Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location Research Articles

RPN (Radius, Position of tumour, iNvasion of renal sinus) Classification and Nephrometry Scoring System: An Internationally Developed Clinical Classification To Describe the Surgical Difficulty for Renal Masses for Which Robotic Partial Nephrectomy Is Planned

BackgroundThe surgical difficulty of partial nephrectomy (PN) varies depending on the operative approach. Existing nephrometry classifications for assessment of surgical difficulty are not specific to the robotic approach. ObjectiveTo develop an international robotic-specific classification of renal masses for preoperative assessment of surgical difficulty of robotic PN. Design, setting, and participantsThe RPN classification (Radius, Position of tumour, iNvasion of renal sinus) considers three parameters: tumour size, tumour position, and invasion of the renal sinus. In an international survey, 45 experienced robotic surgeons independently reviewed de-identified computed tomography images of 144 patients with renal tumours to assess surgical difficulty of robot-assisted PN using a 10-point Likert scale. A separate data set of 248 patients was used for external validation. Outcome measurements and statistical analysisMultiple linear regression was conducted and a risk score was developed after rounding the regression coefficients. The RPN classification was correlated with the surgical difficulty score derived from the international survey. External validation was performed using a retrospective cohort of 248 patients. RPN classification was also compared with the RENAL (Radius; Exophytic/endophytic; Nearness; Anterior/posterior; Location), PADUA (Preoperative Aspects and Dimensions Used for Anatomic), and SPARE (Simplified PADUA REnal) scoring systems. Results and limitationThe median tumour size was 38 mm (interquartile range 27–49). The majority (81%) of renal tumours were peripheral, followed by hilar (12%) and central (7.6%) locations. Noninvasive and semi-invasive tumours accounted for 37% each, and 26% of the tumours were invasive. The mean surgical difficulty score was 5.2 (standard deviation 1.9). Linear regression analysis indicated that the RPN classification correlated very well with the surgical difficulty score (R2 = 0.80). The R2 values for the other scoring systems were: 0.66 for RENAL, 0.75 for PADUA, and 0.70 for SPARE. In an external validation cohort, the performance of all four classification systems in predicting perioperative outcomes was similar, with low R2 values. ConclusionsThe proposed RPN classification is the first nephrometry system to assess the surgical difficulty of renal masses for which robot-assisted PN is planned, and is a useful tool to assist in surgical planning, training and data reporting. Patient summaryWe describe a simple classification system to help urologists in preoperative assessment of the difficulty of robotic surgery for partial kidney removal for kidney tumours.

Roughness of the renal tumor surface could predict the surgical difficulty of robot-assisted partial nephrectomy.

IntroductionPreoperative prediction of surgical difficulty of partial nephrectomy (PN) is essential to minimize the perioperative complications and to achieve a good surgical outcome. Recently, various scoring systems have been used to evaluate the difficulty of PN including R.E.N.A.L (Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location) nephrometry score. There were no scoring systems evaluating the roughness of the renal tumor surface and we hypothesized that the roughness of the renal tumor surface might affect the surgical difficulty of robot‐assisted partial nephrectomy (RAPN). This study aimed to evaluate the impact of roughness of the renal tumor surface on the surgical outcome of RAPN.MethodsOverall, 161 patients underwent RAPN performed by the same surgeon between May 2016 and April 2019. We divided those tumors into two groups, like “roughness positive (tumor with roughness of tumor surface)” and “roughness negative (tumor without roughness of tumor surface)” according to the roughness of the endophytic region on preoperative computed tomography images. Clinical and pathological outcomes were compared between the two groups.ResultsEighty‐five and 78 tumors were identified roughness negative and positive, respectively. Cases with roughness positive showed a significantly longer operative time, console time, and ischemia time and had greater blood loss than those with roughness negative. Significant and independent predictors of ischemia time and estimated glomerular filtration rate (eGFR) decrease were roughness of tumor surface, tumor size (not for eGFR decrease), and N score of the R.E.N.A.L nephrometry score.ConclusionRoughness of renal tumor surface was significantly and positively associated with ischemia time and the eGFR decrease rate.

Clampless Laparoscopic Tumor Enucleation for Exophytic Masses Greater Than 4 cm: Is Renorrhaphy Necessary?

