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

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Review

–

Kidney

Cancer

Predictive

Value

of

Nephrometry

Scores

in

Nephron-sparing

Surgery:

A

Systematic

Review

and

Meta-analysis

Alessandro

Veccia

a,b

,

Alessandro

Antonelli

b

,

Robert

G. Uzzo

c

,

Giacomo

Novara

d

,

Alexander

Kutikov

c

,

Vincenzo

Ficarra

e

,

Claudio

Simeone

b

,

Vincenzo

Mirone

f

,

Lance

J. Hampton

a

,

Ithaar

Derweesh

g

,

Francesco

Porpiglia

h

,

Riccardo

Autorino

a,

*

a_Division_of_Urology,_VCU_Health_System,_Richmond,_VA,_USA;b_Urology_Unit,_ASST_Spedali_Civili_Hospital,_Brescia,_Italy_and_Department_of_Medical_and SurgicalSpecialties,RadiologicalScience,andPublicHealth,UniversityofBrescia,Italy;c_Division_of_Urology,_Fox_Chase_Cancer_Center,_{Philadelphia,}_PA,_USA; d_Department_of_Oncologic,_Surgical_and_{Gastrointestinal}_Sciences,_Urologic_Unit,_University_of_Padua,_Italy;e_Department_of_Human_and_Pediatric_Pathology “GaetanoBarresi_”,UrologicSection,UniversityofMessina,Italy;f_Department_of_Urology,_Federico_II_University,_Naples,_Italy;g_Department_of_Urology,_UCSD HealthSystem,LaJolla,CA,USA;h_Division_of_Urology,_San_Luigi_Hospital,_University_of_Turin,_Orbassano,_Italy

EUROPEANUROLOGYFOCUS XXX(2019)XXX–XXX

a v ai l a b l e a t w w w . s c i e n c e d i r e c t . c o m

j o u r n al h o m e p a g e : w w w . e u r o p e an u r o l o g y . c o m / e u f o c u s

Articleinfo

AssociateEditor:MalteRieken

Keywords: Nephrometryscore Partialnephrectomy Radicalnephrectomy Tumorcomplexity Abstract

Context: Overthelastdecade,severalnephrometryscores(NSs)havebeenintroduced withtheaimoffacilitatingpreoperativedecisionmaking,planning,andcounselingin the field of nephron-sparing surgery. However, their predictive role remains controversial.

Objective: Todescribecurrentlyavailablenephrometryscoresandtodeterminetheir predictive rolefordifferentoutcomesbyperformingasystematic reviewand meta-analysisoftheliterature.

Evidenceacquisition: PubMed,Embase1,andWebofSciencewerescreenedtoidentify eligiblestudies.Identiﬁcationandselectionofthereportswereconductedaccordingtothe PreferredReportingItemsforSystematicReviewsandMeta-analyses(PRISMA).Apooled analysisofNSpredictiveroleofintraoperative,postoperative,oncological,andfunctional outcomeswasperformed.Oddsratiowasconsideredtheeffectsize.Alltheanalyseswere performedusingStata15.0,andstatisticalsigniﬁcancewassetatp 0.05.

Evidencesynthesis: Overall,51studiesmeetingourinclusioncriteriawereidentiﬁed andconsideredfortheanalysis.Except foroneprospectiverandomizedtrial,allthe studieswereretrospective.Allthestudieswerefoundtobeofintermediatequality, exceptforoneofhighquality.Moststudiesassessedthepredictiveroleofthe Radius-Exophytic/Endophytic-Nearness-Anterior/Posterior-Location(RENAL)andPreoperative Aspects and DimensionsUsed for anAnatomical (PADUA) scores,mostly regarding complicationsafternephron-sparingsurgery.RENALwasanindependentpredictorofan on-clamp procedure (p< 0.001). Mayo Adhesive Probability score was related to adhesiveperinephricfat(p= 0.005). Continuousand high-complexityRENALscores werepredictorsofwarmischemiatime(WIT;p= 0.006andp_< 0.001,respectively). Continuous(p< 0.001)andhigh-complexity(p< 0.001)PADUAscoreswererelatedto WIT.Continuousandhigh-complexityRENALscoreswerepredictorsofoverall compli-cations(p= 0.002andp< 0.001,respectively).PADUAscorewasrelatedto complica-tionsbothascontinuous(p< 0.001)andasacategoricalvalue(p< 0.002).TheRENAL scoresR=3(p= 0.008),E=2(p= 0.039),andhilarlocation(p= 0.006)werepredictors ofhistologicalmalignancy.ContinuousandcategoricalRENALscoreswereindependent

*Correspondingauthor.DivisionofUrology,VCUHealth,POBox980118,Richmond,VA23298-0118, USA.Tel.+1-804-828-5320,Fax:+1-804-828-2157.

E-mailaddress:ricautor@gmail.com (R.Autorino). EUF-836;No.ofPages15

Pleasecitethis articlein pressas: VecciaA, etal. PredictiveValue of NephrometryScoresin Nephron-sparingSurgery: A SystematicReviewandMeta-analysis.EurUrolFocus(2019),https://doi.org/10.1016/j.euf.2019.11.004

https://doi.org/10.1016/j.euf.2019.11.004

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1. Introduction

Withtheestablishmentofnephron-sparing surgery(NSS)

asthepreferredtreatmentoptionforthemanagementof

renalmasses[1],thepastdecadehaswitnessedthe

devel-opmentof“nephrometryscores.”In2009,the

Radius-Exo-phytic/Endophytic-Nearness-Anterior/Posterior-Location

(RENAL)[2]andthePreoperativeAspectsandDimensions

Usedfor anAnatomical (PADUA)[3]systems were

intro-ducedwiththecommonaimofobjectifyingtheanatomical

complexityof arenal mass,assisting insurgical decision

making, and facilitating outcome assessment [4]. Since

then,severalotherscoringsystemshavebeen

conceptual-ized and reportedin an effort to improve the predictive

value and promote clinical applicability (Fig. 1) [2,3,5–

20]. While comparisons among the different systems

remainsparse,RENALandPADUAremainthemostknown

andusedonesintheliterature[21,22].

Notwithstanding this significant research effort, it

remainsunclearwhatistheuptakeofthesescoringsystems indailyclinicalpracticeandtheirpredictivevalue.Theaim ofthepresentstudyistoassess,inasystematicfashion,the

entirespectrumofcurrentlyavailablenephrometryscores

andtheirperformanceinthepredictionofclinicaloutcomes

inpatientsundergoingNSS.

2. Evidenceacquisition

2.1. Literaturesearch

Afterestablishingastudyprotocol,twoauthors(A.V.and

A.A.) performed an independent literature research on

PubMed,Embase1,and WebofScience toidentify

rele-vantstudiesuptoApril2019(Supplementarymaterial).It

wasfilteredtoincludeoriginalarticlesonly,while

confer-ence abstract, conference paper, reviews, letters, notes,

editorials,andbookchapterswereexcluded.Identification

andselection ofthe studieswas conducted accordingto

the Preferred Reporting Items for Systematic Reviews

and Meta-analyses (PRISMA) statement (www.

prisma-statement.org;SupplementaryFig.1)[23,24].Title

and abstracts were first reviewed to ascertain whether

theywouldpotentiallyfollowtheinclusioncriteria

(stud-ies on nephrometry score reportingmultivariate logistic

regressionanalysesexpressedbyodds ratio[OR]).A

full-text analysis wasperformed to confirm inclusion.

