DeepDyve requires Javascript to function. Please enable Javascript on your browser to continue.
The R.E.N.A.L score’s relevance in determining perioperative and oncological outcomes: a Middle-Eastern tertiary care center experience The R.E.N.A.L score’s relevance in determining perioperative and oncological outcomes: a...
Abou Heidar, Nassib; Hakam, Nizar; El-Asmar, Jose M; Najdi, Jad; Khauli, Mark A.; Degheili, Jad; El-Hajj, Albert; Nasr, Rami; Wazzan, Wassim; Bulbul, Muhammad; Mukherji, Deborah; Khauli, Raja
2022-07-03 00:00:00
ARAB JOURNAL OF UROLOGY 2022, VOL. 20, NO. 3, 115–120 https://doi.org/10.1080/2090598X.2022.2064041 ORIGINAL ARTICLE The R.E.N.A.L score’s relevance in determining perioperative and oncological outcomes: a Middle-Eastern tertiary care center experience a b a a c a Nassib Abou Heidar , Nizar Hakam , Jose M El-Asmar , Jad Najdi , Mark A. Khauli , Jad Degheili , Albert El- a a a a a a Hajj , Rami Nasr , Wassim Wazzan , Muhammad Bulbul , Deborah Mukherji and Raja Khauli a b Division of Urology and Renal Transplantation, American University of Beirut Medical Center, Beirut, Lebanon; The Breyer Lab, University of California San Francisco, San Francisco, California, United States; Massachussets General Hospital, Boston Massachussets ABSTRACT ARTICLE HISTORY Received 12 January 2022 Objective: The aim of this study is to evaluate the significance of the R.E.N.A.L nephrometry Accepted 4 April 2022 scoring system in predicting perioperative and oncological outcomes and determining the surgical approach of choice for kidney tumors. KEYWORDS Patients and Methods: Our study retrospectively reviewed outcomes from the year 2002 to Kidney cancer; renal cell 2017. Mann-Whitney U test was used to compare continuous variables and chi-square test was cancer; RENAL score; kidney used to compare categorical variables. Kaplan-Meier estimates and multivariable cox propor- tumor; outcomes tional hazard regression were performed to determine an association between the different R. E.N.A.L categories and disease recurrence or mortality. Results: A total of 325 patients underwent kidney surgery The most common R.E.N.A.L score category in our cohort study was intermediate (41.2%), followed by low, (33.2%) and high (25.5%). Patients with a high R.E.N.A.L score had worse perioperative outcomes compared to those with a low R.E.N.A.L score. High R.E.N.A.L score patients were 3 times more likely to receive blood transfusions compared to those with a low R.E.N.A.L score (19.4% vs 6.3%, p = 0.018), and a statistically significant longer hospital length of stay was also observed between the two groups (median 4.5 vs 4 days, p = 0.0419). In addition, the only predictor of disease recurrence or mortality was a high R.E.N.A.L score (Hazard Ratio (HR) 3.65, 95% Confidence Interval (CI) 1.05–12.7, p = 0.041). Conclusion: Our study sheds light on the use of R.E.N.A.L nephrometry score in predicting perioperative, postoperative, and oncological outcomes. Such findings may play a role in optimizing surgical approaches and pre-operative patient counseling. Introduction hypertension), smoking and obesity have all been shown to be associated with postoperative complica- Partial nephrectomy (PN) is the most widely utilized tions and decreased survivorship after PN [6]. surgical approach in the management of stage 1 loca- To objectively evaluate tumor complexity, the R.E.N. lized kidney tumors [1,2]. PN, whenever feasible, pro- A.L nephrometry score has been introduced as vides similar oncologic outcomes to radical a standardized tool that relies solely on anatomical nephrectomy (RN) while at the same time allowing variables. These variables include mass radius, percent for the preservation of functional renal parenchyma volume of the mass that is exophytic, proximity to renal [3]. Widespread use of cross-sectional imaging has sinus, and