Objective: To demonstrate the safety of clampless 3D laparoscopic tumor enucleation (cLTE) for exophytic T1b kidney masses, avoiding suture to achieve hemostasis. Methods: Between January 2010 and January 2021, 241 consecutive patients with an exophytic renal tumor underwent sutureless cLTE. Patients with predominantly endophytic growth or tumors 4 mm closer to the collecting system less were excluded. In all cases, an attempt was made to accomplish surgery without suturing kidney parenchyma. Data were obtained from a retrospective review of history and physical examinations, operative and pathology reports, anesthesia records during the hospital stay, and follow-up visits. Results: Among 241 patients who underwent cLTE, 148 had cT1a and 93 had cT1b renal tumor. The median tumor size was 32 mm, and the median R.E.N.A.L. (radius exophytic/endophytic nearness anterior/posterior location) score was 6. Renorrhaphy was necessary in 5 cases. The median operative time (OT) was 100 minutes, and the estimated blood loss (EBL) was 150 mL. The median 24-hour decrease in hemoglobin was 1.8 g/dL. The median length of stay was 4 days. Nineteen patients had postoperative complications: 3 cases had Clavien-Dindo (CD) 3a or more, 6 had CD2, and 10 had CD1. Comparing the T1a and T1b groups, except for the median OT and the EBL, no significant differences were observed in all the other variables analyzed. In both groups, renal function was preserved after 1 year from surgery. Conclusion: Our experience showed that sutureless cLTE is safe and feasible for T1b tumors leading to radical oncological outcomes and preserving renal function.

Predicting Strict Trifecta Outcomes after Robot-Assisted Partial Nephrectomy: Comparison of RENAL, PADUA, and C-Index Scores.

Nephrometry scores are designed to characterize tumors and stratify the surgical complexity. It remains unclear as to which nephrometry score can accurately predict the surgical outcomes. We aimed to assess the utility of radius, exophytic/endophytic, nearness, anterior/posterior, location (RENAL), preoperative aspects and dimensions used for anatomic classifications (PADUA), and centrality index (C-index) nephrometry scores for predicting the strict Trifecta achievement from a single institution series robotic-assisted partial nephrectomy (RAPN). We retrospectively identified the prospectively maintained robotic surgery database records of 91 patients who underwent RAPN between June 2015 and September 2020 in Antalya Training and Research Hospital. The main outcome of the study was the achievement of strict Trifecta (negative surgical margin, no major urologic complications, warm ischemia time ≤25 min, and ≥85% preservation of estimated glomerular filtration rate). A multivariable analysis was performed to identify the factors of strict Trifecta success. The mean patient age was 55.82 ± 13.37 years with a median clinical tumor size of 3.5 cm (IQR 2.5–4.9). The median RENAL, PADUA, and C-index score were 7(IQR 6–8), 8(IQR 7–10), and 2.01(IQR 1.64–2.72), respectively. A strict Trifecta could be achieved in 54 patients (59.3%). Clinical tumor size (P = 0.011), RENAL risk groups (low:reference; intermediate; P = 0.040; high; P = 0.009), PADUA risk groups (low:reference; intermediate; P = 0.044; high; P = 0.001) and C-index risk groups (low:reference; high; P = 0.015) were the independent predictors of strict Trifecta attainment in the multivariate analysis. None of the nephrometry scores were a superior predictor compared to other nephrometry scores in comparative analysis. RENAL, PADUA, and C-index scores were all independent predictors of a strict Trifecta achievement. Our comprehensive comparison of the three scores identified that none of the nephrometry scores proved to be inferior to others nephrometry scores.

Diagnostic renal mass biopsy is associated with individual categories of PADUA and RENAL nephrometry scores: Analysis of diagnostic and concordance rates with surgical resection

