Is surgeon intuition equivalent to models of operative complexity in determining the surgical approach for nephron sparing surgery?

Abstract

Introduction:The choice of approach for partial nephrectomy often depends on surgical complexity. We aimed to determine if surgeon intuition was equivalent to markers of operative complexity, such as RENAL nephrometry and Mayo adhesive probability (MAP) score, in determining the surgical approach for partial nephrectomy (PN).Materials and Methods:We retrospectively identified 119 masses removed for suspected renal cell carcinoma from January 2012 to September 2014 by a single surgeon who intuitively chose treatment with one of three surgical approaches: Open PN (OPN), robotic-assisted transperitoneal PN (RATPN), or robotic-assisted retroperitoneal PN (RARPN). Clinicodemographic characteristics, pathological features, and postoperative outcomes were compared for each approach. Logistic regression was performed to identify independent predictors of open surgical resection, our primary endpoint.Results:Fifty-four tumors (45%) were resected via OPN, 40 (34%) via RATPN, and 25 (21%) via RARPN. OPN was performed in patients with more comorbidities (P = 0.02), lower baseline renal function (P < 0.01), more solitary kidneys (P < 0.01), and more multifocal disease (P < 0.01). Patients undergoing OPN had higher median nephrometry scores compared to RATPN and RARPN patients (8 vs. 7 vs. 7, respectively; P = 0.03), but MAP scores were no different among all three groups (P = 0.36). On multivariate analysis, higher nephrometry scores (odds ratio: 1.41, 95% confidence interval: 1.10-1.81; P = 0.007) were independently associated with open surgical resection. Nephrometry score was predictive of OPN (area under curve = 0.64, P = 0.01) with a score of 6.5 having the highest sensitivity and specificity (76% and 42%, respectively).Conclusions:RENAL nephrometry score was associated with surgical approach intuitively chosen by an experienced surgeon, but the presence of adherent perinephric fat did not correlate with decision-making.

Predictive Value of Nephrometry Scores in Nephron-sparing Surgery: A Systematic Review and Meta-analysis

“…Previous literature had suggested that patients with more complex renal masses were more likely to have an open PN [36]. Sharma et al [52] found that patients with a higher RENAL score were more likely to undergo an open procedure as well. On the contrary, the presence of adhesive perinephric fat did not influence the decision making.…”

“…The DAP score (p = 0.018) [49] and PASS (p = 0.02) [18] were independent predictors of renal function variation. PADUA (p = 0.05) [52] and RAIV (p = 0.052) [18] demonstrated a sort of correlation with renal function variation but they did not achieved the usual levels of statistical significance. (Table 2 and Fig.…”

“…Prediction of the use of an MIS approach was evaluated in only two studies [36,52]. Their pooled analysis failed to show RENAL as a predictor ( Table 2 and the Supplementary material).…”

“…Their pooled analysis failed to show RENAL as a predictor ( Table 2 and the Supplementary material). The MAP score was assessed in only one study [52], and it also failed to demonstrate a predictive role.…”

The R.E.N.A.L. nephrometry score in radiologist’s practice

“…Анализ результатов исследований ряда авторов свидетельствует о наличии статистически значимой взаимосвязи между нефрометрическими данными и объемом хирургического вмешательства. При этом, помимо общей суммы, в роли отдельных предикторов выступают различные переменные и их сочетания [20,[28][29][30][31]. Также имеются немногочисленные данные о связи нефрометрических параметров с выбором методики хирургического вмешательства.…”