location [7]. Other nephrometry scores have increased the overall incidence of renal tumors and been devised as well including the C-index, which esti- has resulted in overall stage migration towards more mates the mass’ proximity to the renal center [8], and localized kidney tumors [4]. The increased incidence of the PADUA score, which utilizes similar characteristics as incidentally found small kidney tumors, in addition to the R.E.N.A.L scoring system such as tumor size and the introduction of minimally-invasive surgical techni- location [9]. Multiple studies have shown close associa- ques popularized PN. However, Figure 2 the feasibility tion between the aforementioned tumor complexity of PN is dependent on many patient-related variables scores and operative difficulty, peri-operative complica- as well as on certain tumor characteristics [5]. tions, and intraoperative conversion to RN [10,11]. Their The decision to perform PN relies heavily on tumor use in preoperative assessment has been vital in the characteristics; however, patients’ comorbidities and decision making towards undergoing partial versus RN. overall general health should also be taken into con- The aim of this study is to assess the impact of the sideration during preoperative assessment. Older age, complexity of renal tumors, stratified by the R.E.N.A.L male gender, medical comorbidities (coronary artery nephrometry scoring system, on surgical outcomes, disease, congestive heart failure, diabetes, and postoperative complications, as well as oncological CONTACT Raja Khauli rkhauli@aub.edu.lb Urology and Surgery, American University of Beirut Medical Center; Urology, University of Massachusetts Medical Center; Director Middle East Prostate Cancer Consortium (MEPCC), P.O.Box 11-0236/ Riad Solh 1107 2020 Beirut, Lebanon © 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 116 N. ABOU HEIDAR ET AL. outcomes in patients undergoing PN versus RN at Results a single institution, coinciding with adoption of robotic We identified 235 patients who underwent kidney sur- assistance. gery with complete data for analysis. The median age was 59 years (IQR 48–66) and 167 (71%) were males. Methods None of the patients had a postoperative urinary leak. The most common R.E.N.A.L score category was inter- After institutional review board approval, a retrospective mediate (41.2%), followed by low, (33.2%) and high chart review was performed for patients with renal cell (25.5%). Table 1 depicts the clinical characteristics of carcinoma (RCC) who underwent surgical treatment at patients, stratified by R.E.N.A.L category. Among a tertiary care center. De-identified data was collected patients with clinical stage T1a-2b, R.E.N.A.L category for patients treated between 2002 and 2017 to allow was associated with pathologic upstaging to T3 (1.4% a minimum of 3 years of patient follow-up. Data in low vs 11.5% in intermediate and 9.8% in high, extracted included clinical parameters such as age, sex, p = 0.041). In those upstaged to pT3, median R.E.N.A. medical comorbidities, tumor pathologic characteristics L was 9 (IQR 7–10) vs 7 (IQR 6–9) in those without (tumor size, stage, Fuhrman grade, histology, margin upstaging, p = 0.0408. Table 2 shows the post- status), surgical characteristics (type of surgery (partial operative outcomes and complications stratified by R. vs radical nephrectomy), approach (open vs laparo- E.N.A.L categories. Patients with a high R.E.N.A.L score scopic vs robotic), estimated blood loss, warm ischemia were 3 times more likely to receive blood transfusion time), pre-operative renal function, and peri-operative compared to those with low R.E.N.A.L score (19.4% vs complications. R.E.N.A.L nephrometry score was calcu- 6.3%, p = 0.018), and had a slightly longer hospital lated for all patients and categorized into 3 groups: low length of stay (median 4.5 vs 4 days, p = 0.0419). (≤6), intermediate (7–9), and high (≤10). The R.E.N.A.L score was also associated with choice Follow- up visits consisted of one post-operative of surgical procedure, where PN was performed in visit at 1–2 weeks and following that, two visits 75.6% of cases with low score, vs 54.6% of cases with per year for follow up cross sectional imaging. intermediate score (p = 0.004), and only 11.7% of those Disease recurrence was defined as any local or distant with high score (p < 0.001). On multivariate analysis, tumor detection with or without histopathological after adjusting for age, clinical T stage, preoperative confirmation. creatinine, and comorbidities, increasing R.E.N.A.L Descriptive statistics were reported as frequencies score by one category was associated with a stepwise and percentages or medians and interquartile ranges decrease in odds of undergoing PN compared to (IQR). Univariate analysis was performed to explore patients with low R.E.N.A.L score (intermediate: associations between R.E.N.A.L categories and patient OR = 0.41, CI 0.17–0.97, p = 0.042; high: OR = 0.05, CI or tumor characteristics. Mann-Whitney U test was 0.02–0.18, p < 0.001). However, Figure 1 demonstrates used to compare continuous variables and chi-square a significant trend over time of increased use of PN for test was used to compare categorical variables. The patients with low category (p = 0.015, R = 0.402) and yearly proportion of patients undergoing partial intermediate category (p = 0.016, R = 0.373), but not nephrectomy within each R.E.N.A.L category was for high category (p = 0.294, R = 0.08). determined, and trends over time were calculated Over a median follow-up of 4.4 years (IQR 2.3–6.9), using linear regression. Multivariable logistic regres- 48 patients (20.4%) experienced disease recurrence or sion was used to explore whether R.E.N.A.L score inde- mortality. The overall 3, 5, and 10-year freedom of pendently predicted surgery type thus influencing disease recurrence or mortality were 92% (CI 87% – clinical decision making, with a priori adjustment for 95%), 81% (CI 75% – 86%), and 62% (CI 51% – 72%). age, clinical T stage, pre-operative creatinine, medical When stratified by R.E.N.A.L category, freedom from comorbidities (coronary artery disease, hypertension, disease recurrence or mortality did not differ signifi - and diabetes mellitus). Model fit was assessed using cantly (log-rank p = 0.1176). On multivariable analysis Hosmer-Lemeshow goodness of fit test. Estimates of (Table 3), the only predictor of disease recurrence or the probability of disease recurrence or mortality were mortality was high R.E.N.A.L score (HR 3.65, CI 1.05– calculated using Kaplan-Meier estimates. The log rank 12.7, p = 0.041), while an intermediate R.E.N.A.L score test was used to compare outcomes of patients with showed a statistically insignificant increased risk low, intermediate, and high R.E.N.A.L categories. (HR = 2.34, CI 0.81–6.81, p = 0.117). Multivariable Cox proportional hazard regression was performed to test whether R.E.N.A.L categories were associated with disease recurrence or mortality, con- Discussion trolling for age, gender, pathological stage, grade, his- In managing renal masses, the choice of procedure tology, and type of surgery. Statistical analysis was (PN or RN) and approach (open or minimally inva- performed using Stata® version 16.1, and statistical sive) classically depends on qualitative data such as significance was deemed at p < 0.05. ARAB JOURNAL OF UROLOGY 117 Table 1. Clinical Characteristics of patients treated with surgery for RCC. R.E.N.A.L Category Low Intermediate p High p (≤6) (7–9) (≥10) N 78 97 60 Median Age (IQR) 58 (49–64) 60 (50–67) 0.2778 59 (47–69) 0.3879 Gender 0.563 0.258 Male 53 (67.1) 69 (71.1) 47 (75.8) Tumor size 3.2 (2.5–5) 4.5 (3.4–7) 0.0019 8 (6–11) < 