BackgroundRenal mass biopsy (RMB) is a safe and accurate method for diagnosis and clinical management of renal masses. However, the non-diagnostic rate is a limiting factor. We tested the hypothesis that imaging characteristics and anatomic complexity of the mass may impact RMB diagnostic outcome using the preoperative aspects and dimensions used for an anatomical (PADUA) classification and radius-exophytic/endophytic-nearness-anterior/posterior-location (RENAL) score. Material and methodsSingle institution, retrospective study of 490 renal masses from 443 patients collected from 2001 to 2018. Outcome measurements include (1) diagnostic and concordance rates amongst RMB types and RMB with surgical resection specimens; (2) association between diagnostic RMB and anatomical complexity of renal masses. The analysis was conducted in unselected masses and small renal masses (SRMs). ResultsRMB was performed by fine needle aspiration (FNA), core needle biopsy (CNB), or both (FNA+CNB). Non-diagnostic rate was significantly higher for FNA compared to CNB and FNA+CNB in both unselected and SRMs. Subset analysis in the FNA+CNB group showed similar diagnostic rates for FNA and CNB. In unselected masses, specificity for FNA, CNB, and FNA+CNB was 100%. Sensitivity was higher for CNB (90.1%, P = 0.002) and FNA+CNB (96.3%, P = 0.004) compared to FNA (66.7%). For unselected masses, endophytic growth predicted a non-diagnostic CNB. R.E.N.A.L location entirely between the polar lines (central) and entirely above the upper polar line predicted a diagnostic CNB. Sonography-guidance predicted a diagnostic FNA. For SRMs, non-diagnostic CNB was associated with endophytic growth, while diagnostic CNB was associated with renal sinus invasion and operator experience. More cystic masses were sampled by FNA, but diagnostic results were similar for FNA and CNB. ConclusionsEndophytic growth consistently predicted a non-diagnostic CNB in unselected and SRMs, whereas sonography-guidance predicted a diagnostic FNA. Cystic masses could be adequately sampled by FNA.

The associations of RENAL, PADUA and C-index nephrometry scores with perioperative outcomes and postoperative renal function in minimally invasive partial nephrectomy.

This study aimed to assess the utility of the radius, exophytic/endophytic, nearness, anterior/posterior, location (RENAL); preoperative aspects and dimensions used for an anatomic evaluation (PADUA), and centrality index (C-index) scores for the outcomes of partial nephrectomy (PN). The patients who underwent PN with contrast-enhanced preoperative imaging from January 2015 to June 2018 were identified. The RENAL, PADUA, and C-index scores were assigned. The correlation between these scoring systems and perioperative and long-term renal functional outcomes were evaluated. A total of 78 patients were included in the study (58 men and 20 women; age, 58±11.4 years). Median warm ischemia time (WIT), estimated blood loss (EBL), and operation time (OT) were 26 min, 115 mL, and 140 min, respectively. The RENAL score was related to WIT, EBL, and OT (p<0.001, p=0.003, and p=0.023, respectively). The PADUA score was associated with WIT, EBL, and OT (p<0.001, p=0.013, and p=0.005, respectively). The C-index score was correlated with WIT, EBL, and OT (p<0.001, p=0.010, and p=0.001, respectively). The C-index score also correlated with the percentage change in the estimated glomerular filtration rate (p=0.037). However, on univariable and multivariable regression analyses, only WIT significantly affected the postoperative estimated glomerular filtration rate reduction. The RENAL, PADUA, and C-index scores were significantly associated with perioperative outcomes of PN. In addition, the C-index score was correlated with long-term renal functional outcomes.

Multi-institutional Retrospective Validation and Comparison of the Simplified PADUA REnal Nephrometry System for the Prediction of Surgical Success of Robot-assisted Partial Nephrectomy

BackgroundThe use of a nephron-sparing surgery for the treatment of localized renal masses is being pushed to more challenging cases. However, this procedure is not devoid of risks, and the Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location (RENAL) and Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classifications are commonly employed in the prediction of complications. Recently, the Simplified PADUA REnal (SPARE) scoring system has been proposed with the aim to provide a more simple system, to improve its reproducibility to predict postoperative risks. ObjectiveWe aim to retrospectively validate and compare the proposed new SPARE system in a multi-institutional population. Design, setting, and participantsThe Transatlantic Robotic Nephron-sparing Surgery (TRoNeS) study group collected data from 737 patients subjected to robot-assisted partial nephrectomy (RAPN) between 2010 and 2016 at three tertiary care referral centers. Of these patients, 536 presented complete demographic and clinical data. Outcome measurements and statistical analysisRenal masses were classified according to the SPARE, RENAL, and PADUA nephrometry scores, and surgical success was defined according to the margin, ischemia, and complication scores. Results and limitationsOf 536 patients, 340 were male; the median age was 61 (53–69) yr and preoperative tumor size was 30 (22–43) mm. The margin, ischemia, and complication score was achieved in 399 of cases (74.4%). All three nephrometry scores were significant predictors of surgical outcomes both in univariate and in adjusted multivariate logistic regression model analysis. In accuracy analysis, the area under the curve (AUC) of the SPARE scoring system (0.73) was significantly higher than those of the PADUA (0.65) and RENAL (0.68) nephrometry scores in predicting surgical success. ConclusionsThe SPARE score appears to be a promising and reliable score for the prediction of surgical outcomes of RAPN, showing a higher accuracy relative to the traditional PADUA and RENAL nephrometry scores. Further, prospective studies are warranted before its introduction in clinical practice. Patient summaryThe Simplified PADUA REnal (SPARE) score is a reproducible and simple nephrometry score, offering better predictive capabilities of surgical success and complications.

