Nefrometrías: reproducibilidad interobservador y predicción de factores perioperatorios

ObjectivesTo validate the relation of the nephrometry scores in a series of patients who underwent partial nephrectomy with perioperative parameters and the urologist-radiologist reproducibility.Material and methodsA retrospective study of open and laparoscopic partial nephrectomy patients performed between 2005 and 2012 registered in prospective filled out database. An urologist and a radiologist calculated the R.E.N.A.L., PADUA and C-index for 86 patients. We carried out a comparative study of the results using the Spearman and Pearson correlation indexes.ResultsDistribution according to the complexity of the tumors with the RENAL calculation was: 42 (49%) low, 35 (41%) moderated and 9 (11%) high complexity. According to PADUA: 35 (41%) low complexity, 32 (37%) intermediate and 19 (22%) high. No statistically significant correlation was found for the appearance of operative complications and the pathology results in case of RENAL and PADUA. A correlation was found in the case of PADUA in relation to the warm ischemia time. Positive correlation according to Spearman's index was found in RENAL, PADUA and C-index between urologist and radiologist evaluations.ConclusionsNephrometry scores can be a useful tool to plan the surgical technique or approach. However, it is not clear if they are really predictors of surgical or pathologic parameters. The correlation between the urologist and radiologist seems to be sufficient to recommend their use by both specialties.     

R.E.N.A.L.,PADUA和C-index三种评分系统在肾部分切除术中的应用价值研究

目的 探讨R.E.N.A.L.,PADUA和C-index三种评分系统在肾部分切除术中的应用价值.方法 对本院2013年1月至2020年6月收治的134例行PN的单侧肾肿瘤患者临床资料进行回顾性分析,阅读134例单侧肾肿瘤患者术前影像学资料,应用R.E.N.AL.,PADUA和C-index三种评分系统对肾肿瘤解剖特征...     

Simplified PADUA renal (SPARE) nephrometry score validation and long-term outcomes after robot-assisted partial nephrectomy

BackgroundInternational guidelines suggest the use of anatomic scores to predict surgical outcomes after partial nephrectomy (PN). We aimed at validating the use of Simplified PADUA Renal (SPARE) nephrometry score in robot-assisted PN (RAPN).Materials and methodsThree hundred and sixty-eight consecutive RAPN patients were included. Primary endpoints were overall complications, postoperative acute kidney injury (AKI) and TRIFECTA achievement. Secondary endpoint was estimated glomerular filtration rate (eGFR) decrease at last follow-up. Multivariable logistic and linear regression models were used.ResultsOf 368 patients, 229 (62%) vs. 116 (31%) vs. 23 (6.2%) harboured low- vs. intermediate- vs. high-risk renal mass, according to SPARE classification. SPARE score predicted higher risk of overall complications (Odds ratio [OR]: 1.23, 95%CI 1.09–1.39; P < 0.001), and postoperative AKI (OR: 1.20, 95%CI 1.08–1.35; P < 0.01). Moreover, SPARE score was associated with lower TRIFECTA achievement (OR: 0.89, 95%CI 0.81–0.98; P = 0.02). Predicted accuracy was 0.643, 0.614 and 0.613, respectively. After a median follow-up of 40 (IQR: 21–66) months, eGFR decrease ranged from -7% in low-risk to -17% in high-risk SPARE.ConclusionsSPARE scoring system predicts surgical success in RAPN patients. Moreover, SPARE score is associated with eGFR decrease at long-term follow-up. Thus, the adoption of SPARE score to objectively assess tumor complexity prior to RAPN may be preferable.     