Refer-encesofcollectedreportsweremanuallyreviewedtofind

additional studies of interest. The study protocol was

registeredonPROSPERO(CRD42019133331).

2.2. Assessmentofstudyquality

Weclassifiedeachstudyaccordingtothelevelofevidence

[25].Thequalityofthestudieswasdeterminedusingthe

Newcastle-Ottawa Scale for nonrandomized controlled

trials[26].Atotalscoreof5wasconsideredlowquality, 6–7intermediatequality,and8–9highquality.Jadadscale

was deemed suitable for evaluating the quality of the

randomizedstudies[27].

2.3. Dataextractionandanalysis

ORandconfidenceinterval(CI)werecollectedtoassessthe

predictivevalueofnephrometryscorestopredictsurgical

strategy(minimallyinvasivesurgery[MIS]vsopen,partial

nephrectomy [PN] vs radical nephrectomy [RN], or

on-clamp resection), prolonged warm ischemia time (WIT;

definedas>20min),adhesiveperinephricfat,overalland

majorcomplications, conversion to RN, pelvicalyceal

sys-tementry/repair,urineleak,malignancy,high-gradetumor,

new-onset chronic kidney disease (CKD), renal function

variation,andtrifectaachievement.

Nephrometryscoreswereconsideredcontinuousand/or

categorical(highcomplexity).ORandCIlowerandupper

limitlogarithmswerecalculated.Theresultsallowedusto

obtainthestandarderror.LogORandlogCIwerepooledto

obtaintheeffectsizeofthevariables.Heterogeneityamong thestudieswasweightedaccordingtorandomeffect[28].If pooledanalysisincluded<25studies,asmallsamplesize

bias was establishedaccording to Egger’s regression test

[29].Anonstatisticallysignificantpvaluewasindicativeof theabsenceofasmallsamplesizebias.Alltheanalyseshave

been performed using Stata 15.0 (StataCorp 2017, Stata

StatisticalSoftware:release15;StataCorpLLC,College

Sta-tion, TX, USA), and statistical significance was set at

predictors of anestimatedglomerular ﬁltrationrate(eGFR) increase(p= 0.006 and p< 0.001,respectively).TheDiameter-Axial-Polar score(p= 0.018)and Peritumoral ArteryScoringSystem(PASS;p= 0.02)werealsoindependentpredictors.

Conclusions: The literature regarding nephrometry scoring systems is sparse, and mostly focusedonRENAL andPADUA, which areeasy tocalculateand havea good correlationwithmostoutcomes.RenalPelvicScoreisthebestpredictorofpelvicalyceal entry/repairandurineleak,whereasSurgicalApproachRenalRankingandPASSstrongly predictsurgicalapproachandrenalfunctionvariation,respectively.Othernephrometry scoresbasedonmathematicalmodelsarelimitedbytheircomplexity, andtheylack evidencesupportingtheirpredictivevalue.

Patientsummary: Wereviewedthemedicalliteratureregardingtheuseandvalueof so-called“nephrometryscores,”whicharescoringsystemsbasedonradiologicalimagingand madetogradethecomplexityofarenaltumor.Weanalyzedwhetherthesescoringsystems canpredictsomeoftheoutcomesofpatientsundergoingsurgicalremovalofrenaltumors. ©2019EuropeanAssociationofUrology.PublishedbyElsevierB.V.Allrightsreserved. EUROPEAN UROLOGY FOCUS XXX(2019)XXX–XXX

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EUF-836;No.ofPages15

Pleasecitethis articlein pressas: VecciaA, et al.PredictiveValue of NephrometryScoresin Nephron-sparingSurgery: A SystematicReviewandMeta-analysis.EurUrolFocus(2019),https://doi.org/10.1016/j.euf.2019.11.004

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p 0.05. A detailed description of statistical codes is

reportedintheSupplementarymaterial.

3. Evidencesynthesis

3.1. Nephrometryscores

Currentlyavailable nephrometryscores canarbitrarily be

groupedintothosebasedonavisualanatomicalassessment

of a renal mass and those based on a mathematical

assessment.

3.1.1. Visualanatomicalassessment-basedscores

Mostofthescoresfallintothisgroupastheyarebasedonan

immediatevisualassessment.TheRENAL[2]andPADUA[3]

scoresevaluatethetumorlocation,itsdegreeofpenetration withinthekidney,anditsrelationshipwiththepelvicalyceal system.TheDiameter-Axial-Polar(DAP)scoreestablishesthe Fig.1–Nephrometryscores.

Fig.2–Predictivevalueofnephrometryscoreforoverallcomplications.ABC=ArterialBasedComplexity;CI=confidenceinterval;C-index=Central Index;CSA=ContactSurfaceArea;MAP=MayoAdhesiveProbability;NePhRO=Nearness-Physical-Radius-Organization;OR=oddsratio;

PADUA=PreoperativeAspectsandDimensionsUsedforanAnatomical;RENAL=Radius-Exophytic/Endophytic-Nearness-Anterior/Posterior-Location; RPS=RenalPelvicScore;RTII=RenalTumorInvasionIndex;SARR=SurgicalApproachRenalRanking;SPARE=SimplifiedPAduaREnal-;ZII=Zero IschemiaIndex;ZS=ZhongshanScore.

EUROPEAN UROLOGY FOCUS XXX(2019)XXX–XXX 3 EUF-836;No.ofPages15

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renalmassdimensionanddistancefromtworeferringlines: axialandpolar lines[6].TheZonal

Nearness-Physical-Radius-Organization(NePhRO)scorepresentsfiveparametersthat

mirrorthoseoftheRENALandPADUAscores.Differently,it

dividesthekidneyintothreezones(zone1:kidney

paren-chyma;zone2:medullaryandsinus;andzone3:collecting

systemandhilum)andadoptsanotherdimensionalscaleto

establish renalmass dimension[7]. Differently, theRenal

PelvicScore(RPS)departsfromtheabovementionedscores.

Indeed, itassessesthepresenceofanintra-orextrarenal pelvisreferringtoasagittallinethatcrossesthekidneyhilum

[9]. Another score, the Surgical Approach Renal Ranking

(SARR),presentsthesamefeaturesasthoseoftheRENAL,

PADUA,andZonalNePhROscores,butitprovidesascoring

systemfrom0to4,whichallowsobtainingmoregranular

stratificationofrenalmasses[10].Mostofthescoresconsider thelongitudinalpositionofthetumor,whiletheZhongshan

score takes into account the transversal tumor position:

lateral, central, and medial [15]. Recently, the Simplified

PAduaREnal(SPARE)nephrometrysystemmergedthemain

featuresofboththenephrometryscorestocreateatumorrim location,renalsinusinvolvement,exophyticrate,and

maxi-mumtumorsize–basedscore[20].TheArterialBased

Com-plexity(ABC)scoringsystemconsidersthevascular involve-mentbythetumor.Thefourcategoriesassessed(1,2,3S,and 3H)arelinkedtotheneoplasmcontactwithinterlobularor arcuate,interlobar,segmental,orhilumarteries,respectively

[14]. Another vasculature-based score is the Peritumoral

ArteryScoringSystem(PASS)[18].Itisathree-dimension– basedscorethatrankstumordissectiondifficultyaccording tothenumberanddiameterofperitumoralarteries.