0.0001 Pathologic T stage 0.002 < 0.001 T1a 52 (67.5) 38 (41.3) 8 (13.8) T1b 13 (16.9) 31 (33.7) 16 (27.6) T2a 5 (6.49) 7 (7.61) 9 (15.5) T2b 3 (3.9) 1 (1.09) 5 (8.62) T3a 2 (2.6) 12 (13.0) 12 (20.7) T3b 0 0 3 (5.17) T3c 0 0 1 (1.72) T4 2 (2.6) 3 (3.26) 4 (6.9) Missing 2 5 4 Fuhrman Grade 0.461 0.032 1–2 43 (55.1) 51 (52.6) 26 (43.3) 3–4 19 (24.4) 31 (31.9) 27 (45) Unknown 16 (20.5) 15 (15.5) 7 (11.7) Histology 0.618 0.783 Clear cell 49 (63.6) 57 (58.8) 38 (61.3) Papillary 9 (11.7) 11 (11.34) 7 (11.3) Chromophobe 11 (14.3) 21 (21.7) 10 (16.1) Other 8 (10.4) 8 (8.2) 7 (11.3) Sarcomatoid 3 (3.8) 2 (2.06) 0.658 4 (6.45) 0.699 LVI 2 (2.53) 5 (5.15) 0.461 11 (17.7) 0.002 Surgery type 0.004 < 0.001 PN 59 (75.6) 53 (54.6) 7 (11.7) RN 19 (24.4) 44 (45.4) 53 (88.3) Median EBL (IQR) 200 (100–300) 200 (150–400) 0.1443 200 (100–300) 0.109 Transfusion 5 (6.33) 15 (15.5) 0.058 12 (19.4) 0.018 Positive margin 4 (5.06) 5 (5.15) 0.99 1 (1.61) 0.385 Ischemia Time 20 (15 − 25) 20.5 (12–27) 0.92 22 (17–25) 0.79 IQR: Inter-Quartile Range EBL: Estimated Blood loss tumor anatomy, patient characteristics, and surgical In keeping with available literature, our series shows expertise. Nephrometry scoring systems played that most patients with high R.E.N.A.L score tumors a major role in quantifying and stratifying the com- underwent RN as most of these tumors are anatomi- plexity of renal masses. The R.E.N.A.L nephrometry cally complex and thus not amenable to PN [14]. Our score utilizes imaging related factors of renal data additionally reveals that when dealing with low masses to objectively assess tumor complexity aid- and intermediate R.E.N.A.L score tumors there was an ing in the decision-making process of the elected increased trend with time favoring PN especially since procedure and type of approach used [7]. In our institutions’ adoption of robotic surgery in the patients undergoing open or minimally-invasive early 2010s. Similarly, Ali et al. report on a major PN, the R.E.N.A.L score has been shown to be asso- increase in the use of PN for treating renal masses, up ciated with perioperative outcomes [12,13]. Our to 60% in 2016 from a previous 5% rate in 2010. study validates the utility of the R.E.N.A.L nephro- Authors conclude that the increased use of the robotic metry score in predicting operative complexity and surgery platform is the main culpable for the change in postoperative morbidity. numbers [15]. It is quite evident that the introduction Table 2. Peri-operative and post-operative outcomes stratified according to R.E.N.A.L category. R.E.N.A.L Category Low Intermediate p High p Median Ischemia time (IQR) 20 (15–25) 20.5 (12–27) 0.923 22 (17–25) 0.7929 Median EBL (IQR) 200 (100–300) 200 (150–400) 0.1443 200 (100–300) 0.109 Transfusion 5 (6.33) 15 (15.5) 0.058 12 (19.4) 0.018 LOS 4 (3–5) 4 (3–5) 0.7635 4.5 (3–5) 0.0419 Any complication 10 (12.66) 13 (13.4) 0.884 10 (16.1) 0.558 Readmission 4 (5.06) 3 (3.09) 0.702 0 0.131 IQR: Inter-Quartile Range EBL: Estimated Blood loss LOS: Length of Stay 118 N. ABOU HEIDAR ET AL. Figure 1. Percentage of Cases Undergoing Partial Nephrectomy Stratified by R.E.N.A.L Category. Table 3. Cox Regression Analysis Depicting the Predictors of urine leaks for patients with higher R.E.N.A.L score Disease Recurrence or Mortality. tumors [17]. In addition, a higher R.E.N.A.L score was HR 95% CI p associated with a longer operative time which was in R.E.N.A.L category turn directly related to an extended length of hospital Low reference stay [18]. Intermediate 2.35 0.81–6.81 0.117 High 3.65 1.05–12.7 0.041 The impact of an RCC’s tumor complexity on Age 1.01 0.97–1.04 0.685 oncologic outcomes is yet to be established. This Gender Female reference study has shown that R.E.N.A.L score has Male 0.95 0.39–2.27 0.912 a prognostic effect on significant oncologic out- Surgery type RN reference comes. For