Critical appraisal of first-generation renal tumor complexity scoring systems: Creation of a second-generation model of tumor complexity

ObjectiveTo investigate whether a combination of variables from each nephrometry system improves performance. There are 3 first-generation systems that quantify tumor complexity: R.E.N.A.L. nephrometry score (RNS), preoperative aspects and dimensions used for an anatomical (PADUA) classification (PC), and centrality index (CI). Although each has been subjected to validation and comparative analysis, to our knowledge, no work has been done to combine variables from each method to optimize their performance.Patients and methodsScores were assigned to each of 276 patients undergoing partial nephrectomy (PN) or radical nephrectomy (RN). Individual components of all 3 systems were evaluated in multivariable logistic regression analysis of surgery type (PN vs. RN) and combined into a “second-generation model.”ResultsIn multivariable analysis, each scoring system was a significant predictor of PN vs. RN (P<0.0001). Of the first-generation systems, CI was most highly correlated with surgery type (area under the curve [AUC] = 0.91), followed by RNS (AUC = 0.90) and PC (AUC = 0.88). Each individual component of these scoring systems was also a predictor of surgery type (P<0.0001). In a multivariable model incorporating each component individually, 4 were independent predictors of surgery type (each P<0.005): tumor size (RNS and PC), nearness to the collecting system (RNS), location along the lateral rim (PC), and centrality (CI). A novel model in which these 4 variables were rescaled outperformed each first-generation system (AUC = 0.91).ConclusionsOptimization of first-generation models of renal tumor complexity results in a novel scoring system, which strongly predicts surgery type. This second-generation model should aid comprehension, but future work is still needed to establish the most clinically useful model.     

Thermal ablation of the small renal mass: Case selection using the R.E.N.A.L.-Nephrometry Score

ObjectivesTreatment decision-making for localized renal lesions remains overly subjective. While the AUA Guidelines list thermal ablation (TA) as a treatment option for the clinical T1 renal mass, few data exist regarding the relationship between TA and tumor complexity. The R.E.N.A.L.-Nephrometry Scoring System (NS) was introduced to objectify salient renal mass anatomy and standardize academic reporting. Here we correlate the salient anatomical attributes of renal masses undergoing TA with technical and oncologic outcomes.Materials and methodsWe queried our prospectively maintained kidney cancer database of 2,312 patients and identified 39 patients who underwent TA with available nephrometry scores. Patient clinical, technical, functional, and oncologic characteristics were reviewed.ResultsMedian patient age, serum creatinine, estimated glomerular filtration rate, and Charlson Comorbidity Index were 71 (range = 57–86) years, 1.37 (range = 0.7–3.5) mg/dl, 57.1 (range = 23.3–93.8) ml/min, and 2 (range = 0–5), respectively. Median Nephrometry Score for patients undergoing tumor ablation was 6 (4–10). Low (NS = 4–6), moderate (NS = 7–9), and high (NS = 10–12) complexity tumors were identified in 20 (51.3%), 17 (43.6%), and 2 (5.1%) patients. Six (15%) patients experienced a tumor recurrence. Of those with a recurrence, 5/6 (83.3%) had moderate complexity tumors with the remaining tumor being low complexity. Minor and major Clavien complications occurred in 4 (10%) and 1 (3%) patients, all of whom had moderate complexity tumors.ConclusionsAt our institution, 95% of tumors undergoing TA were anatomically low or moderate complexity lesions as measured by the R.E.N.A.L.-Nephrometry Scoring System. Nephrometry may help predict disease recurrence and peri-procedural complications, yet multi-institutional analysis is needed to further validate these findings.     

Interpreting nephrometry scores with three-dimensional virtual modelling for better planning of robotic partial nephrectomy and predicting complications