Differ-entlyfrom theaforementioned scores,theMayoAdhesive

Probability(MAP)scoreevaluatestheperinephricfat thick-nessasameantopredictitsadhesiontothekidney,which couldtranslateintoamorechallengingresection[12].

3.1.2. Mathematicalassessment–basedscores

Thiscategoryisbasedeitheronavisualoramathematical

assessmentofthetumor,requiringdetailedimaging

analy-sis.Thefirstone,theCentralityIndex(C-index)classifiesthe

tumorcomplexityaccording toitsmathematical distance

from the center of the kidney: pffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffix2_þ_y2_¼_c; d 2¼r

= ;

c

rCindex

= [5]. Less complex is the Renal Tumor Invasion Index (RTII), which is the ratio of the maximal invasion of thetumorfromthesurfaceofthekidneyintotheparenchyma andtheparenchymalthicknessofthekidneyjustbesidethe tumor(I

P

= ) [8].Othertwoscorescalculatematematicallythe tumorContactSurfaceArea(CSA)andtheRenalAndIschemia Volume(RAIV),withbothusingthemassradiusanddiameter measurements. In addition, the RAIV requires the measure-mentoftheresectedandischemizedrenalparenchymacross section[11–13].Similarly,theZeroIschemiaIndex(ZII) repre-sentstheresultoftheproductofthetumordiameterandits depth within the kidney parenchyma [17]. The only score assessingthevascularcomplexityistheCoefficient,Location, Anterior boundary, Multi-boundary, and Posterior boundary (CLAMP) score. This three-dimensional (3D) imaging-based scoreevaluatestheanatomyofthearteriesthatfeedtherenal mass. Thistool couldpredict theeffectiveness ofsegmental arteryclampingthroughthefollowingmathematicalformula:

ðXþYÞ11þðXþYÞ212þ...ðXþYÞx12, where (X + Y)x= ranking number of the target artery feeding the tumor

[19].Finally, theSpectrum scoreisa puremathematicscore thatallowsevaluationoftheacuteipsilateralrenaldysfunction basedonrenalscintigraphymeasurementsandserum creati-ninelevels[16].

3.2. Descriptionofincludedstudies,andqualityandbias assessment

Overall, 51 studies meeting our inclusion criteria were

identified and considered for the analysis

[8–11,15,17,18,20,30–72]. Except for one prospective ran-domized trial [71], allthe studies were retrospective. All thestudieswerefoundtobeofintermediatequality,except for oneofhighquality[59](Table1).The majorityofthe

studies assessed the predictive role of the RENAL and

PADUA scores, mostlyregarding complications afterNSS

(SupplementaryFig.2and3).

AsmallsamplebiaswasfoundinstudiesassessingWIT,

overallandmajorcomplications,andpelvicalycealsystem

entry/repair.Noobviousbiasesweremarkedregardingthe

otheroutcomesassessed(SupplementaryTable2).

3.3. Predictionofoutcomes

3.3.1. Surgicalstrategy

PredictionoftheuseofanMISapproachwasevaluatedin

only two studies [36,52]. Their pooled analysis failed to

showRENALasapredictor(Table2andtheSupplementary

material). TheMAPscorewasassessedinonlyonestudy

[52],anditalsofailedtodemonstrateapredictiverole. RegardingthedecisiontoperformPNversusRN,thiswas

assessedintwostudies,oneforRENALandSARR[10],and

theotherforPADUAandRTII[62].Nopooledanalysiscould bedone. OnlyRENAL(OR30.45; 95%CI:8.73,106.1;p< 0.001)andSARR(OR39.53;95%CI:10.55,148;p< 0.001)

showedpredictivevalues(Table2andtheSupplementary

material).

A cumulative analysis of three available studies

[59,71,72] showed RENALas anindependent predictorof on-clampresection(OR:1.55;95%CI:1.23,1.95;p< 0.001).

Each of the PADUA, ABC [59], and MAP[72] scores was

assessed inonlyonestudyandassociatedwithon-clamp

technique (allp< 0.001;Table2andtheSupplementary

material).

3.3.2. Adhesiveperinephricfat

Cumulativeanalysisofthetwostudies[46,58]reportingon

thisoutcomedemonstratedtheMAPscoretobean

inde-pendentpredictorofadhesiveperinephricfat(OR:1.98;95%

CI: 1.23,3.18; p= 0.005;Table 2andthe Supplementary

material).

3.3.3. Warmischemiatime

A pooled analysis of five studies demonstrated that the

RENAL score as continuous(OR: 1.53; 95%CI:1.13, 2.06;

p= 0.006)[35–38,59]orcategorical(highcomplexity;OR:

9.29; 95% CI: 5.37, 16.06; p< 0.001) [35,53] is an

EUROPEAN UROLOGY FOCUS XXX(2019)XXX–XXX 4

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Table 1_{– Characteristics of the studies included.} Author Nephrometry

score

Year Journal Institution Study design Patients Surgical procedure Surgical technique Nephrometry score correlations assessed LE SQ

Mottrie et al[30] PADUA 2011 World J Urol Single Retrospective analysis 62 PN Robotic Warm ischemia time20 min 3 *******

Perioperative complications Overall complications Pelvicalyceal repair

Kutikov et al[31] RENAL 2011 Eur Urol Single Retrospective analysis 525 PN NA Malignant histology 3 *******

High-grade histology

Simhan et al[32] RENAL 2011 Eur Urol Single Retrospective analysis 390 PN Open Major complications 3 *******

Laparoscopic Robotic

Ficarra et al[33] PADUA 2011 Eur Urol Multiple Retrospective analysis 349 PN Robotic Warm ischemia time20 min 3 *******

Overall complications

Liu et al[34] RENAL 2012 World J Urol Single Retrospective analysis 179 PN Laparoscopic Overall complications 3 *******

Robotic

Mayer et al[35] RENAL 2012 Urology Single Retrospective analysis 67 PN Laparoscopic Warm ischemia time 3 *******

Robotic Collecting system entry

Stroup et al[36] RENAL 2012 Urology Multiple Retrospective analysis 284 PN Open Undergoing MIS vs OPN 3 *******

Laparoscopic Overall complications Robotic Major complications

Urine leak

Long et al[37] RENAL 2012 BJU Int Single Retrospective analysis 177 PN Open Conversion to RN 3 *******

Laparoscopic

Kopp et al[38] RENAL 2012 Urology Single Retrospective analysis 228 PN Open Warm ischemia time20 min 3 *******

De novo CKD development

Mullins et al[39] RENAL 2012 J Urol Single Retrospective analysis 671 PN Robotic Malignant histology 3 *******

High-grade histology

Tanagho et al[40] RENAL 2013 Urology Multiple Retrospective analysis 886 PN Robotic Perioperative complications 3 *******

Mehrazin et al[41] RENAL 2013 BJU Int Multiple Retrospective analysis 322 PN Open eGFR<60 ml/min/1.73 m2

in the last follow-up

3 ****** Laparoscopic

Robotic

Nisen et al[8] RENAL 2013 Scand J Urol Single Retrospective analysis 285 PN Open Any-grade complications 3 *******

