how tumor complexity influences comparative outcomes between these two approaches remains limited. We conducted a systematic review of major database up to December 2025 and meta-analysis. Studies directly comparing PTA and RAPN in patients with localized Renal Cell Carcinoma (RCC) were included. Outcomes of interest included local recurrence (LR), recurrence-free survival (RFS), metastasis-free survival (MFS), cancer-specific survival (CSS), overall survival (OS), estimated glomerular filtration rate (eGFR) variation, and complication rates (overall and Clavien-Dindo ≥ III). When feasible, subgroup analyses were performed according to tumor complexity (RENAL ≥ 7 or PADUA ≥ 8). Seventeen studies encompassing 2516 patients met the inclusion criteria. Patients undergoing PTA were older with higher comorbidity burden than those treated with RAPN. Primary technical failure of the first PTA session occurred in approximately 10.9% of cases. Compared with RAPN, PTA was associated with a significantly higher rate of local recurrence (pooled logRR 0.97, 95%CI 0.65, 1.28) and this finding persisted in intermediate-high complexity tumors (logRR 1.09, 95%CI 0.74, 1.44). RAPN was associated with a significantly lower hazard of recurrence (pooled logHR - 0.92; 95%CI -1.29 to -0.56), whereas the difference did not reach significance in the intermediate-high complexity subgroup (pooled logHR - 0.75; 95%CI -1.6 to 0.1). No significant differences were observed in major complications or short- and long-term eGFR variation between techniques. No significant between-group differences were found for metastatic progression, CSS, or OS. RAPN offers superior local tumor control compared to PTA, including in anatomically complex renal lesions, without an associated increase in major complications or deterioration of renal function. Long-term survival outcomes appear comparable. PTA remains an appropriate therapeutic option for carefully selected high-risk patients. However, the higher local recurrence rate and the requirement for rigorous post-treatment surveillance should be carefully considered within the context of shared decision-making.