Objective3D models are increasingly used as additional preoperative tools for renal surgery. We aim to evaluate the impact of 3D renal models in the assessment of PADUA, RENAL, Contact Surface Area (CSA) and Arterial Based Complexity (ABC) for the prediction of complications after Robot assisted Partial Nephrectomy (RAPN).Methods and materialsOverall, 57 patients with T1 and 1 patient with T2 renal mass referred to RAPN, were prospectively enrolled. 3D virtual modelling was obtained from 2D computed tomography (CT). Two radiologists recorded PADUA_2D, RENAL_2D, CSA_2D and ABC_2D by evaluation of 2D images; two bioengineers recorded PADUA_3D, RENAL_3D, CSA_3D and ABC_3D by evaluation of the 3D model, using MeshMixer software. To evaluate the concordance between 2D and 3D nephrometry scores, Cohen's j coefficient was calculated. Receiver-operating characteristic (ROC) curves were generated to evaluate the accuracy of 3D and 2D nephrometry scores to predict overall complications. Finally, the impact of 3D model on clamping approach during RAPN was compared to 2D imaging.ResultsPADUA_3D, RENAL_3D, CSA_3D and ABC_3D scores had a significant different distribution compared to PADUA_2D, RENAL_2D, CSA_2D and ABC_2D (all p≤0.03). 2D nephrometry scores may be unchanged, reduced or increased after assessment by 3D models: CSA_3D, PADUA_3D, RENAL_3D and ABC_3D were reduced in14%, 26%, 29% and 16% and increased in 16%, 36%, 38% and 29% of cases, respectively. At ROC curve analysis, PADUA_3D, RENAL_3D and ABC_3D showed were significantly better accuracy to predict complications compared to PADUA_2D, RENAL_2D and ABC_2D. PADUA_3D (OR: 1.66), RENAL_3D (OR: 1.69) and ABC_3D (OR: 2.44) revealed a significant correlation with postoperative complications (all P ≤0.03).ConclusionNephrometry scores calculated via 3D models predict complications after RAPN with higher accuracy than conventional 2D imaging.     

A prospective comparison of the pathologic and surgical outcomes obtained after elective treatment of renal cell carcinoma by open or robot-assisted partial nephrectomy

ObjectiveTo prospectively compare surgical and pathologic outcomes obtained by elective robot-assisted (RAPN) or open partial nephrectomy (OPN) for small renal cell carcinoma (RCC).Materials and methodsBetween 2008 and 2010, after protocol design and patient consent, we prospectively collected clinical data for 100 patients who concurrently underwent either OPN (58) or RAPN (42) by an individual experienced surgeon. Clinical data included age, BMI, and past medical history. Operative data included operative time, warm ischemia time (WIT), and estimated blood loss (EBL). Postoperative outcomes included hospital stay (LOS), creatinine variation, Clavien complications, pathologic results, and survival. We stratified the complexity of the renal tumor using the R.E.N.A.L Nephrometry score.ResultsOf note, RAPN was superior to OPN in terms of EBL (median 143 mL vs. 415; P < 0.001) and LOS (median 3.8 days vs. 6.8; P < 0.0001). The median WIT for the RAPN group was 17.5 minutes (vs. 17.1 OPN; P = 0.3)) and the mean strict operative time was 134.8 minutes (vs. 128.4 OPN; P = 0.097). Regarding immediate, early, and short-term complications, variation of creatinine levels, and pathologic margins, the rates were equivalent for both groups (P > 0.05). According to the R.E.N.A.L nephrometry scores, both groups (RAPN/OPN) had similar rates (%) of low (81/72.4) and intermediate (19/20.7) complexity tumors, though there were 4 high complexity tumors in OPN group (vs. 0; P = 0.03).ConclusionWe found that RAPN is superior to the reference standard (OPN) surgical treatment of small RCCs in terms of blood loss and length of hospital stay with equivalent complications, warm ischemia time, and effect on renal function. Larger randomized trials with longer follow-up will give us further information and insight into the oncologic equivalence.     

Risk factors for intraoperative cyst rupture in partial nephrectomy for cystic renal masses