PADUA Laparoscopic

C-index Robotic

RTII

Krane et al[42] RENAL 2013 BJU Int Single Retrospective analysis 233 PN Robotic Any complication 3 *******

PADUA Major complication

Tomaszewski et al[9] RENAL 2013 Eur Urol Single Retrospective analysis 255 PN Open Urine leak 3 *******

RPS Robotic

Tannus et al[10] RENAL 2014 J Endourol Single Prospective analysis 80 PN Open Surgical approach selection 2 *******

SARR RN Laparoscopic General complications

Robotic

Antonelli et al[43] RENAL 2014 Clin Genitourin Cancer Multiple Retrospective analysis 506 PN Open Malignancy 3 *******

Laparoscopic High-grade features Robotic

Leslie et al[11] PADUA 2014 Eur Urol Single Retrospective analysis 200 PN Laparoscopic Operative time4 h 3 ********

CSA Robotic Estimated blood loss>500 ml

Overall complications Length of stay4 d Warm ischemia time

E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 1 9 ) X X X – X X X 5 EUF-836; No. of Pag es 15 Please cite this article in press as: Veccia A, et al. Predicti ve Value of Nep hrometry Scores in Nephr on-sparing Surgery : A Syst ematic R eview and Meta-analy sis. Eur U rol Focus (20 1 9), https://doi.org/1 0. 1 0 1 6/j.euf.20 1 9 .1 1 .0 0 4

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Table 1 (Continued )

Author Nephrometry score

Year Journal Institution Study design Patients Surgical procedure Surgical technique Nephrometry score correlations assessed LE SQ

Tomaszewski et al[44] RENAL 2014 Urology Single Retrospective analysis 831 PN Open Urine leak 3 *******

RPS Robotic

Reddy et al[45] RENAL 2014 Ann R Coll Surg Engl Single Retrospective analysis 128 PN Open Postoperative complications 3 *******

Laparoscopic

Kocher et al[46] RENAL 2014 BJU Int Single Retrospective analysis 245 PN Laparoscopic Adherent perinephric fat 3 *******

MAP Robotic

Ball et al[47] RENAL 2014 Urol Oncol Multiple Retrospective analysis 1009 PN NA Malignancy 3 *******

Unfavorable pathology

Zhou et al[15] RENAL 2015 Medicine (Baltimore) Single Prospective study 1231 PN NA Overall complications 2 *******

PADUA RN

ZS

Kwon et al[48] RENAL 2015 Ann Surg Oncol Single Retrospective analysis 266 PN NA GFR reduction 3 ******

PADUA New-onset CKD

C-index

Li et al[49] DAP 2015 Medicine (Baltimore) Single Retrospective analysis 237 PN Open Warm ischemia time20 min 3 ******

Laparoscopic eGFR decline>10% Robotic

Kriegmair et al[50] NePhRO 2015 World J Urol Single Retrospective analysis 200 PN Open Perioperative complications 3 ******

Kriegmair et al[51] PADUA 2015 Biomed Res Int Single Retrospective analysis 233 PN Open Major complications 3 *******

Sharma et al[52] RENAL 2016 Indian J Urol Single Retrospective analysis 119 PN Open Predictors OPN 3 ******

MAP Robotic

Raheem et al[53] PADUA 2016 BJU Int Single Retrospective analysis 295 PN Open Trifecta achievement 3 *******

Laparoscopic Robotic

Schiavina et al[54] RENAL 2016 BJU Int Multiple Retrospective analysis 277 PN Robotic Warm ischemia time20 min 3 *******

PADUA Need for UCS repair

Overall complications Major complications

Ricciardulli et al[55] PADUA 2016 Urologia Single Retrospective analysis 402 PN Laparoscopic Warm ischemia time20 min 3 *******

Li et al[17] RENAL 2016 World J Urol Single Retrospective analysis 149 PN Open Estimated blood loss500 ml 3 *******

PADUA Laparoscopic Operative time>2 h

ZII Robotic Overall complications

eGFR decrease>10%

Moskowitz et al[56] RENAL 2016 J Endourol Multiple Retrospective analysis 1139 PN Robotic Overall complications 3 *******

Major complications

Kara et al[57] RENAL 2017 J Urol Single Retrospective analysis 1023 PN Robotic Conversion to RN 3 *******

RN

Martin et al[58] MAP 2017 Urology Single Retrospective analysis 86 PN NA Adherent perinephric fat 3 *******

Kriegmair et al[59] RENAL 2017 J Surg Oncol Single Retrospective analysis 300 PN Open Complications 3 ********

PADUA Robotic On-clamp excision

ABC Ischemia time

Opening of the CS

Matos et al[60] RENAL 2017 Int Braz J Urol Single Retrospective analysis 71 PN Open Major complications 3 *******

RN Laparoscopic

Gu et al[61] ABC 2017 J Surg Oncol Single Retrospective analysis 350 PN Laparoscopic Overall complications 3 *******

Robotic Minor complications

Zhang et al[18] RENAL 2017 Sci Rep Single Retrospective analysis 220 PN NA GFR percent decline10% 3 *******

PADUA GFR percent decline20%

RAIV ABC E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 1 9 ) X X X – X X X 6 EUF-836; No. of Pag es 15 Please cite this article in press as: Veccia A, et al. Predicti v e Value of Nephr ometry Scores in Nep hron-sparing Surgery : A Syst ematic R eview and Meta-analy sis. Eur U rol Fo cus (20 1 9), https://doi.org/1 0. 1 0 1 6/j.euf.20 1 9 .1 1 .0 0 4

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Table 1 (Continued )

Author Nephrometry score

Year Journal Institution Study design Patients Surgical procedure Surgical technique Nephrometry score correlations assessed LE SQ PASS

Tornberg et al[62] PADUA 2017 Scand J Surg Single Retrospective analysis 915 PN NA Performing PN 3 *******

RTII RN

Takagi et al[63] RENAL 2017 J Endourol Single Matched-pair analysis 227 PN Robotic eGFR decrease 10% 3 ******

Correa et al[64] RENAL 2018 Clin Genitourin Cancer Single Retrospective analysis 334 PN NA Malignancy 3 *******

High-grade features

Draeger et al[65] PADUA 2018 Turk J Urol Single Retrospective analysis 213 PN NA Symptoms 3 *******

CT stage T1b, T2 Complications

Petros et al[66] RENAL 2018 Urology Single Retrospective analysis 90 PN Open Conversion to RN 3 *******

RN Laparoscopic

Robotic

Khene et al[67] RENAL 2018 Urol Oncol Single Retrospective analysis 500 PN NA Conversion to RN 3 *******

MAP Overall complications

Major complications Trifecta achievement

Wang et al[68] RENAL 2018 Urol Oncol Single Retrospective analysis 337 PN NA eGFR stabilization or variation 3 ******

Ficarra et al[69] PADUA 2018 BJU Int Multiple Retrospective analysis 531 PN Open Postoperative complications 3 *******

CSA Laparoscopic

Robotic

Yu et al[70] RENAL 2018 Int J Urol Single Matched-pair analysis 375 PN Open AKI or CKD progression 3 ******