instance, patients with low R.E.N.A.L PN 2.12 0.72–6.25 0.174 score have a significantly improved survival rate p T stage T1a reference when compared to patients with higher nephrome- T1b 0.22 0.04–1.14 0.071 try scores. Similarly, a higher rate of recurrence and T2a 1.54 0.45–5.21 0.487 upstaging was revealed with high R.E.N.A.L score T2b 1.07 0.11–10.4 0.956 T3a 1.64 0.48–5.67 0.431 tumors. Previously, Kopp et al. showed that high T3b 1.46 0.18–11.8 0.72 complexity tumors (R.E.N.A.L ≥ 10) had a negative T4 1.81 0.39–8.48 0.45 Grade impact on progression-free survival [19]. Whereas, G 1–2 reference Weight et al. revealed that an increasing R.E.N.A.L G 3–4 1.99 0.89–4.48 0.094 Histology score is associated with increased risk of mortality Clear cell reference from RCC in addition to all-cause mortality [20]. Papillary 0.18 0.02–1.45 0.108 Chromophobe 0.67 0.26–1.69 0.394 Interestingly however, in another study by Hwanik Other 0.59 0.12–3.01 0.53 et al., tumor radius was the sole factor associated with increased mortality [21]. Our study is not without limitations. To start, our of minimally invasive surgery, namely robotic surgery, sample consisted of a pool of patients before and after created a worldwide trend favoring nephron-sparring the adoption of robotic assisted surgery at our institu- surgery which led to improved peri-operative out- tion. Complications during the early adoption phase comes even for highly complex tumors when com- might be in fact related to surgeon expertise which pared to the traditional open partial nephrectomy could not be accounted for in our analysis. Moreover, technique [16]. we included a cohort of patients over a long period of In our series, patients with a higher R.E.N.A.L score time during which indications for PN changed drama- tumors were more likely to receive blood transfusions tically as this technique was being refined and mas- and have an extended length of hospital stay. Similarly, tered. Moreover, radiologic data in nephrometry a systematic review and metanalysis of 20 studies scoring was calculated manually by the authors, showed a clear increase in the incidence of postopera- which is subject to human error. More importantly, tive complications including hemorrhagic ones and ARAB JOURNAL OF UROLOGY 119 Figure 2. Kaplan-Meier Survival Curves with 95% Confidence Intervals Stratified by R.E.N.A.L Category. the relatively small sample size of this study might not [2] Ljungberg B, Albiges L, Abu-Ghanem Y, et al. European Association of Urology Guidelines on Renal Cell allow consequential and generalizable conclusions. Carcinoma: the 2019 Update. Eur Urol. 2019 May;75 Another limitation is that our cox regression model (5):799–810. was likely underpowered to assess disease recurrence [3] Patard JJ, Shvarts O, Lam JS, et al. Safety and efficacy of and mortality separately due to limited outcome partial nephrectomy for all T1 tumors based on an events international multicenter experience. J Urol. 2004 Jun;1716 Pt 1:2181–2185. quiz 2435. [4] King SC, Pollack LA, Li J, et al. Continued increase in Conclusion incidence of renal cell carcinoma, especially in young patients and high grade disease: united States 2001 to Our study reiterates the role of the R.E.N.A.L nephro- 2010. J Urol. 2014 Jun;191(6):1665–1670. metry score in predicting intra and postoperative com- [5] Patel MN, Krane LS, Bhandari A, et al. Robotic Partial Nephrectomy for Renal Tumors Larger Than 4 cm. Eur plications highlighting its importance in pre-operative Urol. 2010;57(2):310–316. surgical planning. Additionally, our results shed light [6] Huynh MJ, Wang Y, Joshi M, et al. Patient factors on the significance of a higher R.E.N.A.L score in pre- predict complications after partial nephrectomy: vali- dicting oncologic outcomes including recurrence and dation and calibration of the Preoperative Risk