PurposeTo determine the risk factors of intraoperative cyst rupture in partial nephrectomy (PN) for a cystic renal mass (CRM) and their effect on the prognosis of patients.Materials and methodsPatients who underwent partial nephrectomy for CRMs from January 2009 to January 2015 were included. Uni/multivariate Logistic/Cox analysis and Kaplan–Meier analysis were performed.ResultsA total of 174 patients were included in this study. There were 27 (15.5%) intraoperative cyst ruptures. The median follow-up time was 60 months. Multivariate logistic analysis showed that the E component (P = 0.018) and N component (P = 0.022) of the R.E.N.A.L. nephrometry score, Bosniak category III (P = 0.044), and surgeon's experience (P = 0.030) were risk factors associated with intraoperative cyst rupture in PN for CRMs. The 5-year recurrence-free survival (RFS), cancer-free survival (CFS) and overall survival (OS) were 92.7%, 90.32% and 94.4%, respectively, in 124 cases of malignant CRM. Kaplan-Meier analysis demonstrated that 5-year RFS and 5-year CFS in patients with cyst rupture was worse than those without cyst rupture (P = 0.006 and 0.003, respectively). Multivariate Cox analysis revealed that intraoperative cyst rupture was independent risk factor for 5-year RFS and 5-year CFS (P = 0.039 and 0.013, respectively). However, there was no significant difference in OS between the two groups (P = 0.275).ConclusionsThe prevalence of intraoperative cyst rupture is relatively high. Higher E and N scores, Bosniak category III, and lacking surgical experience (<20 cases) increase the risk of occurrence of intraoperative cyst rupture.     

Robot-assisted laparoscopic partial nephrectomy for tumors greater than 4 cm and high nephrometry score: Feasibility,renal functional,and oncological outcomes with minimum 1 year follow-up

ObjectivesMinimally invasive robotic assistance is being increasingly utilized to treat larger complex renal masses. We report on the technical feasibility and renal functional and oncologic outcomes with minimum 1 year follow-up of robot-assisted laparoscopic partial nephrectomy (RALPN) for tumors greater than 4 cm.Materials and methodsThe urologic oncology database was queried to identify patients treated with RALPN for tumors greater than 4 cm and a minimum follow-up of 12 months. We identified 19 RALPN on 17 patients treated between June 2007 and July 2009. Two patients underwent staged bilateral RALPN. Demographic, operative, and pathologic data were collected. Renal function was assessed by serum creatinine levels, estimated glomerular filtration rate, and nuclear renal scans assessed at baseline, 3, and 12 months postoperatively. All tumors were assigned R.E.N.A.L. nephrometry scores (http://www.nephrometry.com).ResultsThe median nephrometry score for the largest tumor from each kidney was 9 (range 6–11) while the median size was 5 cm (range 4.1–15). Three of 19 cases (16%) required intraoperative conversion to open partial nephrectomy. No renal units were lost. There were no statistically significant differences between preoperative and postoperative creatinine and eGFR. A statistically significant decline of ipsilateral renal scan function (49% vs. 46.5%, P = 0.006) was observed at 3 months and at 12 mo postoperatively (49% vs. 45.5%, P = 0.014). None of the patients had evidence of recurrence or metastatic disease at a median follow-up of 22 months (range 12–36).ConclusionsRALPN is feasible for renal tumors greater than 4 cm with moderate or high nephrometry scores. Although there was a modest decline in renal function of the operated unit, RALPN may afford the ability resect challenging tumors requiring complex renal reconstruction. The renal functional and oncologic outcomes are promising at a median follow-up of 22 months, but longer follow-up is required.     

Robotic partial nephrectomy outcomes at a single institution and experience with R.E.N.A.L. nephrometry score

Partial nephrectomy is the current gold-standard treatment of small renal masses. The articulated instruments of the surgical robot have made the laparoscopic approach more feasible. We present our experience with 50 robot-assisted laparoscopic partial nephrectomy (RALPN) surgeries and attempt to validate a recently reported nephrometry score. From July 2008 to July 2010, 50 (53 planned) elective RALPNs were performed utilizing the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). All patients had an enhancing renal mass on CT scan pre-operatively. Clinicopathologic, surgical, and renal functional (Cockcroft–Gault formula) outcomes were recorded prospectively and analyzed. Mean tumor size, length of surgery (LS), warm ischemia time (WIT), and nephrometry scores were 3.6 cm (1–8), 303 min (133–610), 29.1 min (11–42), and 6.8 (4–11) respectively. Renal cell carcinoma was found in 39 (78%) patients. When evaluating the nephrometry score, comparison of low, medium, and high complexity tumors for length of surgery, WIT, and estimated blood loss (EBL) showed no difference (p > 0.05). Nearness to the collecting system (N score 1 vs. N score 3) showed increased EBL (195 ml vs. 510 mL, p = 0.005), and location relative to polar lines (L score 1 and L score 2) increased mean LS (265 vs. 359 min, p = 0.02). RALPN is safe and effective. Nephrometry scores are a method of standardizing tumor complexity and can be utilized in comparing tumor cohorts but may not be predictive of intra-operative outcomes.     