Personalised three-dimensional printed transparent kidney model for robot-assisted partial nephrectomy in patients with complex renal tumours (R.E.N.A.L. nephrometry score ≥7): a prospective case-matched study.

To evaluate the effectiveness of a three-dimensional (3D) printed transparent kidney model as a surgical navigator for robot-assisted partial nephrectomy (RPN) in patients with complex renal tumours, defined by a R.E.N.A.L. (Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location) nephrometry score of ≥7. A total of 80 patients who underwent RPN were included in the present prospective case-matched study (case group [n=40, application of 3D-printed transparent kidney model during RPN] vs matching group [n=40, routine protocol]). The RPNs were performed by a single experienced surgeon. The RPN procedure consisted of six steps: (i) preparation of the renal hilar vessel for clamping, (ii) tumour detection and dissection, (iii) robotic ultrasonography, (iv) tumour resection, (v) calyx repair and haemostasis, and (vi) renorrhaphy. The time for each step, console time, and warm ischaemia time were compared between the two groups as a surrogate marker for surgical effectiveness. Both groups were well-balanced for all baseline characteristics. The use of the model reduced the console time by ~20% compared to the matched group (64.6 vs 78.5min, P=0.001). On multivariate logistic regression analysis, tumour radius (P<0.001) and application of the model (P=0.009) were identified as significant predictors of a console time of ≤70min. We established the usefulness of a personalised 3D-printed transparent kidney model for more effective RPNs. Use of the 3D-printed transparent kidney model reduced the operative time even for complex renal tumours and would be expected to broaden the indications for PN.

Percutaneous microwave ablation of renal masses in a UK cohort.

To report a tertiary referral centre's experience of microwave ablation (MWA) for suspected renal cell carcinoma (RCC), describing complications and oncological outcomes. Consecutive MWA procedures (n=113) for renal masses (October 2016 to September 2019) were maintained on a prospective database. Data describing patient, disease, procedure, complications, and oncological outcomes were analysed. The median (range) age was 68 (33-85)years, 73% were male, and the median Charlson Comorbidity Index was 0. The median (interquartile range [IQR]) tumour diameter was 25(20-32)mm. In all, 95% had renal mass biopsy, with histologically confirmed cancer in 75%. The median (IQR) R.E.N.A.L. (Radius, Exophytic/Endophytic, Nearness, Anterior/Posterior, Location) nephrometry score was 7(6-8). The median ablation time was 6min and length of stay was 1day for 95% of the patients. Clavien-Dindo complication Grades I, II, IIIb and IV occurred in 18%, 1.8%, 0.9% and 0.9%, respectively. The median follow-up was 12months and the median (IQR) renal function change was -4(-18 to 0)%. One patient (0.9%) had local recurrence, treated with re-ablation; two developed metastatic progression; and two (1.8%) had indeterminate findings on follow-up (one lung nodule and one possible local recurrence), managed with ongoing protocolised computed tomography surveillance. Post-procedure complications were associated with total ablation time (odds ratio [OR] 1.152/min, 95% confidence interval [CI] 1.040-1.277) and total ablation energy (OR 1.017/kJ, 95% CI 1.001-1.033). We describe the largest UK series of MWA treatment for T1a/small T1b renal masses to date. MWA was well tolerated, with 95% discharged the following day and low complication/re-admission rates. Current follow-up demonstrates favourable disease control. MWA appears to be safe and effective and should be considered in future prospective comparisons of treatments for T1a/small T1b renal masses.

Do patients with Stage 3-5 chronic kidney disease benefit from ischaemia-sparing techniques during partial nephrectomy?

