title: Need for intraoperative ultrasound and surgical recommendation for partial nephrectomy: correlation with tumor imaging features and urologist practice patterns.
abstract: OBJECTIVE
  This study aimed to evaluate the need for intraoperative ultrasound (IOUS) and recommendation for surgical approach in the resection of renal tumors through a survey of practicing urologists, with correlation to tumor imaging features and urologist practice pattern.
  
  
  METHODS
  An institutional review board-approved retrospective review, compliant with the Health Insurance Portability and Accountability Act, of 44 renal tumors that underwent laparoscopic partial nephrectomy at the study institution was performed. The numeric component of the RENAL nephrometry score (radius [diameter], % exophytic, nearness [to collecting system/renal sinus], location) was calculated for each case using preoperative computed tomography/magnetic resonance imaging. Five anonymized images of each tumor were presented to 4 academic urologists with varying practice patterns. Reviewers independently scored each case for its need for IOUS, for recommendation of a surgical technique, and for the difficulty of the proposed surgery.
  
  
  RESULTS
  The RENAL scores were as follows: RENAL 1 (low complexity, score 4-6; n = 19); RENAL 2 (moderate complexity, score 7-9; n = 23); RENAL 3 (high complexity, score 10-12; n = 2). The only RENAL score component significantly influencing need for IOUS was percentage exophytic (P = 0.00002). There was an inverse relationship between normalized and averaged need for IOUS and percentage exophytic (P < 0.0001). The predominant influence for recommendation of surgical method was the reviewer him/herself, with each reviewer's recommendations closely matching his/her practice pattern. Size and percentage exophytic represented the only tumor features significantly (P = 0.03) influencing surgical recommendation.
  
  
  CONCLUSIONS
  There was a significant difference in the perceived need for IOUS and surgical recommendation when 4 academic urologists reviewed a series of renal masses requiring resection. Percentage exophytic correlated inversely with need for IOUS. Urologist's practice pattern and tumor size and percentage exophytic were most predictive of surgical recommendation.
authors.affiliation: Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA. msun@bidmc.harvard.edu
authors.forename: Maryellen R M
authors.initials: MR
authors.lastname: Sun
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Wagner
authors.forename: Ignacio F
authors.initials: IF
authors.lastname: San Francisco
authors.forename: Alexander
authors.initials: A
authors.lastname: Brook
authors.forename: Louis
authors.initials: L
authors.lastname: Kavoussi
authors.forename: Paul
authors.initials: P
authors.lastname: Russo
authors.forename: Graeme
authors.initials: G
authors.lastname: Steele
authors.forename: Rosalia
authors.initials: R
authors.lastname: Viterbo
authors.forename: Ivan
authors.initials: I
authors.lastname: Pedrosa
mesh_terms: D003937:Diagnosis, Differential; D006801:Humans; D007432:Intraoperative Period; D007668:Kidney / Q000000981:diagnostic imaging* / Q000473:pathology; D007680:Kidney Neoplasms / Q000175:diagnosis* / Q000601:surgery; D010535:Laparoscopy; D008279:Magnetic Resonance Imaging; D009392:Nephrectomy / Q000379:methods*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D015203:Reproducibility of Results; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography