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Review article
Utility of the RENAL index – Radius; Exophytic/endophytic; Nearness to sinus; Anterior/posterior; Location relative to polar lines – in the management of renal masses
Utilidad del índice RENAL – Radius; Exo/endophitic; Nearnes to sinus; Anterior/posterior; Location relative to polar lines – en el manejo de las masas renales
C. Konstantinidisa,
Corresponding author
cristiank1979@yahoo.com

Corresponding author.
, E. Trillaa,b, D. Lorentea,b, J. Morotea,b
a Universidad Autónoma de Barcelona, Barcelona, Spain
b Servicio de Urología y Trasplante Renal, Hospital Universitario Vall d’Hebron, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years we have witnessed significant changes in the management of renal masses&#46; There is a clear trend toward the conservation of a greater amount of renal parenchyma&#44; which has resulted in positioning partial nephrectomy &#40;PN&#41; as standard treatment of most kidney tumors in stage T1a&#46; In addition&#44; other therapeutic strategies are being evaluated in selected cases&#44; such as active surveillance &#40;AS&#41; or ablative therapies&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Currently&#44; more than 50&#37; of diagnoses of renal masses are carried out as an incidental finding on ultrasound or computed tomography &#40;CT&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">2</span></a> The therapeutic decision is usually made using clinical information and images&#46; In an attempt to provide more useful information obtained through CT&#44; in 2009 Kutikov and Uzzo published the R&#46;E&#46;N&#46;A&#46;L&#46; Nephrometry Score &#40;Radius&#59; Exo&#47;endophitic&#59; Nearnes to sinus&#59; Anterior&#47;posterior&#59; Location relative to polar lines&#41; which evaluates and standardizes the tumor anatomy according to five criteria that allow for stratifying three levels of complexity for each lesion&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To this day&#44; there is no consensus on the usefulness of the RENAL score to choose the treatment of a patient with a renal mass&#46; This article reviews the scientific evidence linking the RENAL score with aspects related to the management of renal masses&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Evidence acquisition</span><p id="par0020" class="elsevierStylePara elsevierViewall">A search was made in Medline limited to articles in English and Spanish published until November 2015 using the following terms&#58; &#8216;R&#46;E&#46;N&#46;A&#46;L&#46; &#40;125 results&#41;&#44; &#8216;Nephrometry&#8217; &#40;285 results&#41;&#44; &#8216;Renal Score&#8217; &#40;63 results&#41;&#44; &#8216;R&#46;E&#46;N&#46;A&#46;L&#46; Score &#8216;&#40;29 results&#41; and &#8216;R&#46;E&#46;N&#46;A&#46;L&#46; Nephrometry Score &#8216;&#40;74 results&#41;&#46; Twenty-three additional citations from previous references were obtained&#46; A selection process and discard of citations according to the PRISMA statement was conducted&#46; Finally&#44; 96 articles &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; were reviewed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Evidence synthesis</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">RENAL score definition and characteristics</span><p id="par0025" class="elsevierStylePara elsevierViewall">The RENAL score is a scoring system to characterize important aspects of renal tumors considering its size&#44; location and depth&#46; In this way&#44; tumor complexity is standardized according to the final score as low &#40;4&#8211;6&#41;&#44; moderate &#40;7&#8211;9&#41;&#44; and high &#40;10&#8211;12&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The histological correlation of the RENAL score was studied in 2011 by Uzzo and Kutikov&#46; They published a retrospective study in which they analyzed 525 surgically intervened masses and compared the RENAL score with histological findings&#46; They observed a significant association between RENAL score and malignancy mass and Fuhrman grade&#46; The authors developed a nomogram that included sex&#44; age and RENAL score variables&#44; which can be consulted in <a id="intr0010" class="elsevierStyleInterRef" href="http://www.cancernomograms.com/nephrometrynomogram">www&#46;cancernomograms&#46;com&#47;nephrometrynomogram</a>&#46; The nomogram quantitates the likelihood of malignancy and high-grade disease&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Similarly&#44; in 2012 Wang et al&#46; published a retrospective study of external validation of the nomogram in 391 patients confirming its validity&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">5</span></a> In 2014 Koo et al&#46; conducted a similar study on 1219 renal masses and confirmed the validity of the model exclusively for predicting malignity&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Interobserver variability</span><p id="par0040" class="elsevierStylePara elsevierViewall">In 2011&#44; Weight et al&#46; studied the interobserver variability to calculate the RENAL score between six reviewers&#58; two urologists&#44; a radiologist&#44; a urology resident&#44; a radiology resident and a medical student in 96 consecutive renal tumors&#46; They observed a high level of agreement between all participants&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">7</span></a> Another study in 2011 by Kolla et al&#46; compared the score obtained by three surgeons for each of the variables of the score applied to 51 patients&#46; They noted a complete concordance score of 0&#46;80&#44; and for individual variables&#44; 0&#46;95 &#40;R&#41;&#44; 0&#46;86 &#40;E&#41;&#44; 0&#46;76 &#40;N&#41;&#44; 0&#46;84 &#40;A&#41; and 0&#46;73 &#40;L&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The analysis of the relationship between certain radiographic findings and specific genetic mutations is known as radiogenomic&#46; It has been associated with prognosis&#44; biological behavior&#44; and sensitivity to medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">9</span></a> In 2015&#44; Shinagare et al&#46; published a retrospective study that analyzed small renal masses &#40;SRMs&#41; in 103 patients&#46; They found an association between exophytic growth and a mutation of good prognosis in the mucin 4 gene&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">10</span></a> These findings show that the RENAL score could be related to the biological behavior of a renal mass &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Relationship between RENAL score and active surveillance</span><p id="par0050" class="elsevierStylePara elsevierViewall">In the selected patients&#44; the AS is a strategy for increasing acceptance in the management of SRMs&#46; Several studies have observed a rate of metastatic disease during follow-up lower than 2&#37;&#46; Moreover&#44; we know from the histological analysis of the SRMs that only 20&#8211;25&#37; is a potentially aggressive cancer&#44; while 60&#37; is an indolent tumor and the remaining 20&#37; is benign lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Tomaszewski et al&#46; published in 2014 a retrospective study involving more than 1000 patients&#44; of which 195 were managed by AS&#46; They reported that each component of the RENAL score was significantly related to the decision for AS or immediate surgical treatment&#46; In addition&#44; they reported that both the final score and the modified score &#40;which assesses tumor morphology regardless of the size&#44; eliminating the variable R&#41; significantly influence the decision&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The linear growth rate of lesion is commonly used to define the need for a definitive treatment when a AS protocol is established&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">13</span></a> Mehrazin et al&#46; in 2015 conducted a retrospective study with 346 patients and 401 SRMs in AS with a median follow-up of 37 months and analyzed the association between the pattern of linear growth and RENAL score&#46; When comparing patients who remained in AS with those who required surgery&#44; the authors determined that the tumors that were located near the collecting system or contacted artery or renal vein were significantly associated to receive surgical treatment&#46; The authors proposed a predictive model in which each point of the RENAL score would add an increase per year of 0&#46;037<span class="elsevierStyleHsp" style=""></span>cm of the lineal score growth&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Relationship between RENAL score and ablative therapy</span><p id="par0065" class="elsevierStylePara elsevierViewall">Ablative therapies are treatment alternatives to the PN in the management of SRMs in patients that are not suitable candidates for surgery or who reject it&#46; Although this type of treatment still requires a long-term validation&#44; it has been reported rates of recurrence-free survival greater than 90&#37; and survival rate greater than 95&#37; at 5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">15</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In 2015 Camacho et al&#46; conducted a retrospective 5-year study with 87 patients&#46; There were a total of 101 renal masses included with an average diameter of 2<span class="elsevierStyleHsp" style=""></span>cm &#40;all with positive biopsy for CCR&#41;&#46; Patients were treated with cryotherapy or percutaneous radiofrequency &#40;54 and 46&#37;&#44; respectively&#41;&#46; It was observed that a RENAL score greater than eight was significantly associated with an increased incidence of complications&#44; post-treatment relapse in the first year and overall rate of relapse&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">16</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In 2013 Schmit et al&#46; studied the prognostic value of RENAL score in 627 patients and 751 tumors with a mean diameter of 2&#46;7<span class="elsevierStyleHsp" style=""></span>cm&#46; They were treated with cryotherapy &#40;57&#37;&#41; or percutaneous radio-frequency &#40;43&#37;&#41;&#46; The authors observed a significant association between RENAL score and ablation failure &#40;defined as the persistence of contrast enhancement in the treated area during the first three months&#41; and recurrence within the first two years&#46; The authors noted that the average RENAL score of tumors with ablative failure was 7&#46;6 vs&#46; 6&#46;7 of tumors that did not fail &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; They also reported a significant association between RENAL score and the rate of major complications &#40;Clavien-Dindo<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">However&#44; they found no association between RENAL score and the development of renal function&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Relationship between RENAL score and partial nephrectomy</span><p id="par0085" class="elsevierStylePara elsevierViewall">The PN is considered the standard treatment of SRMs&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">1</span></a> The oncological results are comparable to those of radical nephrectomy &#40;RN&#41;&#46; However&#44; it is associated