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Can Simplified PADUA Renal (SPARE) Nephrometry Scoring System Help Predict Renal Function Outcomes after Robot-Assisted Partial Nephrectomy? (UroCCR Study 93) - Beyond the Abstract

Over the last few years, the indications for robot-assisted partial nephrectomy (RAPN) have increased, and it has become the gold standard for the management of small localized (cT1a-b) renal tumors.1

At the same time, various nephrometry scoring systems (NSs) have been developed to evaluate tumor complexity and therefore facilitate surgical decision making. Since 2009 the two most used NSs are RENAL and PADUA respectively described in 2009 by A.Kutikov and al.2 and by Ficarra and al.3 However, these methods have limitations such as poor inter-observer reproducibility, incomplete quantification of relevant anatomical features, and variable correlation with perioperative outcomes.

To simplify and improve NSs, Ficarra et al. recently introduced a new Simplified PADUA Renal(SPARE) scoring system to predict the risk of postoperative complications.4 This score includes only four features: rim location, renal sinus involvement, exophytic rate, and maximal tumor size. Since 2019, the accuracy of the SPARE system in predicting perioperative complications after partial nephrectomy (PN) compared to the RENAL and PADUA scores has been studied in several external validation studies,5–8  but only a few studies have specifically investigated its accuracy in predicting functional outcomes after PN.9

This study aimed to evaluate and compare the accuracy of SPARE NS in predicting functional outcomes after RAPN and the success of surgery in a multi-institutional French population.

A multicenter retrospective study was conducted using the French kidney cancer network (UroCCR, NCT 03293563) database, including 1171 patients who underwent RAPN for cT1a-b stage tumors according to the TNM classification between May 2010 and March 2021 from 21 French hospitals. Patients with multiple renal tumors, metastatic disease, those who received neoadjuvant or adjuvant treatment, or those with missing data were excluded.

The primary endpoint of our study was to evaluate and compare the accuracy of the SPARE nephrometry score (vs. RENAL, PADUA, and Tumor Size) to predict postoperative renal function. It was assessed using:

  • Acute Kidney Injury (AKI) according to the Risk/Injury/Failure/Loss/End-stage (RIFLE) classification defined as eGFR loss ≥ 25% on post-operative day one.
  • Chronic Kidney Disease (CKD) upstaging and de Novo CKD (according to CKD classification) at 3-6 months follow-up after surgery.
Concerning the perioperative features, the mean age was 59.5 (± 12.1), BMI was 27.2 (± 5.3), pre-operative eGFR was 85.8 (± 21.6), and mean tumor size was 3.4 cm (± 1.4). The mean PADUA, RENAL, and SPARE score were 8.6 (±1.8), 7.1 (± 1.9) and 3.3 (± 2.6) respectively. Mean operative time was 155.1 minutes (± 63.9), estimated blood-loss was 234.3 ml (± 282.2) and warm ischemic time (WIT) was 14.7 minutes (±11.1). Regarding the clamping strategy, 190 (16.2 %) and 218 (18.6 %) selective and off-clamp techniques were performed, respectively. In our cohort, 22.7% (n=266), 7.4% (n=87), and 8% (n=94) of the patients had AKI on post-operative day one, de novo CKD, and CKD upgrade at 3-6 months.

In multivariate analysis, all three nephrometry scores and tumor size were independent predictors of AKI on postoperative day 1, de novo CKD, and upgrade at 3-6 post-operative follow-up visits. These results were confirmed by comparing AUCs. There was no evidence of statistical difference between the ROC curves of each score for the models (p>0.05).

We may conclude that SPARE appears to be a valid alternative to PADUA and RENAL scores in predicting renal function outcomes in patients undergoing RAPN. Nevertheless, in this large multicenter cohort, the tumor size was as accurate as that of NSs in predicting postoperative outcomes. Because it is simple and replicable, it should be the standard of choice for surgical decisions.