Laparoscopic

Antonelli et al[71] RENAL 2019 J Urol Multiple Randomized controlled trial 149 PN Robotic On-clamp excision 1 3a

Qian et al[72] RENAL 2019 Urology Single Retrospective analysis 225 PN Laparoscopic Segmental artery clamp 3 *******

MAP

Ficarra et al[20] CSA 2019 BJU Int Multiple Retrospective analysis 531 PN Open Overall complications 3 *******

SPARE Laparoscopic

Robotic

ABC = Arterial Based Complexity; AKI = acute kidney injury; C-index = Centrality Index; CKD = chronic kidney disease; CS = collecting system; CSA = Contact Surface Area; DAP = Diameter-Axial-Polar; eGFR = estimated GFR; GFR = glomerularﬁltration rate; LE = level of evidence; MAP = Mayo Adhesive Probability; MIS = minimally invasive surgery; NePhRO = Nearness-Physical-Radius-Organization; OPN = open partial nephrectomy; PADUA = Preoperative Aspects and Dimensions Used for an Anatomical; PASS = Peritumoral Artery Scoring System; PN = partial nephrectomy; RAIV = Renal and Ischemia Volume; RENAL = Radius-Exophytic/Endophytic-Nearness-Anterior/Posterior-Location; RN = radical nephrectomy; RPS = Renal Pelvic Score; RTII = Renal Tumor Invasion Index; SARR = Surgical Approach Renal Ranking; SPARE = Simpliﬁed PAdua REnal; SQ = study quality; UCS = urinary collecting system; ZII = Zero Ischemia Index; ZS = Zhongshan Score.

a_{LE according to the Jadad scale for randomized controlled trials.}

E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 1 9 ) X X X – X X X 7 EUF-836; No. of Pag es 15 Please cite this article in press as: Veccia A, et al. Predicti ve Value of Nep hrometry Scores in Nephr on-sparing Surgery : A Syst ematic R eview and Meta-analy sis. Eur U rol Focus (20 1 9), https://doi.org/1 0. 1 0 1 6/j.euf.20 1 9 .1 1 .0 0 4

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Table2–Predictivevaluesofnephrometryscores.

Outcomes t2 _x2 _df _p_value _l2_(%) _OR _95%_CI _p_value

RENAL

Minimallyinvasivesurgery 0.28 28.29 1 0.000 96.5 0.95 0.44,2.03 0.896a

PNvsRNb _– _– _– _– _– _30.45 _8.73,_106.10 _<0.001a

On-clampresection 0.02 4.13 2 0.127 51.6 1.55 1.23,1.95 <0.001a

Warmischemiatime 0.04 5.04 2 0.082 60.3 1.53 1.13,2.06 0.006a

0.05 1.32 1 0.251 24.1 9.29 5.37,16.06 <0.001c Overallcomplications 0.01 24.05 9 0.004 62.6 1.17 1.05,1.30 0.002a 0.00 2.87 6 0.825 0.0 2.75 1.80,4.23 <0.001c Majorcomplications 0.00 1.70 3 0.638 0.0 1.07 0.96,1.21 0.212a 0.00 3.03 4 0.553 0.0 3.55 2.00,6.28 <0.001c ConversiontoRN 0.00 0.01 1 0.940 0.0 1.40 1.14,1.73 0.001a 1.07 7.30 2 0.026 72.6 1.52 0.38,6.03 0.551c

Pelvicalycealsystementry/repair 0.02 2.02 1 0.155 50.5 1.53 1.15,2.04 0.003a

1.72 4.63 1 0.031 78.4 6.42 0.83,49.78 0.075c

Urineleakb _– _– _– _– _– _1.56 _1.17,_2.06 _0.002a

Malignancy 1.44 4.09 1 0.043 75.6 3.49 0.54,22.63 0.190c

New-onsetCKD 0.04 8.10 2 0.017 75.3 1.28 0.96,1.70 0.086a

Renalfunctionvariation 0.00 0.56 1 0.455 0.0 1.28 1.07,1.53 0.006a

0.14 1.46 1 0.228 31.3 5.64 2.22,14.32 <0.001c Trifectaachievementb – – – – – 0.77 0.34,1.70 0.518c PADUA PNvsRNb _– _– _– _– _– 0.72 0.60,0.86 <0.001a On-clampresectionb _– _– _– _– _– _1.53 _1.23,_1.90 _<0.001a

Warmischemiatime 0.00 2.55 2 0.280 21.5 1.28 1.12,1.45 <0.001a

0.00 2.63 4 0.621 0.0 2.93 2.05,4.20 <0.001c

Overallcomplications 0.00 7.48 5 0.187 33.1 1.34 1.20,1.49 <0.001a

0.34 12.62 5 0.027 60.4 2.23 1.21,4.13 0.010c

Majorcomplications – – – – – 1.95 1.29,2.94 0.001a,b

0.00 0.60 2 0.742 0.0 2.39 1.36,4.20 0.002c

Pelvicalycealsystementry/repairb _– _– _– _– _–

1.41 1.18,1.67 <0.001a

0.00 0.13 1 0.722 0.0 3.27 1.96,5.46 <0.001c

Renalfunctionvariationb

– – – – – 0.60 0.36,1.00 0.050a Trifectaachievementb _– _– _– _– _– 0.88 0.14,5.18 0.888c C-index Overallcomplicationsb _– _– _– _– _– _0.63 _0.49,_0.81 _<0.001a DAP

Warmischemiatimeb _– _– _– _– _–

1.74 1.37,2.20 <0.001a

Renalfunctionvariationb _– _– _– _– _–

1.29 1.04,1.59 0.018a NePhRO Overallcomplicationsb – – – – – 1.20 1.03,1.44 0.020a – – – – – 3.24 1.15,9.12 0.026c RTII PNvsRNb _– _– _– _– _– _0.55 _0.19,_1.58 _0.267a Overallcomplicationsb – – – – – 2.91 1.52,5.52 0.001a RPS Overallcomplications 0.00 0.48 1 0.002 0.0 34.25 13.89,84.43 <0.001a Majorcomplications 0.00 0.49 1 0.483 0.0 34.25 13.89,84.43 <0.001a 1.11 0.30,4.10 0.876c Urineleak 0.00 0.49 1 0.483 0.0 34.12 13.87,83.93 <0.001a SARR PNvsRNb _– _– _– _– _– _39.53 _10.55,_148.13 _<0.001a Overallcomplicationsb _– _– _– _– _– 1.39 0.36,5.31 0.631c CSA

3.51 1.24,9.94 0.018c

Overallcomplications 0.00 9.25 1 0.002 89.2 1.05 0.98,1.13 0.152a

– – – – – 4.08 1.40,11.88 0.010c,b

MAP

Minimallyinvasivesurgeryb _– _– _– _– _–

1.04 0.81,1.33 0.760a

Adhesiveperinephricfat 0.07 2.73 1 0.098 63.4 1.98 1.23,3.18 0.005a

On-clampresectionb – – – – – 3.91 2.18,6.99 <0.001a Overallcomplicationsb _– _– _– _– _– 1.05 0.86,1.28 0.631a – – – – – 1.32 0.56,3.08 0.522c Majorcomplicationsb _– _– _– _– _– _1.11 _0.81,_1.52 _0.516a – – – – – 1.10 0.30,4.09 0.876c ConversiontoRNb _– _– _– _– _– 7.66 3.10,18.94 <0.001a – – – – – 3.29 1.39,7.77 0.007c Trifectaachievementb _– _– _– _– _– _0.79 _0.38,_1.60 _0.515c RAIV

Renalfunctionvariationb _– _– _– _– _–

1.11 1.00,1.23 0.052a

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independent predictor of prolonged WIT. Similarly, the

pooledanalysis showed the PADUAscore to predict

pro-longedWITasacontinuousvariable(OR:1.28;95%CI:1.12, 1.45;p< 0.001) [33,54,58]and a categorical(high com-plexity)variable (OR:2.93;95%CI:2.05,4.20;p< 0.001)

[11,30,33,54,55].Onlyonestudywasreportedascontinuous

onDAP[49]andABC[59]andascategoricalon CSA[11],

withDAPandCSAfoundto beindependent predictorsof

WIT(p< 0.01;Table2andtheSupplementarymaterial).