mortality. Future prospective studies investigating the Evaluation for Partial Nephrectomy (PREP) score. BJU correlation between R.E.N.A.L nephrometry score and Int. 2021 Mar;127(3):369–374. oncologic outcomes are needed to further validate its [7] Kutikov A, Smaldone MC, Egleston BL, et al. Anatomic features of enhancing renal masses predict malignant prognostic role in RCC. and high-grade pathology: a preoperative nomogram using the RENAL Nephrometry score. Eur Urol. 2011 Aug;60(2):241–248. Disclosure statement [8] Simmons MN, Ching CB, Samplaski MK, et al. Kidney tumor location measurement using the C index No potential conflict of interest was reported by the author(s). method. J Urol. 2010 May;183(5):1708–1713. [9] Ficarra V, Novara G, Secco S, et al. Preoperative aspects and dimensions used for an anatomical (Padua) classi- fication of renal tumours in patients who are candi- ORCID dates for nephron-sparing surgery. Eur Urol. 2009 Nassib Abou Heidar http://orcid.org/0000-0003-3811- Nov;56(5):786–793. [10] Okhunov Z, Rais-Bahrami S, George AK, et al. The comparison of three renal tumor scoring systems: c-Index, P.A.D.U.A., and R.E.N.A.L. nephrometry scores. J Endourol. 2011 Dec;25(12):1921–1924. References [11] Basu S, Khan IA, Das RK, et al. RENAL nephrometry score: predicting perioperative outcomes following [1] Campbell SC, Novick AC, Belldegrun A, et al. Guideline open partial nephrectomy. Urol Ann. 2019 Apr-Jun;11 for management of the clinical T1 renal mass. J Urol. (2):187–192. 2009 Oct;182(4):1271–1279. 120 N. ABOU HEIDAR ET AL. [12] Park DS, Hwang JH, Kang MH, et al. Association between [17] Shi N, Zu F, Shan Y, et al. The value of renal score in R.E.N.A.L. nephrometry score and perioperative out- both determining surgical strategies and predicting comes following open partial nephrectomy under cold complications for renal cell carcinoma: a systematic ischemia. Can Urol Assoc J. 2014 Mar-Apr;8(3–4):E137–41. review and meta-analysis. Cancer Med. 2020 Jun;9 [13] Corradi RB, Vertosick EA, Nguyen DP, et al. Nephrometry (11):3944–3953. scores and perioperative outcomes following robotic [18] Bazzi WM, Sjoberg DD, Grasso AA, et al. Predicting partial nephrectomy. Int braz j urol. 2017 Nov-Dec;43 length of stay after robotic partial nephrectomy. (6):1075–1083. Int Urol Nephrol. 2015 Aug;47(8):1321–1325. [14] Veccia A, Dell’oglio P, Antonelli A, et al. Robotic partial [19] Kopp RP, Mehrazin R, Palazzi KL, et al. Survival out- nephrectomy versus radical nephrectomy in elderly comes after radical and partial nephrectomy for clin- patients with large renal masses. Minerva Urol Nefrol. ical T2 renal tumours categorised by R.E.N.A. 2020 Feb;72(1):99–108. L. nephrometry score. BJU Int. 2014 Nov;114 [15] Ali S, Ahn T, Papa N, et al. Changing trends in surgical (5):708–718. management of renal tumours from 2000 to 2016: [20] Weight CJ, Atwell TD, Fazzio RT, et al. a nationwide study of Medicare claims data. ANZ A multidisciplinary evaluation of inter-reviewer agree- J Surg. 2020 Jan;90(1–2):48–52. ment of the nephrometry score and the prediction of [16] Garisto J, Bertolo R, Dagenais J, et al., editors. Robotic long-term outcomes. J Urol. 2011 Oct;186 versus open partial nephrectomy for highly complex (4):1223–1228. renal masses: comparison of perioperative, functional, [21] Kim H, Kim JK, Ye C, et al. Recurrence after radical and and oncological outcomes. Urologic Oncology: semi- partial nephrectomy in high complex renal tumor nars and Original Investigations. Elsevier; 2018, using propensity score matched analysis. Sci Rep. (10):471.e1-471.e9. doi: 10.1016/j.urolonc.2018.06.012 2021 Feb 3;11(1):2919.
http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png
Arab Journal of Urology
Taylor & Francis
http://www.deepdyve.com/lp/taylor-francis/the-r-e-n-a-l-score-s-relevance-in-determining-perioperative-and-gJbiyvKEZN
