title: Is surgeon intuition equivalent to models of operative complexity in determining the surgical approach for nephron sparing surgery?
abstract: BACKGROUND
  The choice of approach for partial nephrectomy often depends on surgical complexity. We aimed to determine if surgeon intuition was equivalent to markers of operative complexity, such as RENAL nephrometry and Mayo adhesive probability (MAP) score, in determining the surgical approach for partial nephrectomy (PN).
  
  
  METHODS
  We retrospectively identified 119 masses removed for suspected renal cell carcinoma from January 2012 to September 2014 by a single surgeon who intuitively chose treatment with one of three surgical approaches: Open PN (OPN), robotic-assisted transperitoneal PN (RATPN), or robotic-assisted retroperitoneal PN (RARPN). Clinicodemographic characteristics, pathological features, and postoperative outcomes were compared for each approach. Logistic regression was performed to identify independent predictors of open surgical resection, our primary endpoint.
  
  
  RESULTS
  Fifty-four tumors (45%) were resected via OPN, 40 (34%) via RATPN, and 25 (21%) via RARPN. OPN was performed in patients with more comorbidities (P = 0.02), lower baseline renal function (P < 0.01), more solitary kidneys (P < 0.01), and more multifocal disease (P < 0.01). Patients undergoing OPN had higher median nephrometry scores compared to RATPN and RARPN patients (8 vs. 7 vs. 7, respectively; P = 0.03), but MAP scores were no different among all three groups (P = 0.36). On multivariate analysis, higher nephrometry scores (odds ratio: 1.41, 95% confidence interval: 1.10-1.81; P = 0.007) were independently associated with open surgical resection. Nephrometry score was predictive of OPN (area under curve = 0.64, P = 0.01) with a score of 6.5 having the highest sensitivity and specificity (76% and 42%, respectively).
  
  
  CONCLUSIONS
  RENAL nephrometry score was associated with surgical approach intuitively chosen by an experienced surgeon, but the presence of adherent perinephric fat did not correlate with decision-making.
authors.affiliation: Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA.
authors.forename: Pranav
authors.initials: P
authors.lastname: Sharma
authors.affiliation: Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA.
authors.forename: Barrett Z
authors.initials: BZ
authors.lastname: McCormick
authors.affiliation: Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA.
authors.forename: Kamran
authors.initials: K
authors.lastname: Zargar-Shoshtari
authors.affiliation: Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA.
authors.forename: Wade J
authors.initials: WJ
authors.lastname: Sexton
keywords: Intuition; Mayo adhesive probability score; nephrometry score; partial nephrectomy; robotic surgery; surgical approach