REVIEW

CURRENT
OPINION Nephrometry scoring systems for surgical decision-
making in nephron-sparing surgery
Matthias Waldert and Tobias Klatte

Purpose of review
Herein, we review the various recently published nephrometry scoring systems and the available data on
their ability to predict clinical outcomes and their usefulness for new operative techniques.
Recent findings
Several studies showed that the preoperative aspects and dimensions used for anatomical classification
score, the RENAL system, and the centrality index are reproducible and able to predict certain clinical
intraoperative and postoperative variables in patients undergoing nephron-sparing surgery. Addition of
variables, such as the BMI, to the pre-existing scores might improve their predictive abilities.
Summary
Nephrometry scoring systems may allow better preoperative planning and counseling of patients. If they
gain widespread use in clinical practice, they may also help to give reliable comparisons of morbidity
rates among different partial nephrectomy techniques, individual surgeons, and institutions.
Keywords
centrality index, nephrometry, preoperative aspects and dimensions used for anatomical classification
score, RENAL system

to draw meaningful conclusions from the literature

INTRODUCTION
Today, with the advent of ultrasound and computed
tomography (CT) as routine diagnostic modalities,
more than 60% of renal tumors are diagnosed inci-
dentally. These tumors are generally smaller and
have a lower risk of developing metastases [1].
In patients with undergoing treatment for these
small renal masses, the importance of nephron-
sparing surgery (NSS) to minimize the risk of deteri-
&&
oration of renal function is increasing [2 ]. Preop-
erative planning is greatly dependent on lesion size
and location. Tumor size is the most widely reported
parameter and has been shown to influence postop-
erative outcomes such as glomerular filtration rate
and local complications such as opening of the
collecting system with subsequent urinary leakage
[3,4]. In the case of tumor location, the classification
differs among various authors. Some describe it as a
dichotomous variable, describing tumors as either
central/hilar or peripheral. Others rate it as a cate-
gorical variable, based on how much of the lesion is
endophytic or exophytic [3,4].
But with the advent of new minimally invasive
treatment options such as laparoscopic cryothera-
py, more accurate descriptions of tumor character-
istics are needed. A further problem is that it is hard
on the above-mentioned subjects since no stan-
dardized methods exist for describing renal masses.
This makes the comparison of various interven-
tions or even the comparison of the same interven-
tion done by different centers challenging.
Resection of a tumor that might be difficult for
one surgeon may be a routine for another surgeon
of a different institution and skill level. The scoring
systems discussed in this review try to standardize
the reporting of anatomical tumor features and,
thus, determine surgical complexity. To fulfill their
purpose, each of the methods has to be objective
and reproducible with a low interobserver variabil-
ity. Subsequently, the scoring systems have to ac-
curately reflect the operative complexity and gain
widespread use and importance within the urologic
community.
Department of Urology, Medical University of Vienna, Vienna, Austria
Correspondence to Dr. Matthias Waldert, Department of Urology,
Medical University of Vienna, W€ahringer Gürtel 18-20, Vienna
A-1090, Austria. Tel: +43 1 40400 2615; fax: +43 1 40400 2332;
e-mail: matthias.waldert@meduniwien.ac.at
Curr Opin Urol 2014, 24:437–440
DOI:10.1097/MOU.0000000000000085

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 Nephron-sparing surgery for renal cancers