with a higher rate of complications&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">18</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In 2011 Simhan et al&#46; conducted a retrospective review of 390 patients undergoing PN &#40;55&#46;4&#37; open and 44&#46;6&#37; robotic PN&#41; by SRMs&#46; They stratified the results according to RENAL score &#40;low 28&#37;&#44; moderate 55&#46;6&#37; and high 16&#46;4&#37;&#41;&#44; and the severity of complications according to Clavien&#8211;Dindo classification&#46; The authors observed that the presence of major complications &#40;Clavien&#8211;Dindo 3&#8211;4&#41; was greater in the group of high complexity &#40;21&#46;9&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41; in contrast to groups of moderate complexity &#40;11&#46;1&#37;&#41; and low &#40;6&#46;4&#37;&#41;&#46; Overall&#44; the authors found that patients with highly complex SRMs according to the RENAL score treated by PN had a 5&#46;4 times higher likelihood of presenting major complications&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">19</span></a> These results are consistent with those presented in 2011 by Bruner et al&#46; In their series of 124 PN&#44; they found a significant association between RENAL score and the risk of urinary fistula &#40;being the &#8220;E&#8221; parameter which had the highest association&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">20</span></a> They are also consistent with the results published in 2012 by Stroup et al&#46; who analyzed 281patients undergoing PN&#46; They showed a significant association between RENAL score and the development of postoperative urinary fistula&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">21</span></a> Also&#44; in 2012 Rosevear et al&#46; observed that RENAL scores were higher in 91 with PN who developed complications than in patients with PN who did not develop complications &#40;6&#46;9 vs&#46; 6&#46;0&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#41;&#46; However&#44; they did not notice differences in the severity of those complications according to the Clavien&#8211;Dindo classification&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">22</span></a> Another study published in 2013 by Liu et al&#46; analyzed 181 PN &#40;128 laparoscopic and 53 robotic&#41; in cT1 tumors&#46; They found significant differences in the rate of postoperative complications&#58; according to RENAL score 5&#46;8&#37;&#44; 16&#37; and 50&#37; of postoperative lesions were low&#44; medium and high complexity&#44; respectively&#46; The authors observed a significant association between RENAL score and the incidence of major complications &#40;Clavien&#8211;Dindo 3&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">23</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In contrast to previous studies&#44; other authors have found no association between RENAL score and complication rate&#46; Moreno-Alarc&#243;n et al&#46; published in 2014 a retrospective review of 84 PN without showing significant relationship between RENAL score and the appearance of complications&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">24</span></a> Similarly&#44; Long et al&#46;&#44; in their retrospective study of 177 PN&#44; did not observe a significant association between RENAL score and the development of postoperative complications&#46; However&#44; they noted that the RENAL score was a predictive factor for the conversion to RN and prolonged warm ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">25</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The loss of renal mass and a warm ischemia time longer than 25<span class="elsevierStyleHsp" style=""></span>min are the key factors that determine the loss of renal function in the context of PN&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">26</span></a> In 2014&#44; Tomaszewski et al&#46; conducted a retrospective study of 375 patients undergoing robotic PN&#46; They analyzed the relationship between RENAL score and prolonged warm ischemia longer than or equal to 30<span class="elsevierStyleHsp" style=""></span>min&#46; The authors observed a significant association between prolonged ischemia and RENAL score of high and moderate complexity&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">27</span></a> These results are consistent with those previously published by Altunrende et al&#46; in 2013&#46; They described the results of 187 robotic PN and found a significant difference between ischemic times of each group of complexity &#40;low 13&#46;6<span class="elsevierStyleHsp" style=""></span>min&#59; moderate 20&#46;3<span class="elsevierStyleHsp" style=""></span>min&#59; high 28&#46;1<span class="elsevierStyleHsp" style=""></span>min&#41;&#46; The authors found a significant relationship between ischemia time and individual score parameters &#8220;R&#8221;&#44; &#8220;E&#8221; and &#8220;N&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">28</span></a> Liu et al&#46; also evaluated the ischemia time differences between the three groups of complexity according to RENAL score&#44; observing 29&#44; 33 and 39<span class="elsevierStyleHsp" style=""></span>min times for low&#44; medium and high complexity groups&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">23</span></a> These results contrast with those published in 2011 by Mufarrij et al&#46; on 92 robot-assisted PN&#44; which they did not observe a relationship between the RENAL score and ischemia time&#44; the rate of complications&#44; operative time and hospital length of stay&#46; However&#44; the same authors point out that the lack