Value Of Combining R.E.N.A.L And C-index Scoring System On The Choice Of T1 Stage Renal Mass Surgical Approach

Objective: To evaluate the impact of kidney cancer imaging scoring system(R.E.N.A.L and C-index)on the surgical approaches for T1 stage renal masses.Methods: Retrospectively analyzing the clinical data of 213 patients in Jiangsu Province Hospital, who underwent surgery for renal masses from January 2010 to December 2014, and also the relativity among R.E.N.A.L, C-index, the combining of the two system and surgical approaches by assessing imaging data. In this study, the cases were consisted of 140 males and 73 females. The average age was 58±12 yrs(range 25-80yrs). The mean tumor size was 3.7±1.8cm(range: 2.0-6.9cm). Of the 213 cases, 150 were diagnosed with cT1aN0M0, and leaving the 63 cases with cT1bN0M0.Among all of the patients, 191 received partial nephrectomy(PN) and 22 received radical nephrectomy(RN).Additionally, 4 patients who received PN converted to RN(3 of them without successful clamping accessory renal artery resulted in uncontrolled bleeding and 1 case also suffered uncontrolled blooding due to parenchyma tearing during suturing). The mean warm ischemia time was 18.1±5.2min with mean blood loss of 47.0±49.8ml. The pathological diagnoses were as following: 175 were clear cell renal cell carcinoma(ccRCC), 6 were chromophobe renal cell carcinoma(CRCC), and 4 were papillary renal cell carcinoma,with angiomyolipoma making up the balance.Results: According to R.E.N.A.L scoring system, the complexity of renal tumor was associated with the percentage of partial nephrectomy(p<0.01), intraoperative warm ischemia time(p<0.01). Among the high level complexity tumors, the proportion of partial nephrectomy was low, but the warm ischemia time increased. As for the C-index scoring system, tumor complexity was associated with the percentage of partial nephrectomy(p<0.01), intraoperative warm ischemia time(p<0.01) and intraoperative blood loss(p<0.01). The patients with high complexity tumors received less possibility of partial nephrectomy, but suffered longer warm ischemia time and more blood loss. Then, wecombined R.E.N.A.L and C-index. The complexity of renal tumor was divided into six groups: low(low), low(high), middle(low), middle(high), high(low), high(high).Comparing low(low) with low(high), the percentage of partial nephrectomy(p<0.05),intraoperative warm ischemia time(p<0.05), and intraoperative bleeding volume(p<0.05)were statically different. In low(low) group, the surgical difficulty was lower than low(high) group. In addition, the percentage of partial nephrectomy(p<0.05), intraoperative warm ischemia time(p<0.05), and intraoperative bleeding volume(p<0.05) showed significant differences when comparing middle(low) with middle(high). We also noted that middle(low) group had lower surgical difficulty than middle(high) group. However,there is no difference between high(low) and high(high) group.Conclusions: The R.E.N.A.L scoring system provided 5 renal tumors’ anatomic-characteristics, and C-index could reflect the tumor size and centrality. These factors could help to assess the difficulty of surgery and to choose surgical approaches.Combining the two scoring systems(R.E.N.A.L and C-index) suggested more reasonable and accurate choices for surgical approaches. Also this combining reduced the occurrence of adverse events, such as intraoperative mass bleeding, the injury of collection system,and long warm ischemic time, which owed to inappropriate surgical approaches.