a computed kidney tomography or MRI. Every tu-

KEY POINTS
 The RENAL score, PADUA score, and C-Index all show
excellent interobserver reliability.
 Combination of the RENAL or PADUA score with BMI and
CCI improves the predictive ability for complications.
 All scores may help in comparing results of NSS series
thus standardizing scientific reporting in the future.
THE RENAL SYSTEM
In the year 2009, Kutikov and Uzzo [5] reported their
nephrometry system called the RENAL nephrometry
score. The acronym stands for (R)adius, which scores
tumor size as the maximal diameter; (E)xophytic/
endophytic growth; (N)earness of the deepest tumor
part to collecting system or sinus; (A)nterior/poste-
rior; and (L)ocation relative to the polar line. RENAL
are scored on a 1, 2, or 3-point scale. The radius is
subdivided according to the TNM system in
4 cm
and >4 cm but <7 cm and ³7 cm. Exophytic/endo-
phytic properties are classified in ³50% exophytic,
<50% exophytic, or entirely endophytic. Nearness
of the tumor to the collecting system/sinus is mea-
sured in millimeters and mirrors the TNM Classifi-
cation of Malignant Tumors (tumor size/node
status/distant metastasis) size staging: distance
³7 mm; >4 mm but <7 mm; and
4 mm. Conce-
rning location, the polar line is designated as the
plane of the kidney above or below which the
medial lip of the parenchyma is interrupted by
the renal sinus fat, the vessels, or the collecting
system. Tumors are graded in being entirely above
the upper or below the lower polar line, crossing a
polar line, and being more than 50% across polar
line or crossing the axial renal midline or being
entirely between the polar lines.
According to this classification system, the
authors retrospectively quantified 50 consecutive
renal masses and concluded that the RENAL score
sum was lower (sum 4–6 and 7–9) in tumors that
more often underwent partial nephrectomy using a
minimally invasive approach whereas lesions with a
score of 10–12 were more likely to undergo laparo-
scopic radical nephrectomy or open partial nephre-
ctomy (OPN).
THE PADUA SCORE
Ficarra et al. [6] published their classification system
in 2009. The term PADUA is the abbreviation of
‘preoperative aspects and dimensions used for ana-
tomical classification’. At the core, similar to the
RENAL system, there are nonetheless important
differences. Imaging modalities needed are either
mor gets assigned the following seven parameters:
anterior or posterior face; longitudinal location (up-
per, middle, and lower defined by the kidney sinus
lines: >50% crossing the line, <50% crossing the
line, between the sinus lines); rim location (lateral
and medial); relationship with sinus (without or
located/extended); relationship with the collecting
system (absent or present); percentage of tumor
deepening into the kidney (>50% exophytic,
<50% exophytic, endophytic); and maximal diam-
eter in centimeters (4 cm, 4.1–7 cm, >7 cm). Each of
these parameters is given a score ranging from 1 to 3.
The final output is a single sum score. The main
difference to the RENAL score is the usage of the
renal sinus and the corresponding sinus lines to
topographically subdivide the kidney into upper,
middle, and lower part. The sinus lines can be
identified on CT or MRI by the appearance of the
adipose, hypodense tissue inside renal paranchyma.
The other difference is the inclusion of renal sinus
involvement as a separate parameter. The score is
based on the prospective evaluation of 164 patients
with cT1 tumors who underwent NSS. In this cohort,
the PADUA score was found to be a predictor for the
occurence of overall complications in univariate
(P < 0.001) and multivariate analysis. A PADUA
score between 8 and 9 meant a 14-fold and a score of
at least 10 a 30-fold higher risk of complications as
compared to scores from 6 to 7.
C-INDEX
The tumor centrality index (C-Index) was first de-
scribed by Simmons et al. [7] in 2010. As for the other
morphometric scoring systems, one needs a standard
cross-sectional, two-dimensional CT for measure-
ment. In the initial study, 133 patients who under-
went transperitoneal laparoscopic partial
nephrectomy (LPN) were analyzed. The system uses
three variables; y is the height in centimeters from the
hilar center to the plane of the maximum tumor
diameter along a vertical 90° axis, x represents the
horizontal distance from the central hilar axial refe-
rence point to the tumor center, and c is the hypote-
nuse of the triangle formed by x and y, that is, the
distance from kidney center to tumor center. The last
required parameter is tumor diameter (d) that is
divided by 2 to obtain the tumor radius (r). Next
the ratio c/r has to be calculated to assess the prox-
imity of the tumor edge to the center of the kidney.
Thus, the higher the C-Index, the lower is the central
extension of the tumors, and NSS should be more
feasible with lesser chance of complications related
to tumor location than in tumors with a low C-Index.
In the initial publication, the median C-Index was