Presurgical sunitinib reduces tumor size and may facilitate partial nephrectomy in patients with renal cell carcinoma

ObjectiveTo determine whether presurgical sunitinib reduces primary renal cell carcinoma (RCC) size and facilitates partial nephrectomy (PN).MethodsData from potential candidates for PN treated with sunitinib with primary RCC in situ were reviewed retrospectively. Primary outcome was reduction in tumor bidirectional area.ResultsIncluded were 72 potential candidates for PN who received sunitinib before definitive renal surgery on 78 kidneys. Median primary tumor size was 7.2 cm (interquartile range [IQR]: 5.3–8.7 cm) before and 5.3 cm (IQR: 4.1–7.5 cm) after sunitinib treatment (P<0.0001), resulting in 32% reduction in tumor bidirectional area (IQR: 14%–46%). Downsizing occurred in 65 tumors (83%), with 15 partial responses (19%). Tumor complexity per R.E.N.A.L. score was reduced in 59%, with median posttreatment score of 9 (IQR: 8–10). Predictors of lesser tumor downsizing included clinical evidence of lymph node metastases (P<0.0001), non–clear cell histology (P = 0.0017), and higher nuclear grade (P = 0.023). Surgery was performed for 68 tumors (87%) and was not delayed in any patient owing to sunitinib toxicity. Grade≥3 surgical complications occurred in 5 patients (7%). PN was performed for 49 kidneys (63%) after sunitinib, including 76% of patients without and 41% with metastatic disease (P = 0.0026). PN was completed in 100%, 86%, 65%, and 60% of localized cT1a, cT1b, cT2, and cT3 tumors, respectively.ConclusionPresurgical sunitinib leads to modest tumor reduction in most primary RCC, and many patients can be subsequently treated with PN with acceptable morbidity and preserved renal function. A randomized trial is required to definitively determine whether presurgical therapy enhances feasibility of PN.     

Validation of the preoperative aspects and dimensions used for an anatomical (PADUA) score in a robot-assisted partial nephrectomy series

Objectives

PADUA score is a standardized anatomical classification of renal tumors proposed with the aim to objectivize the decision-making process of any urologist evaluating kidney tumors potentially suitable for nephron-sparing surgery. The system was proposed in a series of patients treated with open partial nephrectomy (PN) and was recently validated in a series of patients treated with either open or laparoscopic PN. The purpose of the present study was to validate the PADUA score in a series of consecutive patients who underwent robot-assisted PN (RPN).

Methods

We evaluated retrospectively all the MRI or CT images of 62 consecutive patients who underwent RPN for renal tumors at a nonacademic teaching institution by a single surgeon between September 2006 and November 2009.

Results

PADUA score (6–7 vs. 8–11) was correlated with warm ischemia time (WIT) (P = 0.002), console time (P = 0.001), blood loss (P = 0.009), percentage of pelvicaliceal repair (P = 0.002), and overall complications (P = 0.02). PADUA score was the only variable able to predict the risk of the overall complications (P = 0.02). PADUA score turned out to be an independent predictor of WIT >20 min in multivariable analysis (OR 5.4; P = 0.002), once adjusted for surgeon’s experience Finally, PADUA score was the only independent predictor of the need for pelvicaliceal repair (OR 3.7; P = 0.006).

Conclusions

PADUA classification was an effective tool to predict WIT and risk of perioperative complications also in patients who underwent RPN. This classification must be considered useful to improve patients counseling and selection for RPN.     

Implementation and external validation of preoperative aspects and dimensions used for an anatomical (padua) score for predicting complications in 74 consecutive partial nephrectomies

Study Type – Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Partial nephrectomy (PN) is the gold standard operation for small renal tumours. The decision for or against a PN has been based mostly on preoperative radiological evaluation of the tumour. Three nephrometry scoring systems have been recently proposed for prediction of postoperative complications of PN (RENAL, C‐index and PADUA). We validate externally the accuracy of the PADUA system and suggest for the first time a novel scoring system, based on the original PADUA system, which implements three other significant factors for the postoperative course of a partial.

