预测T_(1b)期肾肿瘤保留肾单位手术疗效和安全性的列线图模型

Development and validation of a novel nephrometry nomogram model predicting perioperative outcomes of partial nephrectomy for T_(1b)renal masses

目的分析R.E.N.A.L.、PADUA、C-index、DAP评分与T_(1b)期肾肿瘤保留肾单位手术(NSS)疗效和安全性的相关性,并通过组合多项参数构建预测手术疗效和安全性的列线图模型。方法回顾性分析海军军医大学第一附属医院2020年3月至2021年7月收治的80例接受NSS的T_(1b)期肾肿瘤患者的资料。男59例,女21例;年龄(56.9±10.2)岁。肿瘤直径(4.7±0.9)cm;左右侧各40例;肿瘤位于上/下极46例,中部34例;肿瘤位于外侧59例,内侧21例;肿瘤外凸64例,内生16例;圆形肿瘤53例,小叶形18例,不规则形9例。R.E.N.A.L.评分中位值8(4~10)分,DAPUA评分9(6~12)分,C-index评分1.5(0.6~4.9)分,DAP评分7(4~9)分,梅奥肾周粘连指数(MAP)1(0~5)分。行开放手术1例,腹腔镜手术43例,机器人手术36例;经腹腔途径42例,经后腹腔途径38例。将手术切缘阴性、热缺血时间<20 min、无严重并发症3项指标均实现的综合结局(MIC)作为评估手术疗效和安全性的主要指标;次要指标为手术时间、术中出血量、术后住院时间、术后肌酐变化值和血红蛋白变化值。4种肾肿瘤评分与术后是否达成MIC的关系采用单因素logistic回归分析,与其他围手术期量化指标的相关性采用Spearman相关性分析。通过logistic回归分析相关危险因素,并构建预测手术疗效和安全性的列线图模型。采用受试者工作特征(ROC)曲线,比较列线图模型与其他评分系统的预测效能。结果80例中达成MIC者28例,未达成MIC者52例。两组体质指数、肿瘤形态、热缺血时间、术后第1天肌酐升高值、术后第1天血红蛋白下降值、术后并发症分级、R.E.N.A.L.评分和PADUA评分差异均有统计学意义(P<0.05)。单因素logistic回归分析结果示,PADUA、R.E.N.A.L.评分是达成MIC的危险因素(OR=1.419,P=0.038;OR=1.358,P=0.038);C-index评分和DAP评分不是达成MIC的危险因素(P>0.05)。相关性分析结果显示,R.E.N.A.L.评分与术后血红蛋白下降值显著相关(R^(2)=0.197);PADUA评分与术后住院时间显著相关(R^(2)=0.186);C-index评分与术后肌酐升高值显著相关(R^(2)=-0.221);DAP评分与手术时间显著相关(R^(2)=0.192)。单因素logistic回归分析结果显示,体质指数(OR=1.257,P=0.025)、肿瘤形态(OR=18.741,P=0.005)、肿瘤纵向位置(OR=1.992,P=0.038)、肿瘤与集合系统的关系(OR=4.886,P=0.002)是达成MIC的危险因素,将这些指标联合MAP共同构建列线图预测模型。ROC曲线显示,列线图模型及R.E.N.A.L.、PADUA、C-index、DAP评分的曲线下面积分别为0.834、0.645、0.643、0.526、0.593,列线图模型对T_(1b)期肾肿瘤达成MIC的预测效能最高。结论肾肿瘤评分系统中,PADUA和R.E.N.A.L.评分可预测T_(1b)期肾肿瘤NSS后是否达成MIC;由患者体质指数、肿瘤形态、肿瘤纵向位置、肿瘤与集合系统关系和MAP构建的列线图模型能更好地预测T_(1b)期肾肿瘤NSS后是否达成MIC。

Objective To analyze the correlation between R.E.N.A.L.,PADUA,C-index,DAP scoring system and the efficacy and safety of nephron-sparing surgery(NSS)for T_(1b) renal tumors,and to construct a nomogram model to predict the efficacy and safety of surgery by combining multiple parameters.Methods The data of 80 patients with stage T_(1b) renal tumor who received NSS from March 2020 to July 2021 in Changhai Hospital of Naval Military Medical University were retrospectively analyzed.There were 59 males and 21 females,aged(56.9±10.2)years old.The tumor diameter was(4.7±0.9)cm,with 40 cases on the left and 40 on the right sides.Tumors were located in the upper/lower pole in 46 cases and in the middle in 34 cases.The tumors were located in 59 cases laterally,21 cases medially,and 74 cases were bulging,16 cases endogenous.There were 53 round tumors,18 lobular tumors,and 9 irregular tumors.One case underwent open surgery,43 cases underwent laparoscopic surgery,and 36 cases underwent robotic surgery.42 cases underwent transperitoneal approach,and 38 cases underwent retroperitoneal approach.The composite outcome(MIC)achieved by all three indicators,including negative surgical margins,warm ischemia time<20 min,and no serious complications,was used as the main indicator to evaluate the efficacy and safety of surgery.Secondary indicators were operation time,intraoperative blood loss,postoperative hospital stay,postoperative creatinine changes and hemoglobin changes.Relevant risk factors were analyzed by logistic regression,and a nomogram model for predicting surgical efficacy and safety was constructed.Receiver operating characteristic(ROC)curves were used to compare the predictive power of the nomogram model with other scoring systems.Results Univariate logistic regression analysis showed that PADUA and R.E.N.A.L.scores were risk factors for MIC achievement(OR=1.419,P=0.038;OR=1.358,P=0.038).However,C-index and DAP were not risk factors for MIC achievement(P>0.05).The results of correlation analysis showed that R.E.N.A.L.score was significantly correlated with postoperative hemoglobin decrease(R^(2)=0.197).PADUA score was significantly correlated with postoperative hospital stay(R^(2)=0.186).C-index was significantly correlated with postoperative creatinine increase(R^(2)=-0.221).DAP was significantly associated with operation time(R^(2)=0.192).The results of univariate logistic regression analysis showed that body mass index(OR=1.257,P=0.025),tumor morphology(OR=18.741,P=0.005),longitudinal location of tumor(OR=1.992,P=0.038),the relationship between tumor and collection system(OR=4.886,P=0.002)were risk factors for MIC attainment.A nomogram prediction model was constructed by combining these indicators with the Mayo adhesive probability(MAP)index.The ROC curve showed that the area under the curve(AUC)of the nomogram model and R.E.N.A.L.score,PADUA score,C-index,and DAP were 0.834,0.645,0.643,0.526,and 0.593,respectively.The nomogram model had the highest predictive power for T_(1b) renal tumors achieving MIC.Conclusions In the renal tumor scoring system,PADUA and R.E.N.A.L.scores can predict whether the MIC of T_(1b) renal tumor NSS is achieved or not.The nomogram model composed of patient body mass index,tumor shape,longitudinal position of tumor,relationship between tumor and collecting system and MAP can better predict whether the MIC of T_(1b) renal tumor NSS is achieved or not.