Predicting trifecta outcomes after robot-assisted nephron-sparing surgery: Beyond the nephrometry score

Abstract

PurposeRENAL nephrometry score (RNS) was devised for deciding the approach for renal tumors. It is increasingly used in predicting perioperative outcomes with variable results. The actual difficulty encountered during surgery depends on a number of other variables. The main purpose of this prospective study was to identify these variables which are not addressed by current RNS.Materials and MethodsForty-nine patients undergoing robotic nephron sparing surgery from January 2015 onward were included. RNS was calculated from the imaging. Operating surgeon rated each surgery on a Likert scale of 0–4 after the completion of the procedure. The questionnaire was pre-validated in 5 cases before administration. The correlation between the surgeon rating and RNS with perioperative parameters and trifecta outcomes were calculated.ResultsForty-seven percent surgeries were rated easy, and 53.0% were rated as difficult. Surgeries for hilar, posterior location and presence of supernumerary vessels were found to be the a cause of difficulty. Trifecta outcomes were achieved in 37/49 patients (75.5%). The mean rating was 2.580±0.900 in trifecta negative patients while it was 1.410±0.832 in trifecta positive patient (p<0.0001). Surgeon's rating correlated positively with trifecta outcomes (likelihood ratio=15.75, p=0.006).ConclusionsThe RNS remained a useful tool for determining renal tumor complexity. The intraoperative difficulty faced by the surgeon can be rated which can better predict perioperative trifecta outcomes. A useful predicting tool can be developed using the two parameters (RNS and surgeon rated difficulty).

Nephrometry Scores: Can Preoperative Assessment of Sectional Imaging Really Mirror Intraoperative Renal Tumor Anatomy?

“…They found the MAP score to be an independent predictor of Trifecta achievement on multivariable analysis, while RENAL score presented a significant association only on univariable analysis [31]. This aspect is supported by the results obtained by Sharma et al [21]. They divided their study population into 2 groups according to the Trifecta status (Trifecta positive and negative patients).…”

“…RENAL and PADUA scores correlated strongly featuring a correlation coefficient of 0.79 which was comparable to our results. Sharma et al [21] compared the RENAL score with a subjective surgeon’s rating and identified a statistically significant correlation. Similarly, Khene et al [29] analyzed a subjective assessment given pre- and postoperatively by the surgeon in comparison with RENAL, PADUA, and the MAP score.…”

“…The surgeon’s rating significantly correlated with the 2 subgroups, while there was no such link regarding the RENAL score. It was argued by the authors that the postoperative evaluation by the surgeon can more adequately predict Trifecta achievement as it comprises pre- and intraoperative factors [21]. Another study conducted by Khene et al [29] revealed limited predictive potentials for all scores analyzed (RENAL, PADUA, and MAP scores), while again the surgeon’s rating seemed to be superior in predicting Trifecta outcomes.…”

“…Another study conducted by Khene et al [29] revealed limited predictive potentials for all scores analyzed (RENAL, PADUA, and MAP scores), while again the surgeon’s rating seemed to be superior in predicting Trifecta outcomes. In 2018, Sharma et al [21, 32] compared nephrometry scores for their capability of predicting different perioperative outcome parameters. Neither RENAL nor PADUA scores showed significant correlations with Trifecta achievement or any other tested variable [21, 32].…”

“…Consequently, recent studies have proposed a simple semiquantitative surgeon’s assessment as a predictor of perioperative outcome. Irrespective of its subjective nature, promising results have been obtained [21].…”