3.3.4. Overallcomplications

Continuous(OR: 1.17; 95% CI: 1.05,1.30; p= 0.002) and

high-complexity(OR:2.75;95%CI:1.80,4.23;p< 0.001)

RENALscoreswerefoundtobeindependentpredictorsof

overall complications. In addition, the PADUA score was

relatedtocomplicationsascontinuous(OR:1.34;95%CI:

1.20,1.49;p< 0.001)andcategorical(OR:2.23;95%CI:1.21, 4.13;p<0.002)value.Acumulativeanalysiswasnot possi-blefortheNePhROscore[49],Zhongshanscore[15],ZII[17],

andSPARE[20],whichwasshowntoberelatedtooverall

complications.CSAwascorrelatedtooverallcomplications

as a categorical variable (p= 0.010) [11] but not as a

continuous one [20,69]. C-index was not a predictor of

overall complications (OR: 0.63; 95% CI: 0.49, 0.81; p< 0.001;Table2andtheSupplementarymaterial)(Fig.2).

3.3.5. Majorcomplications

BothRENALhighcomplexity(OR:3.55;95%CI:2.00,6.28;

p<0.001)[9,37,42,53,66]andPADUAcategorical(OR:2.39;

95%CI:1.36,4.20;p=0.002)[42,54,65]wereindependent

predictorsofmajorcomplications.RPSwasstronglyrelated totheincidenceofmajorcomplications(OR:34.25;95%CI: 13.89,84.43;p< 0.001)[9,43].Apooledanalysiswasnot

feasibleforPADUAaswellasforMAPascontinuous

vari-ablesbecauseonlyonestudyreportedthesedataforeach

nephrometryscore[50,65].OnlyPADUAwasfoundtobea

predictorofmajorcomplications(Table2andthe

Supple-mentarymaterial).

3.3.6. ConversiontoRN

ContinuousRENALscorewasanindependent predictorof

conversion toRN(OR: 1.40;95%CI:1.14,1.73;p= 0.001)

[65,66], but this was not the case for high-complexity

RENAL score (p=0.551). Only one study reported about

MAPasapredictorofconversiontoRNbothascontinuous

(p<0.001)andascategorical(p= 0.007;Table2andthe

Supplementarymaterial).

3.3.7. Pelvicalycealsystementry/repair

Only two studies per nephrometry score were available

regardingthisoutcome[30,35,54,59].RENALasa

continu-ous variable was directly related to pelvicalyceal system

entry/repair (OR: 1.53; 95% CI: 1.15, 2.04; p= 0.003)

[35,59].This wasnot thecaseforhigh-complexityRENAL

score,whereashigh-complexityPADUAscorewasshownto

beanindependentpredictorofpelvicalycealeffraction(OR: 3.27;95%CI:1.96,5.46;p< 0.001)[30,54].Onlyonestudy assessedABC,whichwasastrongpredictorofpelvicalyceal

system entry/repair(p< 0.001; Table 2andthe

Supple-mentarymaterial).

3.3.8. Urineleak

RPSasacontinuousvaluewasdemonstratedtopredictthe

riskofurineleakstrongly(OR:34.12;95%CI:13.87,83.93; p< 0.001)[9,44].Theonlyothernephrometryscore

evalu-ated regardingthisoutcomewastheRENALscore,which

Table2 (Continued)

Outcomes t2 _x2 _df _p_value _l2_(%) _OR _95%_CI _p_value

ABC

On-clampresectionb _– _– _– _– _– _1.84 _1.31,_2.57 _<0.001a

1.25 0.95,1.62 0.098a

Overallcomplicationsb _– _– _– _– _–

1.31 0.88,1.94 0.181a

– – – – – 1.38 0.93,2.04 0.108c

Pelvicalycealsystementry/repairb _– _– _– _– _– _1.85 _1.37,_2.49 _<0.001a

Renalfunctionvariationb

– – – – – 3.98 0.09,164.91 0.467c ZS Overallcomplicationsb _– _– _– _– _– 3.70 1.71,8.08 0.001c ZII Overallcomplicationsb _– _– _– _– _– 1.26 1.04,1.52 0.019a PASS

Renalfunctionvariationb SPARE

Overallcomplicationsb _– _– _– _– _–

1.20 1.10,1.30 <0.001a ABC=Arterial Based Complexity; CI=confidence interval; C-index=Centrality Index; CKD=chronic kidney disease; CSA= Contact Surface Area; DAP=Diameter-Axial-Polar;df=degreesoffreedom;MAP=MayoAdhesiveProbability;NePhRO=Nearness-Physical-Radius-Organization;OR=oddsratio; PADUA=PreoperativeAspectsandDimensionsUsedforanAnatomical;PASS=PeritumoralArteryScoringSystem;PN=partialnephrectomy;RAIV=Renaland IschemiaVolume; RENAL=Radius-Exophytic/Endophytic-Nearness-Anterior/Posterior-Location;RN=radicalnephrectomy; RPS=Renal Pelvic Score; RTII =RenalTumorInvasionIndex;SARR=SurgicalApproachRenalRanking;SPARE=SimplifiedPAduaREnal;ZII=ZeroIschemiaIndex;ZS=ZhongshanScore. Boldpvaluesindicatestatisticalsignificance.

a _Nephrometry_score_value:_continuous. b

Pooledanalysisnotpossible. c

Nephrometryscorevalue:categorical.

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wasshowntopredicturineleaktoo(p= 0.002;Table2and

theSupplementarymaterial)[36].

3.3.9. Malignanthistology

ThecategoricalRENALscorewastheonlyscoretobeassessed

asa predictor of malignancy, but it was not found to be

predictive(p= 0.190;Table2andtheSupplementary

mate-rial)[39,47].Asubanalysisofitssinglecomponentsshowed thatN=3(OR:1.98;95%CI:1.18,3.34;p= 0.010)wasan

independent predictor of histological malignancy

[31,43,64].InonlyonestudyR=3wasassessed,whichwas

shownto bea predictorofmalignanthistology and

high-gradetumor(OR:4.05;95%CI:1.43, 11.39;p= 0.008andOR: 3.89;95%CI:2.12,7.11;p< 0.001,respectively)[31].RENAL E=2wasanindependentpredictorofhigh-gradetumor(OR: 1.67;95%CI:1.07,2.62;p= 0.024;Fig.3)[31,43,64].

