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A Novel Scoring System for Rating the Complexity of Renal Tumors
Lei Wang, MD1, Kyle T. Finnegan, BS2, Anoop M. Meraney, MD2, Stuart S. Kesler, MD2, Steven J. Shichman, MD2.
1Qilu Hospital of Shandong University, Jinan, China, 2Hartford Hospital, Hartford, CT, USA.

Background: With increased utilization of nephron sparing surgery, we introduce PARTIAL, a concise and reproducible scoring system to quantify the location and complexity of renal tumors for laparoscopic and robotic surgery. We felt that more complex cases were being performed with the robotic partial nephrectomy (RPN) technique, but we had no objective way of actually measuring the complexity of these cases. The PARTIAL scoring system is a novel approach based on the RENAL nephrometry scoring system, with more precise evaluation of tumor location and involvement with the renal hilum. The aim of this study is to describe this scoring system and evaluate its application. This innovative PARTIAL scoring system is used in the analysis of more than 200 cases of partial nephrectomy (PN) performed using a laparoscopic partial nephrectomy (LPN) or RPN technique.

Methods: The PARTIAL scoring system assigns each tumor a score from 5-16, derived from the imaging and surgical findings based on 6 features of the renal mass: P (properties of endophytic/exophytic), A (adjacency to collecting system), RT (radius and total volume), I (hilar), A (location in axial cross-section), L (location in the coronal section) (Table 1). To evaluate PARTIAL, a retrospective study of 210 patients who underwent robotic-assisted laparoscopic and pure laparoscopic partial nephrectomies from July 2003 to September 2009 was performed. Propensity score was produced with surgery type as the dependent variable in logistic regression. A second logistic regression with propensity score adjustment was used to determine independent predictors of warm ischemia time (WIT), <30 minutes vs. ≥30 minutes.

Results: Of 210 surgery patients, 51% (N=107) were RALPN and 49% (N=103) were LPN. Tumor score of the RALPN group was significantly larger than LPN (7.03 vs. 5.89, p<0.001). Logistic regression after propensity score adjustment showed that tumor score (odds ratio 1.375, 95% CI 1.175-1.608) and surgery type (odds ratio 2.911, 95% CI 1.496-5.665) were independent predictors of WIT. Our results also showed a direct relationship between the tumor score and the WIT. Additionally, the analysis showed that compared to LPN, RALPN is associated with shorter WIT.

Conclusions: Our PARTIAL scoring system is devised according to the demand of transperitoneal PN. It facilitates the evaluation and comparison of renal tumors between different surgeons at different stages of PN; open, LPN and RPN. It is a concise, effective and reproducible system which uses 6 important characteristics of solid renal masses to predict the complexity of tumors. The scoring system demonstrated that masses that scored higher were being completed with the RPN approach, which shows that this technique may be very beneficial for the treatment of renal cancer, even when the cases are complex. Also, the PARTIAL scoring system has been used to predict surgery related clinical outcomes such as WIT. Further studies are needed to confirm these results and the validity of the PARTIAL scoring system.

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