of homogeneity of the groups analyzed &#40;there were 66&#44; 22&#44; and 4 patients in the low&#44; medium&#44; and high complexity group&#44; respectively&#41; could have conditioned their outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">29</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Kwon et al&#46; conducted an accurate assessment of the change in renal function after a PN and established a possible predictive role of RENAL score&#46; They evaluated the renal function before and after surgery by estimating the glomerular filtration rate using technetium-99m&#46; Kwon et al&#46; conducted a retrospective analysis of 185 patients treated with PN in whom glomerular filtration prior to surgery was determined and in postoperative controls at 6&#44; 18 and 30 months&#46; They noted that patients with RENAL score of moderate or high complexity showed significantly further deterioration of glomerular filtration rate than those with low complexity tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">30</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">There is little scientific evidence linking the RENAL score with the oncological outcome&#46; In 2014&#44; Kopp et al&#46; analyzed 202 patients with renal tumor in stage cT2 treated by RN &#40;80&#41; or PN &#40;122&#41; with a mean follow-up of 41 months&#46; In the overall analysis&#44; the only significant difference between these two groups was tumor size&#44; which was higher in the RN group &#40;10&#46;2 vs&#46; 8&#46;8<span class="elsevierStyleHsp" style=""></span>cm&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; When evaluating the results according to the type of surgery performed&#44; the authors did not find differences in overall survival&#44; cancer-specific and recurrence-free survival between these two treatments &#40;RN vs&#46; PN&#41;&#46; However&#44; Kopp et al&#46; divided the results into two groups according to RENAL score and observed that patients who had tumors greater than or equal to 10 score showed five times higher risk of recurrence and seven times higher risk of overall mortality&#44; regardless of the surgical technique used&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Relationship between RENAL score and radical nephrectomy</span><p id="par0115" class="elsevierStylePara elsevierViewall">There is scarce scientific evidence that links the results of the RN with RENAL score&#46; In 2016 Nagahara et al&#46; published a retrospective study comprising 91 patients with non-small localized renal cell carcinoma &#40;pT1b&#8211;T2b&#41; undergoing RN&#46; They found that patients with tumors greater than or equal to 10 score had a lower recurrence-free survival at 5 and 10 years of follow-up &#40;70&#37; and 55&#37;&#44; respectively&#41; compared with the group that had a score lower than 10 &#40;95&#37; for both&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">32</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">An increased number of renal mass diagnoses and a broadening range of treatment make it necessary to have tools to choose the most appropriate option for each patient&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">17</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The RENAL score standardizes the complexity of renal masses&#44; which facilitates the comparison of the results observed in the different series&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">33</span></a> From the clinical point of view&#44; the RENAL score would allow for an individualized approach on the rate of complications&#44; changes in renal function and oncologic outcomes for each of the treatments available&#46; In addition&#44; some authors show that the RENAL score could be used to adapt the learning curve according to the surgeon&#39;s experience and tumor complexity&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">21</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">As minimally invasive techniques are becoming more common&#44; we urologists are increasingly demanding their applications&#46; The assessment of the emerging techniques may be enhanced by the use of RENAL score&#46; Thus&#44; there are studies like the one published by Wang et al&#46; in which the robotic PN was compared to laparoscopic in renal masses with RENAL score greater than or equal to 7&#46; They noted that both strategies had complication rates&#44; preservation of renal function and similar oncologic results&#46; However&#44; they noted that robotic PN had lower transfusion rates while laparoscopic PN was the most efficient strategy for this type of tumor&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">34</span></a> In another study by Wang et al&#46; a small incision is proposed to perform an open PN in renal tumors with RENAL score greater than or equal to 10&#46; They concluded that this technique can be beneficial in high-complexity tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">35</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In addition to the RENAL score&#44; there are other scoring systems to evaluate the anatomy of renal masses&#46; Ficarra et al&#46; proposed in 2009 the Preoperative Aspects and Dimensions used for an Anatomical Classification system&#44; better known as PADUA&#44;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">36</span></a> while Simmons et al&#46; presented in 2010 the C-index&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">37</span></a> Two years later&#44; Simmons et al&#46; proposed a RENAL score integration with the C-index to generate the DAP &#40;diameter-axial-polar