3.3.10. Postoperativerenalfunction

Meta-analysisofnew-onsetCKDwasfeasiblefortheRENAL

scoreonly,butitdidnotpredictit(p= 0.086;Table2and

theSupplementarymaterial) [38,41,70]. Intermsofrenal

function variation, continuous [18,70] and categorical

RENAL scores [19,63] were independent predictors of an

estimatedglomerular filtration rate (eGFR)increase (OR:

1.28;95%CI:1.07, 1.53;p= 0.006,andOR:5.64;95%CI:2.22, 14.32;p< 0.001,respectively).Apooledanalysiswasnot

feasiblefortheothernephrometryscoresbecauseonlyone

studypernephrometryscorewasavailable.TheDAPscore

(p= 0.018)[49]andPASS(p= 0.02)[18]wereindependent

predictorsofrenalfunctionvariation.PADUA(p= 0.05)[52]

andRAIV(p= 0.052)[18]demonstratedasortofcorrelation withrenalfunctionvariationbuttheydidnotachievedthe usuallevelsofstatisticalsignificance.(Table2andFig.4).

3.3.11. Trifectaachievement

None of the nephrometry scores included was

demon-stratedtobeaneffectivepredictoroftrifectaachievement (Table2andtheSupplementarymaterial).

3.4. Discussion

Herein, wepresentthefirstsystematicreviewand

meta-analysisassessingthepredictiveroleofnephrometryscores

in NSS. Our findings raise some interesting points of

discussion.

Sincetheirintroductionin2009[2,3],theaimofthese toolswastofacilitatepreoperativeplanning,surgical

deci-sion making,andcounseling.Ouranalysis found

nephro-metryscoresto beapredictorofsurgicalstrategy.

Never-theless, this was not the case regarding the decision to

perform a MIS. Previous literature had suggested that

patientswithmorecomplexrenalmassesweremorelikely

to have an open PN [36]. Sharma et al [52] found that

patients with a higher RENAL score were more likely to

undergoan openprocedureaswell. On thecontrary,the

presenceofadhesiveperinephricfatdidnotinfluencethe

decisionmaking.Today,thisparadigmischanging,andMIS,

especiallyroboticsurgery,hasbeenshowntobesafeand

feasibleevenforlargeandcomplexrenaltumors.Datafrom

theROSULACollaborativeGroupdemonstratedroboticPN

to befeasiblefor large renal masses, maximizing kidney

function withoutcompromisingon oncological outcomes

[73].DespitetheencouragingdataregardingNSSforT1b-T2

tumors[74],RNisrecommendedwhen PNisnot feasible

[1],andourdatademonstratedtheroleofthenephrometry

scoreduringpreoperativeplanning.Indeed,higherRENAL

andPADUAscoresincreasedthechances ofoptingforRN

rather thanPN. Tannus et al[10] developed an “ad hoc”

nephrometryscore,theSARR,whichassessedthe

relation-ship betweentumor complexityandtheoddsofRN. The

authorsevaluatedthecomputedtomographyandmagnetic

resonance images of 257patients, showingthat patients

withhigherSARRhadalmost39-foldoddstoundergoRN

comparedwiththosewithsmallerscores[37].Thisisthe

onlystudyintheliteratureonthisscore.

Wealsoassessedthepredictiveroleofthescores

regard-ing hilar management during tumor resection. RENAL,

Fig.3–HistologypredictivevalueofRENALcomponents.CI=confidenceinterval;OR=oddsratio;RENAL= Radius-Exophytic/Endophytic-Nearness-Anterior/Posterior-Location.

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PADUA,andABCwerepredictorsofhilarclamping,butthe MAPscoreseemedtobethestrongestone[72].Datafroma

newrandomizedtrialsuggestedahigherRENALscoretobe

apredictorof thetransition fromanoff-clamp toan

on-clamproboticPN[71].Recently,theCLAMPscorehasbeen

developedtoevaluatepatientssuitableforselectiveartery

clamping. This is a 3D imaging–based tool that allows

evaluationoftheopportunitytoperformeselectiveartery clamp,stratifyingpatientsaccordingtothevascular anat-omy[19].Theuseofscoringsystemstopredicttheclamping

techniqueremainspoorlyinvestigated.

Regarding surgical outcomes, a higher nephrometry

scoredirectlyinfluencedWIT,whichisasurrogateoftumor

complexity [75]. Indeed, a pooledanalysis of RENAL and

PADUA demonstrated an increased probability of longer

WIT.Thesedatawerealreadyachievedbyalarge

multicen-terstudyon227patients.Inthisreport,theauthors

con-cluded that patients with high-complexity RENAL and

PADUAscoreshad5.7-and2.6-foldhigherratesoflonger

WIT,respectively[54].BesidesRENALandPADUA,onlyCSA,

DAP,andABCwereinvestigatedregardingthedurationof

ischemiatime[11,49,59].TheABCscorewastheonlyone

unrelatedto WIT, andthiscouldbea consequenceof its

designthataccountsonlyfortumorlocation,disregarding

otherdatasuchasdiameter,degreeofdepth,and

longitu-dinalposition.Interestingly,Kriegmairetal[59]evaluateda

modifiedversionoftheABCscorethatalsoincludedtumor

diameter. The authors found that the inclusion of this

parameter made the ABC an independent predictor of

WIT.These data suggestthat tumordimension isone of

themainparameterstoconsiderduringnephrometryscore

development[62].

Overallandmajorcomplicationswerethemost

inves-tigated outcomes among the nephrometry scores. The

first-generation nephrometry scores showed once again

theirpredictiveroleofoverallcomplicationsasboth

con-tinuous and categorical variables. Kriegmair et al [76]

achievedthesameresultinalargecohortseriescomparing

four different scores. Interestingly, the authors analyzed

NePhRO score and C-index, with the first related to

complications(p= 0.011).Thesedatareflectedourresults

showing the inferiority of C-index compared with the

others. In addition, except for C-index and MAP score,

all the nephrometry scores appeared to be potentially

independent predictors of overall and major

complica-tions. Nevertheless, RPS was underlined to be superior

with34.25-foldchancesofcomplicationsforpatientswith

ahigherscore.Particularly,RPSassessedtherenalpelvic

anatomiccomplexityandseemedtobestrictlyrelatedto

urineleakincidence andduration.Tomaszewskietal[9]

speculatedthatthereasoncouldbetheinterpretationof

RPS as a surrogateof renal pelvis volume and pressure.

Thus, intrarenal pelvis mightpresent higher inner

pres-sure,increasingtheriskofruptureduringtumorresection

and yielding to delayedhealing of urine leak.The urine

leak could be a consequence of more complex tumor

resection.Infact,highernephrometryscoresand

complex-ity were related to pelvicalyceal system entry/repair.

Potretzke et al [77] conducted a review of studies on

urinaryfistula afterrobotic PN,andfoundthat

pelvicaly-ceal system entry and tumor size were related to the

development of urine leak.These twoparameters could

beinterpretedasareflectionoftumorcomplexity,which

couldbethereasonforurinaryfistulaincidence.Ourdata

reflect thesefindings,andRENALscore andPADUA

com-plexitywere shownto belinkedto pelvicalyceal system

entry/repair.Potentially,ahigherABCscorecouldindicate

the risk of urinary tract effraction/repair, but only one

studyinouranalysisreportedthisoutcome[59].