OBJECTIVE

• ? To externally validate the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification of renal tumours managed by partial nephrectomy (PN).

PATIENTS AND METHODS

• ? Seventy‐four consecutive patients in a single academic tertiary institution underwent open PN.
• ? Incidence of 90‐day complications was stratified by several clinicopathological variables, such as gender, age of the patient, hospital stay, pathology report, tumour characteristics and positive surgical margins. PADUA scores were given to each case.
• ? The severity of complications was also categorized with the Clavien system.

RESULTS

• ? The optimal threshold of PADUA for the prediction of complications was 8 with a sensitivity equal to 90.9% and a specificity equal to 77.8% (area under the curve [AUC], 0.89; 95% confidence interval [CI], 0.73–1.00).
• ? Multivariate analysis revealed that that PADUA is an independent predictor for the risk of complications.
• ? Also, PADUA score ≥8 identified a group of patients with almost 20‐fold higher risk of complications (hazard ratio [HR]= 19.82; 95% CI, 1.79–28.35; P= 0.015).
• ? Patients with papillary histology had greater risk for complications than those with clear‐cell tumours (HR = 4.88; 95% CI, 1.34–17.76; P= 0.016).

CONCLUSIONS

• ? The PADUA score is a simple anatomical system that predicts the risk of postoperative complications. This is the first external validation of this system for open PN from a single centre.
• ? The authors believe that PADUA is an efficient tool, since the only variable of the present study that predicted a higher incidence of complications was the histology type, which is determined after surgery.
• ? However, it should be applied to laparoscopic and robot‐assisted series and it could also include the ischaemia time and surgeon experience in the overall scoring to be complete.

     

Analysis of Surgical Complications of Renal Tumor Enucleation with Standardized Instruments and External Validation of Padua Classification

Purpose

To assess surgical results and morbidity of tumor enucleation (TE), and to evaluate their correlation with PADUA nephrometric score.

Methods

We prospectively gathered data, including accurate analysis of tumor nephrometry, from 244 consecutive patients treated with TE for clinically localized renal cell carcinoma. All surgical results were collected, and perioperative complications were stratified for severity according to Clavien system. Correlation between preoperative variables and surgical results/complications was assessed with uni- and multivariate analysis.

Results

Mean (range) tumor size was 3.6 (0.8–10.0) cm, and mean (range) warm ischemia time was 16.8 (5–35) min. Overall, perioperative complications occurred in 45 patients (18.4 %), and of those 8 were medical and 37 were surgical (4 Clavien grade 1, 25 grade 2, and 8 grade 3) complications. Urine leakage rate was 2.0 %. No grade 4/5 complications occurred in this series. At univariate analysis PADUA score, endophytic tumor growth, tumor diameter, involvement of UCS and renal sinus resulted associated with warm ischemia time (p < 0.0001 each) and surgical complications (p = 0.0007, p = 0.049, p = 0.021, p = 0.036, and p = 0.029, respectively). At logistic regression, nephrometry score resulted independently associated with overall complications (related risk for each increased point 1.54; p = 0.017), surgical complications (related risk 1.58; p = 0.016), and Clavien grade 3 surgical complications (related risk 2.99; p = 0.008).

Conclusions

The TE technique was associated with a 15.2 % surgical complication rate with a 3.3 % reintervention rate (including ureteral stenting and superselective renal artery embolization). Tumor nephrometry and surgical indication resulted independent predictors of Clavien grade 3 complications. The PADUA score is a reliable tool to predict surgical results and morbidity of TE.     