Written by: Clément Klein,1 Gaelle Margue,2 Cécile Champy,3  Bastien Parier,4  Thibaut Waeckel,5  Karim Bensalah,6  Jonathan Olivier,7  Nicolas Doumerc,8,9  François Audenet,10  Nicolas Branger,11  Morgan Roupret,9,12  Louis Surlemont,13  Franck Bruyere,14  Xavier Durand,15  Mathieu Durand,16  Jean-Alexandre Long,17  Victor Gaillard,18  Evanguelos Xylinas,19  Maxime Vallee,20  Benjamin Rouget,21  Pierre Bigot,9,22 and Jean-Christophe Bernhard2,9  

  1. Department of Urology, University Hospital of Bordeaux, Bordeaux, France
  2. Department of Urology, University Hospital. of Bordeaux, Bordeaux, France.
  3. Department of Urology, Henri Mondor Hospital, Paris, France.
  4. Department of Urology, Kremlin Bicêtre Hospital, Paris, France.
  5. Department of Urology, Caen University Hospital, Caen, France.
  6. Department of Urology, University Hospital of Rennes, Rennes, France.
  7. Department of Urology, University Hospital of Lille, Lille, France.
  8. Department of Urology, University Hospital of Toulouse, Toulouse, France.
  9. Comité de Cancérologie de l'Association Française d'Urologie (CCAFU), Groupe Rein, Paris, France.
  10. Department of Urology, European Georges Pompidou Hospital, Paris, France.
  11. Department of Urology, Paoli Calmettes Institute, Marseille, France.
  12. Department of Urology, La Pitié Salpêtrière Hospital, Paris, France.
  13. Department of Urology, University Hospital of Rouen, Rouen, France.
  14. Department of Urology, University Hospital of Tours, Tours, France.
  15. Department of Urology, Saint Joseph Hospital, Paris, France.
  16. Department of Urology, University Hospital of Nice, Nice, France.
  17. Department of Urology, University Hospital of Grenoble, Grenoble, France.
  18. Department of Urology, University Hospital of Strasbourg, Strasbourg, France.
  19. Department of Urology, Bichat Hospital, Paris, France.
  20. Department of Urology, University Hospital of Poitiers, Poitiers, France.
  21. Department of Urology, Hospital of Libourne, Libourne, France.
  22. Department of Urology, University Hospital of Angers, Angers, France.
References:

  1. Ljungberg B, Albiges L, Abu-Ghanem Y, Bensalah K, Dabestani S, Fernández-Pello S, et al. European Association of Urology Guidelines on Renal Cell Carcinoma: The 2019 Update. European Urology. 2019 May;75(5):799–810.
  2. Kutikov A, Uzzo RG. The R.E.N.A.L. Nephrometry Score: A Comprehensive Standardized System for Quantitating Renal Tumor Size, Location and Depth. Journal of Urology. 2009 Sep;182(3):844–53.
  3. Ficarra V, Novara G, Secco S, Macchi V, Porzionato A, De Caro R, et al. Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) Classification of Renal Tumours in Patients who are Candidates for Nephron-Sparing Surgery. European Urology. 2009 Nov;56(5):786–93.
  4. Ficarra V, Porpiglia F, Crestani A, Minervini A, Antonelli A, Longo N, et al. The Simplified PADUA Renal ( SPARE ) nephrometry system: a novel classification of parenchymal renal tumours suitable for partial nephrectomy. BJU International. 2019 Oct;124(4):621–8.
  5. Weprin S, Falagario U, Veccia A, Nandanan N, Emerson D, Ovanez C, et al. Simplified PADUA Renal (SPARE) Nephrometry Scoring System: External Validation, Interobserver Variability, and Comparison with RENAL and PADUA in a Single-center Robotic Partial Nephrectomy Series. European Urology Focus [Internet]. 2020 Jun [cited 2020 Nov 1]
  6. Diana P, Lughezzani G, Uleri A, Casale P, Saita A, Hurle R, et al. Multi-institutional Retrospective Validation and Comparison of the Simplified PADUA REnal Nephrometry System for the Prediction of Surgical Success of Robot-assisted Partial Nephrectomy. European Urology Focus. 2021 Sep;7(5):1100–6.
  7. Huang CP, Chang CH, Wu HC, Yang CR, Hsieh PF, Chen GH, et al. External validation of the Simplified PADUA REnal (SPARE) nephrometry system in predicting surgical outcomes after partial nephrectomy. BMC Urology [Internet]. 2020 Dec [cited 2020 Nov 1];20(1).
  8. Khene ZE, Mazouin C, Larcher A, Peyronnet B, Gasmi A, Roumiguié M, et al. Predicting Complications After Robotic Partial Nephrectomy: Back to Simplicity. European Urology Focus. 2021 May;S2405456921001231.
  9. Rosiello G, Piazza P, Puliatti S, Mazzone E, Amato M, Tames V, et al. Simplified PADUA renal (SPARE) nephrometry score validation and long-term outcomes after robotassisted partial nephrectomy. Urologic Oncology: Seminars and Original Investigations. n 2021 Nov;S1078143921004452.
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