Anotherconsequenceoftumorcomplexityistheriskof

intraoperative conversiontoRN.Inourreview,few

anal-ysesreportedthesedata[37,59,65,66],andpooled

estima-tionunderlinedtheRENALscorecorrelationwith

conver-sion rate. Nevertheless, the MAP score overcame the

RENAL score. Indeed, patients with a higher MAP score

andahigherMAPriskhad,respectively,7.66-and3.29-fold

higherriskstobeconvertedtoRN.Itmightbespeculated

that a higher MAP score could be a consequence of

advanced disease, prompting thesurgeon to convertthe

casetoaradicalone[78].

Fig.4–PredictivevalueofNephrometryscoreforrenalfunctionvariation.ABC=ArterialBasedComplexity;CI=confidenceinterval;DAP= Diameter-Axial-Polar;OR=oddsratio;PADUA=PreoperativeAspectsandDimensionsUsedforanAnatomical;PASS=PeritumoralArteryScoringSystem;RAIV =RenalandIschemiaVolume;RENAL=Radius-Exophytic/Endophytic-Nearness-Anterior/Posterior-Location.

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Thepotentialroleofnephrometryscorestopredict

malig-nancy and tumor grade was postulated by Kutikov et al

[31].The authorsevaluated eachRENALscorecomponent

onacohortof525patientsandfoundthatR=3,E=2,and L=3werepredictorsofmalignanthistologyandhigh-grade tumors.Equally,wefoundR=3,E=2,andhilarlocationas predictorsofmalignancy.Correaetal[64]hypothesizedthat

tumor growth within the inner renal environment could

promoteitsprogression,explainingthemajoraggressiveness ofhilarand endophyticmasses.Notably, high-stage,

hilar-located renal tumors, especially clear cell carcinomas,

showedahigherexpressionofGLUT5,whichisrelatedto

glucosemetabolismandneoplasmgrowth[79].

Interms offunctionaloutcomes,theRENAL scorewas

not an independent predictor of new-onsetCKD. On the

contrary,itwasfoundtobelinkedtopostoperativerenal

functionvariation,aswellasPADUAandPASS.Thelatter,

whichisa3Drendering–basedscoreassessingperitumoral

arteryvolume,wasdemonstratedtobethestrongest

pre-dictor of eGFR variation. The authors found that tumors

withhigher PASS scoreswere morelikely tohavehigher

RENALscorestoo. Consequently,resectioncouldbemore

difficult,requiringlongerischemiatimeandlargerhealthy

parenchyma removal [80]. The aforementioned reasons

could unfold the strong relationship between PASS and

renalfunctionvariation.Zhangetal[16]developeda math-ematicalscoretoevaluate theacuteipsilateralrenal dys-functionafterPN:theSpectrumscore.Thisinterestingscore

isbased on the followingformula: (observed peak SCr–

SCrideal-peak)/(SCrworstcase-peak – SCrideal-peak); its modified

version,proposedbyLeeetal[81],quantifiedacute

ipsilat-eral renal dysfunction and renal recoveryafter PN (beta

–0.515, p< 0.001). This novel tool could betterforecast renalfunctionvariation,butavailabledataarestillweakto consideritasaneffectivepredictor.

Overall,RENAL andPADUAseem torepresentthebest

tools to report complexity and prediction of morbidity.

Despiteother nephrometryscoresbeing promising,their

roleinpredicting specificoutcomesdoes notoutperform

thesefirst-generationscores.

This study presents limitations. The reports included

were all retrospective and of intermediate quality, and

theonlyrandomizedtrialdidnotaddressthetopic

specifi-cally [71]. Moreover, a cumulative analysis was possible

onlyforalimitednumberofscoresandalimitednumber

ofoutcomes.Therefore,anarrativereviewwasadoptedto

summarizesomeoftheoutcomes. Inaddition,itwasnot

possibletoaccountforopen,laparoscopic,orrobotic pro-cedures,sotheresultsmightbereliableforonetechnique

butnot for the other. The interobserver variabilitycould

have influenced the results, but these data were not

accountable again. Last, most of the literature available

comes from repeat publications from the same working

group;therefore,onecanarguethatsomedatacouldhave

beenassessedwithinthesamecohort,translatingintoan

additional bias. Notwithstanding these limitations, the

main strength of thisstudy is its designas a systematic

reviewand meta-analysis thatmakes itdepart from the

previousdescriptiveones.

4. Conclusions

The literature on nephrometry scoringsystems issparse,

anditismostlyfocusedonRENALandPADUA.Thesetwo

scoresareeasytocalculate,andtheycarryagood

correla-tionwithmostoftheoutcomesforwhichtheyhavebeen

assessed.RPS,SARR,andPASScanofferabetterpredictive valueforpelvicalycealentry/repairandurineleak,surgical approach,andrenalfunctionvariation,respectively.

Never-theless,the implementationof othernephrometryscores

basedonmathematicalmodelsislimitedbytheir

complex-ityandlackofevidencesupportingtheirpredictivevalue.

Uptodate,theRENALandPADUAscorescanberegardedas

the standardsfor reporting complexityand predictionof

morbidity,whereasothernewertoolsdidnotshowbetter

performance than the first-generation ones. The present

findingscanaidinfurtherresearcheffortinthisfieldand fosterthedevelopmentofbetterpredictivetools.

Authorcontributions:RiccardoAutorinohadfullaccesstoallthedatain thestudyandtakesresponsibilityfortheintegrityofthedataandthe accuracyofthedataanalysis.

Studyconceptanddesign:Veccia,Autorino. Acquisitionofdata:Veccia,Antonelli.

Analysisandinterpretationofdata:Veccia,Autorino. Draftingofthemanuscript:Veccia,Autorino.

Criticalrevisionofthemanuscriptforimportantintellectualcontent: Auto-rino,Veccia,Antonelli,Uzzo,Novara,Kutikov,Ficarra,Simeone,Mirone, Hampton,Derweesh,Porpiglia.

Statisticalanalysis:Veccia.

Obtainingfunding:None.

Administrative,technical,ormaterialsupport:None.

Supervision:Autorino,Antonelli,Uzzo,Novara,Kutikov,Ficarra,Simeone, Mirone,Hampton,Derweesh,Porpiglia.

Other:None.

Financialdisclosures:RiccardoAutorinocertifiesthatallconflictsof interest, including specific financial interests and relationships and affiliationsrelevanttothesubjectmatterormaterialsdiscussedinthe manuscript(eg,employment/af_filiation,grantsorfunding, consultan-cies,honoraria,stockownershiporoptions,experttestimony,royalties, orpatentsfiled,received,orpending),arethefollowing:Dr.Vecciaisan ItalianSocietyofUrology-AmericanUrologicalAssociation(SIU-AUA) researchfellow.FundingforhisfellowshipisalsoprovidedbytheVCU UrologyResearchFund.

Funding/Supportandroleofthesponsor:None.

AppendixA. Supplementarydata

Supplementary material related to this article can be

found, in the online version, at doi:https://doi.org/10.

1016/j.euf.2019.11.004.

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