Utilization of a three-dimensional printed kidney model for favorable TRIFECTA achievement in early experience of robot-assisted partial nephrectomy

BackgroundThis retrospective study aimed to investigate whether a three-dimensional (3D) model would improve the achievement of TRIFECTA, which was defined as the absence of perioperative complications and positive surgical margins and a warm ischemia time of <25 minutes, during robot-assisted partial nephrectomy (RAPN).MethodsPrior to RAPN, a 3D-square type kidney model was prepared and used for all RAPN procedures in patients with T1a renal cell carcinoma (RCC) treated at a single center between March 2016 and April 2019. All RAPN procedures were performed by a single surgeon.ResultsThe study included 50 patients, of whom 22, 24, and 4 had low-, intermediate-, and high-risk R.E.N.A.L Nephrometry scores, respectively. The TRIFECTA achievement rate was 86.0%, and transfusion or conversion to radical nephrectomy was not required in any of the patients. Only one Clavien-Dindo grade 3 complication was reported—a pseudoaneurysm that required embolism. The TRIFECTA achievement rate was independent of the R.E.N.A.L Nephrometry scores and the surgeon’s experience level (25 cases each of early and advanced experience).ConclusionsThe 3D model contributed to the achievement of TRIFECTA during RAPN performed by a less-experienced surgeon. These findings should be further evaluated in studies involving a larger number of cases and surgeons.     

Tiempo de isquemia caliente y complicaciones postoperatorias después de la nefrectomía parcial por carcinoma de células renales

ObjectiveTo evaluate the correlations between PADUA and RENAL scores, WIT and postoperative complications in a cohort of patients who underwent elective open or minimally invasive nephron sparing surgery for renal cell carcinoma.Material and methodsWe analyzed 96 consecutive patients who underwent partial nephrectomy for renal cell carcinoma between 2004 and 2013 at our Institution. The Spearman test was used to compare categorical variables. For all statistical analyses, a two-sided P < .05 was considered statistically significant.ResultsThe median (IQR) PADUA score was 7 (7-8) and the median (IQR) RENAL score was 7 (6-8). The median (IQR) warm ischemia time was 14 min (8-20). Low grade and high grade postoperative complications were found in 27 (28.1%) and 6 (6.3%) patients, respectively. PADUA risk group categories significantly correlated with WIT > 20 minutes and high grade postoperative complications, respectively (P = .04), regardless of the surgical approach. RENAL risk group categories significantly predicted longer hilar clamping time in our cohort (P = .04), but no statistically significant correlations with high grade postoperative complications were found.ConclusionsIn our retrospective series nephrometric scores demonstrated to significantly predict longer warm ischemia time and higher postoperative complications, especially in those patients with more challenging and complex renal tumors. Therefore, when planning to perform partial nephrectomy, urologists should widely use these comprehensive tools.     

R.E.N.A.L.肾肿瘤评分系统与保留肾单位手术的相关研究

目的:探讨R.E.N.A.L.肾肿瘤评分系统用于保留肾单位手术(NSS)方式选择的临床意义。方法:回顾性分析行NSS的124例(127例次)肾肿瘤患者临床资料,按R.E.N.A.L.肾肿瘤评分系统进行评分,运用t检验、χ2检验、Fisher确切检验、logistic回归,分析R.E.N.A.L.肾肿瘤评分系统与NSS方式(腹腔镜或开放)的相互关系。结果:127例次手术中,良性肿瘤14例次,恶性肿瘤113例次;腹腔镜保留肾单位手术(LNSS)71例次,开放保留肾单位手术(ONSS)56例次;R.E.N.A.L.肾肿瘤评分系统低、中、高度复杂肿瘤分别为46例次、58例次、23例次,行LNSS分别为38例次(82.6%)、30例次(51.7%)、3例次(13.0%);LNSS组(5.8±1.9)和ONSS组(8.1±1.7)的R.E.N.A.L.评分均值差异有统计学意义(P0.05);R.E.N.A.L.肾肿瘤评分系统与LNSS方法的选择有显著相关性(χ2=30.9,P0.05),低度及大部分中度复杂肿瘤适合行LNSS;单因素R、E、N、L与NSS方法的选择有关,N与LNSS方式关联强度最大,而A、h无明显相关性。结论:R.E.N.A.L.肾肿瘤评分系统可评估肾肿瘤的复杂程度,并可指导NSS方式的选择。     