To analyse whether selective arterial clamping (SAC) and off-clamp (OC) techniques during robot-assisted partial nephrectomy (RPN) are associated with a renal functional benefit in patients with Stage 3-5 chronic kidney disease (CKD). The change in estimated glomerular filtration rate (eGFR) over time was compared between 462 patients with baseline CKD 3-5 that underwent RPN with main arterial clamping (MAC) (n=375, 81.2%), SAC (n=48, 10.4%) or OC (n=39, 8.4%) using a multivariable linear mixed-effects model. All follow-up eGFRs, including baseline and follow-up between 3 and 24months, were included in the model for analysis. The median follow-up was 12.0months (interquartile range 6.7-16.5; range 3.0-24.0months). In the multivariable linear mixed-effects model adjusting for characteristics including tumour size and the R.E.N.A.L. (Radius; Exophytic/Endophytic; Nearness; Anterior/Posterior; Location) Nephrometry Score, the change in eGFR over time was not significantly different between SAC and MAC RPN (β=-1.20, 95% confidence interval [CI] -5.45, 3.06; P=0.582) and OC and MAC RPN (β=-1.57, 95% CI -5.21, 2.08; P=0.400). Only 20 (15 MAC, two SAC, three OC) patients overall had progression of their CKD stage at last follow-up. The mean ischaemia time was 17min for MAC and 15min for SAC. There was no benefit to SAC or OC in terms of blood loss, perioperative complications, length of stay, or surgical margins. SAC and OC techniques during RPN were not associated with benefit in preservation of eGFR in patients with baseline CKD.

Validation of radius exophytic/endophytic nearness anterior/posterior location and preoperative aspects and dimensions used for an anatomical nephrometric scores in patients undergoing partial nephrectomy for renal cancer: A single-center experience and literature review.

Introduction:Nephrometric scores are used to predict perioperative and postoperative complications, with no uniform results in the current literature.Materials and Methods:A retrospective study of 141 patients in a single center who underwent open partial nephrectomy between June 2006 and 2016 for T1a and T1b renal tumor was conducted. Univariate and multivariate analyses were used to evaluate the correlations between preoperative aspects and dimensions used for an anatomical (PADUA) and radius exophytic/endophytic nearness anterior/posterior location (RENAL) scores and their components with pre-, peri-, and post-operative parameters. Linear regression (F-tests) and logical regression models were used to test for significance of the association and predictability of outcomes.Results:Total RENAL score (P = 0.032), its components R (P = 0.004), E (P = 0.022), L (P = 0.011), and total PADUA score (P = 0.016) were significantly associated with ischemic time. In postoperative complications, the PADUA components: sinus line location (P = 0.008), lateral/medial rim score (P = 0.029), and collecting system score (P = 0.006) showed significance. None of the variables showed correlation with operation time and change in estimated glomerular filtration rate (eGFR). On multivariate analysis, sinus line location and gender (P = 0.012) showed significance in predicting eGFR changes and RENAL score component: A (P = 0.049) was significant in predicting estimated blood loss. Both RENAL and PADUA components were significantly associated with hospital length of stay.Conclusion:Both RENAL and PADUA scores showed important correlation in predicting outcomes. We further demonstrated the importance of knowing the individual components of the scores, which can independently give outcome predictions. The scoring systems can still be improved and standardized for broad clinical use with larger cohort and multicenter-based studies.

Preoperative scoring systems used in retroperitoneoscopic partial nephrectomy for T1-T2 renal tumors

Introduction. P.A.D.U.A. (The preoperative aspects and dimensions used for anatomic), R.E.N.A.L. (radius exophytic/endophytic nearness anterior/posterior location) and zonal NePhRO scoring were developed in an effort to predict the intraoperative (warm time ischemia, blood loss) and postoperative complications in patients undergoing partial nephrectomy, with an important role on surgical decision-making (2-4). Materials and methods. Between January 2014 and July 2017, 37 patients(p) underwent retroperitoneoscopic nephro-sparing surgery at our center for clinically localized renal tumor. All patients had a normal contralateral kidney. The selection of patients for nephro-sparing surgery was based on preoperative CT scan, location of the tumor, the individual general health status of the patient and individual surgeon preferences. A chart review was carried out, including age, sex, anatomic preoperative scoring system (P.A.D.U.A., R.E.N.A.L. nephrometry and zonal NePhRO), operative time (skin opening to skin closing), estimated blood loss (EBL), warm ischemia time (WIT), hospital stay. Results. The mean age of patients with partial nephrectomy was 54.3±9.1 years. Mean preoperative serum creatinine level for the patient group was 0.97±0.14 mg/dl. All patients had normal contralateral kidney. Average tumor diameter in this group was 3.6± 0.86 cm. When using P.A.D.U.A. score to predict warm time ischemia p value was of 0.001, even if the mean warm ischemia time is higher in medium risk patients than in high risk patients 24.3 min vs. 23.2 min. R.E.N.A.L. nephrometry score was able to predict the warm ischemia time according to the risk groups (17.6 vs. 23.9 vs. 31 min) with a p value under 0.001. Zonal NePhRO score was statistically correlated with total operative time, blood loss, warm ischemia and renal function decrease, all with a p value &lt; 0.05. Conclusion. P.A.D.U.A. score, R.E.N.A.L. nephrometry score and Zonal NePhRO score have proved to be reliable preoperative tools in order to evaluate surgical complexity and to predict outcomes such as warm time ischemia, blood loss, postoperative estimated GFR and complications rate.