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 Nephrometry scoring systems for surgical decision making Waldert and Klatte
2.7 (range 0.7–9.6) and was independently associated
with warm ischemia time (P ¼ 0.004). Ischemia and
operating time tended to be longer and estimated
blood loss was higher in tumors with a C-Index less
than 2. Intraobserver variability was low with a maxi-
mum of 7%. The learning curve required approxi-
mately 14 measurements.
RISK OF SURGICAL COMPLICATION
SCORE
Published in 2014 by a working group from Italy, this
score includes either the values from the PADUA or
the RENAL nephrometry scores and combines them
with the Charlson comorbidity index (CCI) and BMI
&&
[8 ]. The authors speculate that perioperative com-
plications are not only dependent on tumor comple-
xity but also on these two parameters. They
prospectively reclassified 320 tumors operated in
two institutions according to the PADUA classifica-
tion and the RENAL score. Patients were classified in
low, moderate, and high-complexity groups. An al-
gorithm that incoporated the PADUA/RENAL score,
BMI and CCI was created. The resulting score was then
named risk of surgical complication (RoSCo) score.
With an overall complication rate of 26.6% (n ¼ 85),
the RoSCo was an independent predictor of surgical
complication and performed better than the PADUA
(68 vs 64%) and the RENAL score (68 vs 60%).
EVALUATION AND ASSOCIATION WITH
PERIOPERATIVE AND POSTOPERATIVE
OUTCOMES
One of the main aims of the scoring systems described
earlier is the improvement of risk and functional
outcomes assessment in patients undergoing NSS.
The first external evaluation of the PADUA score
was done by Waldert et al. [9]. They retrospectively
evaluated the data of 240 patients who either unde-
rwent open partial nephrectomy (OPN) or LPN. The
mean score was 7.5 (range 6–13). PADUA score was
able to predict the overall complication risk in uni-
variate analysis but not their severance (P < 0.001 and
P ¼ 0.567, respectively). A higher PADUA score sig-
nificantly predicted a higher overall operating time
and ischemic time (P ¼ 0.024 and 0.034, respe-
ctively), the significance for ischemic time being
most prominent in tumors with a PADUA score of
at least 10 (22 ± 12 vs 34 ± 42 min; P ¼ 0.006), but
failed to predict a higher blood loss (P > 0.05). On
multivariate analysis PADUA score was an indepe-
ndent predictor of the occurrence of complications
(OR 1.34; 95% CI 1.14–1.59; P ¼ 0.001) especially
when comparing patients with a PADUA score <10
and ³10 (OR 3.08; 95% CI 1.55–6.11; P ¼ 0.001).
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For the RENAL score, similar results were found in
141 patients undergoing LPN [10]. For low, moderate,
and high-complexity tumors, a statistically significant
difference in WIT (P ¼ 0.001), estimated blood loss
(EBL) (P ¼ 0.034), and length of hospital stay
(P < 0.001) was reported. No difference was found
in overall operating time, complication rate, or post-
operative renal function. Another study evaluated
the RENAL score on a total of 390 patients undergo-
ing either OPN or robotic-assisted NSS and observed a
higher WIT, EBL, and hospital stay for tumors with a
high (10–12) and intermediate (7–9) RENAL score.
Tumors with a high score also were associated with a
significant higher major complication rate
(P ¼ 0.009) [11].
The C-Index was shown to predict kidney func-
tion after LPN in a retrospective study of 131 patients
done by Samplaski et al. [12]. They reported a positive
correlation between C-Index and the nadir estimated
glomerular filtration rate (r ¼ 0.92; P ¼ 0.002) and a
negative correlation between C-Index and the per-
centage decrease in the estimated glomerular filtra-
tion rate (r ¼ 0.4; P < 0.001). A C-Index of less than
2.5 correlated with a 2.2-fold increased risk of 30% or
greater estimated glomerular filtration rate decrease.
Bylund et al. [13] evaluated the association of