nephrometry&#41; score&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">38</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Studies comparing those nephrometry scores are scarce&#46; In 2011&#44; Okhunov et al&#46; studied the relationship between the results of 101 PN and RENAL and PADUA scores as well as C-index&#46; They noted that three of them had poor interobserver variability and were associated with ischemia time and renal function&#46; However&#44; they found no relationship between any of those scores and the rate of complications&#44; operative time&#44; or hospital length of stay&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">33</span></a> The nephrometry approach is undergoing a rapid development and while some authors question its applicability&#44; others raise new proposals&#46; Tobert et al&#46; analyzed individual variables from RENAL&#44; PADUA scores and C-index and proposed a second-generation score composed of the variables that were statistically significant to each of them&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">39</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Finally&#44; we believe that the use of a nephrometry score to standardize the anatomy of renal masses is currently essential in order to assess the outcomes of the scientific literature&#46; It is also useful as a decision-making tool in clinical practice&#46; The RENAL score has been extensively evaluated by different groups&#44; showing a high interobserver agreement and a high predictive profile on clinical events as relevant as the rate of complications&#44; transfusion rate&#44; warm ischemia time&#44; changes in renal function and oncologic outcomes&#46; Therefore&#44; the inclusion of RENAL score in clinical practice is&#44; in our view&#44; highly recommended&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusions</span><p id="par0150" class="elsevierStylePara elsevierViewall">The RENAL nephrometry score represents an objective and reproducible measurement tool for renal tumor complexity&#46; It correlates with surgical outcomes such as the rate of postoperative complications&#44; the evolution of renal function after a PN and oncologic results&#46; Applying a nephrometry score like RENAL score is useful in order to compare the outcomes of the scientific literature and may be useful as a decision-making tool in clinical practice&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflict of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Evidence acquisition"
        ]
        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Evidence synthesis"
          "secciones" => array:6 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "RENAL score definition and characteristics"
            ]
            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Interobserver variability"
            ]
            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Relationship between RENAL score and active surveillance"
            ]
            3 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Relationship between RENAL score and ablative therapy"
            ]
            4 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Relationship between RENAL score and partial nephrectomy"
            ]
            5 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Relationship between RENAL score and radical nephrectomy"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conclusions"
        ]
        9 => array:2 [
          "identificador" => "sec0060"
          "titulo" => "Conflict of interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-03-04"
    "fechaAceptado" => "2016-04-08"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec764361"
          "palabras" => array:6 [
            0 => "Renal tumor"
            1 => "Active surveillance"
            2 => "Ablative therapy"
            3 => "Partial nephrectomy"
            4 => "Prognosis"
            5 => "RENAL nephrometry index"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec764362"
          "palabras" => array:6 [
            0 => "Tumor renal"
            1 => "Vigilancia activa"
            2 => "Terapia ablativa"
            3 => "Nefrectom&#237;a parcial"
            4 => "Pron&#243;stico"
            5 => "&#205;ndice nefrom&#233;trico RENAL"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Context</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The growing incidence of renal masses and the wide range of available treatments require predictive tools that support the decision making process&#46; The RENAL index &#8211; <span class="elsevierStyleItalic">R</span>adius&#59; <span class="elsevierStyleItalic">E</span>xophytic&#47;endophytic&#59; <span class="elsevierStyleItalic">N</span>earness to sinus&#59; <span class="elsevierStyleItalic">A</span>nterior&#47;posterior&#59; <span class="elsevierStyleItalic">L</span>ocation relative to polar lines &#8211; helps standardize the anatomy of a renal mass by differentiating three groups of complexity&#46; Since the introduction of the index&#44; there have been a growing number of studies&#44; some of which have been conflicting&#44; that have evaluated the clinical utility of its implementation&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To analyze the scientific evidence on the relationship between the RENAL index and the main strategies for managing renal masses&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Acquisition of the evidence</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A search was conducted in the Medline database&#44; which found 576 references on the RENAL index&#46; In keeping with