Surgery-related outcomes and postoperative split renal function by scintigraphy evaluation in robot-assisted partial nephrectomy in complex renal tumors: an initial case series.

To assess surgery-related outcomes and split renal function evaluated by renal scintigraphy in robot-assisted partial nephrectomy (RPN) through the comparison between low and intermediate or highly complex renal tumors. In the initial 39 consecutive RPNs performed for solid renal tumors in our hospital, tumors were categorized for their complexity (low, intermediate, and high risk for partial nephrectomy) by R.E.N.A.L. (radius; exophytic/endophytic; nearness; anterior/posterior; location) nephrometry and P.A.D.U.A. (preoperative aspects and dimensions used for an anatomic) scores. The comparison between low, intermediate, and highly complex tumors according to these scoring systems were performed regarding preoperative factors, surgery-related factors, and postoperative renal function factors (split renal function at 3 months and serum creatinine level and estimated glomerular filtration rate (eGFR) at 1 week, 1, 3, 6, and 12 months postoperatively,). There was no significant difference between low and intermediate or highly complex tumors for all the categories tested in preoperative data. Especially in split renal function, the changes in mercaptoacetyltriglycine (MAG3) effective renal plasma flow (ERPF) from preoperative data were -7.00±20.2 mL/min in low complexity in R.E.N.A.L. nephrometry and -14.1±22.7 mL/min in intermediate or highly complex tumors in R.E.N.A.L. nephrometry (p=0.477), -8.21±21.3 mL/min for low complexity in P.A.D.U.A. and -13.4±22.4 in intermediate or highly complex tumors in P.A.D.U.A. (P=0.607). There was either no significant difference in the decrease of renal function (serum creatinine level and eGFR), operative time, estimated blood loss, or warm ischemia time between low and intermediate or highly complex tumors as measured by both R.E.N.A.L. nephrometry and P.A.D.U.A. scores (P>0.05). Our data showed that RPN can be performed without compromising the outcome in surgery-related factors and postoperative split renal function even in intermediate or highly complex tumors. Further studies with a larger number of cases need to be performed to confirm these findings.

Can RENAL and PADUA Nephrometry Indices Predict Complications of Laparoscopic Cryoablation for Clinical Stage T1 Renal Tumors?

Assessment of anatomical complexity with the RENAL (radius; exophytic/endophytic; nearness; anterior/posterior; location) and preoperative aspects and dimensions used for anatomical classification (PADUA) nephrometry indices is used to predict complications related to surgical extirpation treatment for patients with clinical T1a/b renal mass. This single center study aims to investigate the value of these indices to predict complications in a cohort of patients treated with laparoscopic cryoablation (LCA) for cT1 renal mass. Single institution data from consecutive LCA procedures were prospectively collected from December 2006 to April 2013. Renal mass anatomical complexity was categorized according to RENAL and PADUA indices. Comorbidity was assessed by the Charlson-index. Intraoperative complications (IOCs) were reviewed and categorized: blood loss >100 mL, conversion, tumor fracture, and incomplete ablation. Postoperative complications (POCs) were graded using the modified Clavien-index. Univariate and multivariate logistic regression models addressed the risk for complications. Ninety-nine LCA procedures were included. The median RENAL-score was 7.0 (standard deviation [SD] 1.7), and the median PADUA-score was 8.0 (SD 1.6). IOC occurred in 19 procedures (19%). The risk for IOC was significantly correlated (p<0.05) with tumor diameter (mm), surface, volume, the RENAL domains "R-size," "N-nearness to collecting system," "RENAL score," and the PADUA domain "diameter." In multivariate analysis with surgical complication as the independent variable, tumor diameter, surface, and volume were determining factors. A threshold was set for 35 mm tumor diameter, it being predictive for an increased risk for IOC performing LCA. Twenty-three POC occurred in 20 patients. On univariate analysis, the RENAL domain "nearness to collecting system," and no PADUA domains, had a significant association with POC. The RENAL score, and not the PADUA score, is associated with a higher risk for IOC. A noncategorized method of scoring tumor diameter showed a more significant correlation with the risk for IOC than the categorized method of the nephrometry indices. As a result a threshold diameter of 35 mm was established.