tumor size, location, RENAL, PADUA, and C-Index
scores with perioperative outcomes of 162 patients.
Each of the three scoring systems was found to have a
significant correlation with WIT (P < 0.001), with the
C-Index showing the strongest association (0.482).
Otherwise, there was no strong correlation with the
other investigated parameters such as OR-time, EBL,
and change in eGFR. The PADUA score performed
minimally better than the other two showing a sig-
nificant correlation with OR-time and absolute/
percentage change in eGFR (P < 0.05). All of the three
classification systems performed better than tumor
size and exophytic classification alone. Okhunov
et al. [14] also analyzed the relationship of the three
scoring systems with various perioperative and post-
operative variables. In addition, they assessed the
interobserver reliability; 101 LPN cases were analyzed
for this purpose. Interobserver reliability was excel-
lent in all three scoring systems, showing interclass
correlations of 0.84 for the C-Index, 0.81 for the
PADUA score, and 0.92 for the RENAL score. All of
the three systems showed a significant association
with WIT and percentage change in creatinine level.
Additionaly, the C-Index correlated with hospitali-
zation time. Tumors that were rated being of moder-
ate and high complexity in both the RENAL and
PADUA scoring systems had greater percentage
change in serum creatinine level than low-complex-
ity tumors. Moreover, RENAL score-classified low-
complexity tumors had a significantly shorter WIT
www.co-urology.com 439
 Nephron-sparing surgery for renal cancers
than moderate or high-complexity lesions, a differ-
ence not observed for the PADUA score classification.
APPLICABILITY IN ROBOT-ASSISTED
PARTIAL NEPHRECTOMY
The Da Vinci system is increasingly used in managing
renal tumors with robotic-assisted NSS. Recently, few
articles applied the RENAL score in patients undergo-
ing partial nephrectomy purely with robotic assis-
tance and evaluated its predictive ability
concerning intraoperative and perioperative out-
comes. Mufarrij et al. [15] found that no variables
were associated with any of the outcomes they ana-
lyzed in 95 evaluated patients. They divided the cases
into tertiles based on their RENAL score of low,
medium, or high. They found no statistically signifi-
cant association with WIT, estimated blood loss,
operative time, length of stay, estimated glomerular
filtration rate or Clavien-graded complication rates.
&
Png et al. [16 ] anylazed 83 cases performed with
robotic assistance. In contrast to the first article,
tumors were only divided into two groups: noncom-
plex (RENAL score 4–6) and complex (RENAL score
7–12). Statistical differences were found in operative
time (P ¼ 0.028) and WIT (P ¼ 0.006). On regression
analysis, only WIT showed a significant trend with
the overall RENAL score (P ¼ 0.007). Regarding the
single components N(earness) and L(ocation), the N
score was associated with WIT and intraoperative
complications (P ¼ 0.013 and 0.044, respectively).
The L score was associated with WIT on univariate
&
regression analysis (P ¼ 0.031). Sea et al. [17 ] pre-
sented their retrospective experience with 119 cases
performed via the transperitoneal approach. In their
series, length of stay and collecting system entry were
correlated and predicted by nephrometry grade.
Nephrometry score correlated to operative time
and length of stay and was found to be predictive
in length of stay (P ¼ 0.024).
CONCLUSION
Standardized classifications of renal tumor anatomy
may allow better preoperative planning and counse-
ling of patients. If they gain widespread use in
clinical practice, they may also help to give reliable
comparisons of morbidity rates among different
partial nephrectomy techniques, individual surge-
ons, and institutions.
Acknowledgements
None.
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Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
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