the PRISM Declaration&#44; we selected 100 abstracts and ultimately reviewed 96 articles&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Synthesis of the evidence</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The RENAL index has a high degree of interobserver correlation and has been validated as a predictive nomogram of histological results&#46; In active surveillance&#44; the index has been related to the tumor growth rate and probability of nephrectomy&#46; In ablative therapy&#44; the index has been associated with therapeutic efficacy&#44; complications and tumor recurrence&#46; In partial nephrectomy&#44; the index has been related to the rate of complications&#44; conversion to radical surgery&#44; ischemia time&#44; function preservation and tumor recurrence&#44; a finding also observed in radical nephrectomy&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The RENAL index is an objective&#44; reproducible and useful system as a predictive tool of highly relevant clinical parameters such as the rate of complications&#44; ischemia time&#44; renal function and oncological results in the various currently accepted treatments for the management of renal masses&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Context"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objective"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Acquisition of the evidence"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Synthesis of the evidence"
          ]
          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Contexto</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La creciente incidencia de las masas renales y el amplio abanico de tratamientos disponibles hacen necesario el establecimiento de herramientas predictivas que apoyen la toma de decisiones&#46; El &#237;ndice RENAL &#8211; <span class="elsevierStyleItalic">R</span>adius&#59; <span class="elsevierStyleItalic">E</span>xo&#47;endophitic&#59; <span class="elsevierStyleItalic">N</span>earnes to sinus&#59; <span class="elsevierStyleItalic">A</span>nterior&#47;posterior&#59; <span class="elsevierStyleItalic">L</span>ocation relative to polar lines &#8211; permite estandarizar la anatom&#237;a de una masa renal diferenciando 3 grupos de complejidad&#46; Desde su presentaci&#243;n existe una creciente&#44; y a veces contradictoria&#44; literatura que eval&#250;a la utilidad cl&#237;nica de su aplicaci&#243;n&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Analizar la evidencia cient&#237;fica sobre la relaci&#243;n entre el &#237;ndice RENAL y las principales estrategias para el manejo de una masa renal&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Adquisici&#243;n de la evidencia</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; una b&#250;squeda en la base de datos Medline&#44; encontrando 576 citas bibliogr&#225;ficas sobre el &#237;ndice RENAL&#46; De acuerdo con la Declaraci&#243;n PRISMA se seleccionaron 100 res&#250;menes y finalmente se revisaron 96 art&#237;culos&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">S&#237;ntesis de la evidencia</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El &#237;ndice RENAL tiene un alto grado de concordancia interobservador y ha sido validado como nomograma predictivo de resultado histol&#243;gico&#46; En vigilancia activa se ha relacionado con la velocidad de crecimiento tumoral y la probabilidad de nefrectom&#237;a&#46; En terapia ablativa se ha asociado con la eficacia terap&#233;utica&#44; complicaciones y recidiva tumoral&#46; En nefrectom&#237;a parcial se ha relacionado con la tasa de complicaciones&#44; la conversi&#243;n a cirug&#237;a radical&#44; el tiempo de isquemia&#44; la preservaci&#243;n funcional y la recidiva tumoral&#44; hallazgo tambi&#233;n observado en nefrectom&#237;a radical&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El &#237;ndice RENAL es un sistema objetivo&#44; reproducible y &#250;til como herramienta predictiva de par&#225;metros cl&#237;nicos tan relevantes como la tasa de complicaciones&#44; el tiempo de isquemia&#44; la funci&#243;n renal y los resultados oncol&#243;gicos en los diversos tratamientos actualmente aceptados para el manejo de una masa renal&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Contexto"
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          1 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Objetivo"
          ]
          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Adquisici&#243;n de la evidencia"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "S&#237;ntesis de la evidencia"
          ]
          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Konstantinidis C&#44; Trilla E&#44; Lorente D&#44; Morote J&#46; Utilidad del &#237;ndice RENAL &#8211; Radius&#59; Exo&#47;endophitic&#59; Nearnes to sinus&#59; Anterior&#47;posterior&#59; Location relative to polar lines &#8211; en el manejo de las masas renales&#46; Actas Urol Esp&#46; 2016&#59;40&#58;601&#8211;607&#46;</p>"
      ]
    ]
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        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Selecting and disposal of citations according to the PRISMA Statement&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Representation of the scoring system for calculating the RENAL index taken from Kutikov and Uzzo&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a></p>"
        ]