Evaluation of an Electromagnetic 3D Navigation System to Facilitate Endovascular Tasks: A Feasibility Study

IntroductionWe describe a novel approach to arterial cannulation using the StealthStation^® Guidance System (Medtronic, USA). This uses electromagnetic technology to track the guidewire, displaying a 3D image of the vessel and guidewire.MethodsThe study was performed on a ‘bench top’ simulation model called the Cannulation Suite comprising of a silicone aortic arch model and simulated fluoroscopy. The accuracy of the StealthStation^® was assessed. 16 participants of varying experience in performing endovascular procedures (novices: 6 participants, ≤5 procedures performed; intermediate: 5 participants, 6–50 procedures performed; experts: 5 participants, >50 procedures performed) underwent a standardised training session in cannulating the left subclavian artery on the model with the conventional method (i.e. with fluoroscopy) and with the StealthStation^®. Each participant was then assessed on cannulating the left subclavian artery using the conventional method and with the StealthStation^®. Performance was video-recorded. The subjects then completed a structured questionnaire assessing the StealthStation^®.ResultsThe StealthStation^® was accurate to less than 1 mm [mean (SD) target registration error 0.56 mm (0.91)]. Every participant was able to complete the cannulation task with a significantly lower use of fluoroscopy with the navigation system compared with the conventional method [median 0 s (IQR 0–2) vs median 14 s (IQR 10–19), respectively; p = <0.001]. There was no significant difference between the StealthStation^® and conventional method for: total procedure time [median 17 s (IQR 9–53) vs median 21 s (IQR 11–32), respectively; p = 0.53]; total guidewire hits to the vessel wall [median 0 (IQR 0–1) vs median 0 (IQR 0–1), respectively; p = 0.86]; catheter hits to the vessel wall [median 0.5 (IQR 0–2) vs median 0.5 (IQR 0–1), respectively; p = 0.13]; and cannulation performance on the global rating scale [median score, 39/40 (IQR 28–39) vs 38/40 (IQR 33–40), respectively; p = 0.40]. The intra-class correlation coefficient for agreement between video-assessors for all scores was 0.99. 88% strongly agreed that the StealthStation^® can potentially decrease exposure of the patient to contrast and radiation.ConclusionArterial cannulation is feasible with the StealthStation^®.     

Preoperative predictors of malignancy and unfavorable pathology for clinical T1a tumors treated with partial nephrectomy: A multi-institutional analysis

PurposeTo determine preoperative predictors associated with renal cell carcinoma (RCC) and unfavorable pathology in small renal masses treated with partial nephrectomy (PN).Materials and methodsPN records from 5 centers were retrospectively queried for patients with a clinically localized single tumor <4 cm on imaging (clinical T1a). Between 2007 and 2013, 1,009 patients met the inclusion criteria. Unfavorable pathology was defined as any grade III or IV RCC or tumors upstaged to pathologic T3a disease. Logistic regression models were used to determine preoperative characteristics associated with RCC and with unfavorable pathology.ResultsA total of 771 (76.4%) patients were found to have RCC and 198 (19.6%) had unfavorable pathology. On multivariate, bootstrap-adjusted logistic regression analysis, factors associated with the presence of malignancy were imaging tumor size≥3 cm (odds ratio [OR] = 1.46; P = 0.040), male sex (OR = 1.88; P<0.0001), and nephrometry score≥8 (OR = 1.64; P = 0.005). These same factors were independently associated with risk of unfavorable pathology: size≥3 cm (OR = 1.46; P = 0.021), male sex (OR = 2.35; P<0.0001), and nephrometry score≥8 (OR = 1.49; P = 0.015). The c statistic was 0.62 for the predicting malignancy and 0.63 for unfavorable pathology.ConclusionsIn this multi-institutional cohort, male sex, imaging tumor size≥3 cm, and nephrometry score≥8 were predictors of RCC and adverse pathology following PN. These factors may assist in risk stratification and selective renal mass biopsy before decision making. Further studies are necessary to validate these findings.