Morphometric profile of the localised renal tumors managed either by open or robot-assisted nephron-sparing surgery: the impact of scoring systems on the decision making process

BackgroundNephrometric scoring systems aim to improve the manner in which tumoral complexity is measured and reported. Each system provides a way to objectively measure specific tumor features that influence technical feasibility. In this study we aimed to determine how nephrometric scoring systems tailored our approach to the surgical treatment of localised renal masses.MethodsCharts of the patients with localised renal tumors, who were managed by either open or robot-assisted nephron-sparing surgery between May 2010 and June 2012, were retrospectively reviewed. Nephrometric scores [radius, exophytic/endophytic, nearness, anterior/posterior, location (R.E.N.A.L.) score, preoperative aspects and dimensions used for anatomic (P.A.D.U.A.) classification and centrality index (C-index)] were calculated based on preoperative imaging findings. Perioperative data were recorded. Morphometric characteristics of the renal masses were compared. Additionally, the difference between surgical alternative subgroups in terms of morphometric variables and the predictive power of each scoring system in determining the details of the surgical plan were investigated. Furthermore, surgical preferences in different nephrometric categories were compared.ResultsMean R.E.N.A.L. and P.A.D.U.A. scores of the tumors treated with robotic surgery were significantly lower than those managed by open surgery. R.E.N.A.L. nephrometry score showed significant differences between most of the surgical alternative subgroups. P.A.D.U.A. and C-index differences were significant only between robotic off-clamp and open clamped cases. Tumors that required open conversion had significantly higher mean R.E.N.A.L. and P.A.D.U.A. score. High R.E.N.A.L. score (cut-off: 6.5) and high P.A.D.U.A. score (cut-off: 7.5) were found to be significant predictors of the surgical route. Significantly more tumors with moderate R.E.N.A.L. score were managed through the open approach, while the significant majority of those with low R.E.N.A.L. and low P.A.D.U.A. score were operated by robotic assistance.ConclusionsR.E.N.A.L. and P.A.D.U.A. scores influenced our surgical treatment strategy for localized renal masses. High R.E.N.A.L. and P.A.D.U.A. scores increased the likelihood of an open NSS.

Clinical analysis of the PADUA and the RENAL scoring systems for renal neoplasms: A retrospective study of 245 patients undergoing laparoscopic partial nephrectomy

To investigate the clinical significance of preoperative aspects and dimensions used for anatomic (PADUA) and radius exophytic/endophytic nearness anterior/posterior location (RENAL) scoring systems for renal neoplasms in patients undergoing laparoscopic partial nephrectomy. A retrospective analysis was carried out on clinical data of 245 Chinese patients with renal neoplasms undergoing laparoscopic partial nephrectomy from June 2008 to June 2012. The perioperative complications and variables, as well as PADUA and RENAL score, were compared. The PADUA and RENAL scoring systems were significantly associated with percent change in estimated glomerular filtration rate (P = 0.032 and P = 0.026 respectively), whereas the RENAL scoring system was also significantly associated with warm ischemia time (P = 0.032). On multivariate analysis, both scores were able to predict percent change in estimated glomerular filtration rate (PADUA, P = 0.011; RENAL, P = 0.028). There were no significant associations between the two scoring systems assessed and the occurrence of complications or tumor stage. The correlation between PADUA classification and RENAL nephrometry score was significant (P < 0.0001). Fleiss' generalized kappa was 0.69-0.89 for the various components of the PADUA score and 0.67-0.89 for the RENAL nephrometry components. The PADUA classification and RENAL nephrometry score are comprehensive assessment tools for delineating renal tumor anatomy. The reproducibility of the PADUA and RENAL scores is substantial, but further research is required to evaluate its performance in more accurately predicting operative and patient-related outcomes.