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Taken and adapted from Kutikov and Uzzo&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">3</span></a></p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">One point&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Two points&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Three points&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Maximum radius</span> &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8804;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;4 but &#60;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Exophytic or endophytic</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fully endophytic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Closeness to the collecting system or renal sinus &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8805;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;4 but &#60;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8804;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anterior or posterior&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="3" align="left" valign="top">No score is assigned&#44; only the suffix &#8220;a&#8221;&#44; &#8220;p&#8221; or &#8220;x&#8221; is assigned if it cannot be defined</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Location relative to the polar lines</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Completely above or below the lines&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The injury crosses some polar line&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More than 50&#37; of the tumor crosses some polar line &#40;a&#41; or crosses the axial midline &#40;b&#41; or is completely located between the polar lines &#40;c&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top">The suffix &#8220;h&#8221; is added if the tumor is in contact with the vein or renal artery</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">RENAL index scoring system&#46;</p>"
        ]
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:39 [
            0 => array:3 [
              "identificador" => "bib0200"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guideline for management of the clinical T1 renal mass"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;C&#46; Campbell"
                            1 => "A&#46;C&#46; Novick"
                            2 => "A&#46; Belldegrun"
                            3 => "M&#46;L&#46; Blute"
                            4 => "G&#46;K&#46; Chow"
                            5 => "I&#46;H&#46; Derweesh"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.juro.2009.07.004"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Urol"
                        "fecha" => "2009"
                        "volumen" => "182"
                        "paginaInicial" => "1271"
                        "paginaFinal" => "1279"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19683266"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0205"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "New epidemiologic patterns and risk factors in renal cancer"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46;J&#46; Anglada Curado"
                            1 => "P&#46; Campos Hernandez"
                            2 => "R&#46; Prieto Castro"
                            3 => "J&#46;L&#46; Carazo Carazo"
                            4 => "J&#46;C&#46; Regueiro Lopez"
                            5 => "F&#46; Vela Jimenez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Actas Urol Esp"
                        "fecha" => "2009"
                        "volumen" => "33"
                        "paginaInicial" => "459"
                        "paginaFinal" => "467"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19658298"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0210"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The R&#46;E&#46;N&#46;A&#46;L&#46; nephrometry score&#58; a comprehensive standardized system for quantitating renal tumor size&#44; location and depth"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Kutikov"
                            1 => "R&#46;G&#46; Uzzo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.juro.2009.05.035"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Urol"
                        "fecha" => "2009"
                        "volumen" => "182"
                        "paginaInicial" => "844"
                        "paginaFinal" => "853"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19616235"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anatomic features of enhancing renal masses predict malignant and high-grade pathology&#58; a preoperative nomogram using the RENAL nephrometry score"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Kutikov"
                            1 => "M&#46;C&#46; Smaldone"
                            2 => "B&#46;L&#46; Egleston"
                            3 => "B&#46;J&#46; Manley"
                            4 => "D&#46;J&#46; Canter"
                            5 => "J&#46; Simhan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.eururo.2011.03.029"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Urol"
                        "fecha" => "2011"
                        "volumen" => "60"
                        "paginaInicial" => "241"
                        "paginaFinal" => "248"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21458155"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "External validation of a nomogram using RENAL nephrometry score to predict high grade renal cell carcinoma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;K&#46; Wang"
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Article information
ISSN: 21735786
Original language: English
DOI:10.1016/j.acuroe.2016.09.005
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