World Journal of Urology

, Volume 33, Issue 6, pp 853–858 | Cite as

Interobserver variability of R.E.N.A.L., PADUA, and centrality index nephrometry score systems

  • Massimiliano Spaliviero
  • Bing Ying Poon
  • Omer Aras
  • Pier Luigi Di Paolo
  • Giuliano B. Guglielmetti
  • Christian Z. Coleman
  • Christoph A. Karlo
  • Melanie L. Bernstein
  • Daniel D. Sjoberg
  • Paul Russo
  • Karim A. Touijer
  • Oguz Akin
  • Jonathan A. ColemanEmail author
Original Article



To assess interobserver variability of R.E.N.A.L., preoperative aspects and dimensions used for an anatomical classification system (PADUA), and centrality index (C-Index) systems among observers with varying degrees of clinical experience and each system’s subscale correlation with surgical outcome metrics.


Computed tomography images of 90 patients who underwent open, laparoscopic, or robot-assisted laparoscopic partial nephrectomy were scored by one radiology fellow, two urology fellows, one radiology resident, and one secondary school student. Agreement among readers was determined calculating intraclass correlation coefficients. Associations between radiology fellow scores (reference standard as reader with greatest clinical experience), ischemia time, and percent change in postoperative estimated glomerular filtration rate (eGFR) were evaluated using Spearman’s correlation.


Agreement using C-Index method (ICC = 0.773) was higher than with PADUA (ICC = 0.677) or R.E.N.A.L (ICC = 0.660). Agreement between reference and secondary school student was lower than with other physicians, although the differences were not statistically significant. The reference’s scores were significantly (p < 0.05) associated with ischemia time on all three scoring systems and with percent change in eGFR at 6 weeks using C-Index (p = 0.016). Tumor size, nearness to sinus, and location relative to polar lines (R.E.N.A.L.) and tumor size, renal sinus involvement, and collecting system involvement (PADUA) correlated with ischemia time (all p ≤ 0.001). No R.E.N.A.L. or PADUA subscales significantly correlated with percent change in postoperative eGFR.


Clinical experience reduces interobserver variability of existing nephrometry systems though not significantly and less so when using directly measureable anatomic variables. Consistently, only measures of tumor size and distance to intrarenal structures were useful in predicting clinically relevant outcomes.


Kidney neoplasms Nephrometry Observer variability Partial nephrectomy Outcome assessment 



American Society of Anesthesiologists


Centrality index


Confidence interval


Computed tomography


Chronic Kidney Disease Epidemiology Collaboration


Computed tomography


Estimated glomerular filtration rate


Intraclass correlation coefficient


Interobserver variability


Interquartile range


Memorial Sloan Kettering Cancer Center


Non-medical secondary school student


Nephrometry sum


Preoperative aspects and dimensions used for an anatomical classification system


Physicians (urology fellows + radiology resident)


Partial nephrectomy


Radius, exophytic/endophytic, nearness, anterior/posterior, location


Radiology fellow



Supported in part by NIH/NCI Cancer Center Support Grant to MSKCC (award number P30 CA008748) and The Thompson Family Foundation. The manuscript does not contain clinical studies or patient data.

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Campbell SC, Novick AC, Belldegrun A, Blute ML, Chow GK, Derweesh IH, Faraday MM, Kaouk JH, Leveileee RJ, Matin SF, Russo P, Uzzo RG (2009) Guideline for management of the clinical T1 renal mass. J Urol 182:1271–1279PubMedGoogle Scholar
  2. 2.
    Kutikov A, Uzzo RG (2009) The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth. J Urol 182(3):844–853PubMedGoogle Scholar
  3. 3.
    Ficarra V, Novara G, Secco S, Macchi V, Porzionato A, De Caro R, Artibani W (2009) Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery. Eur Urol 56(5):786–793PubMedGoogle Scholar
  4. 4.
    Simmons MN, Ching CB, Samplaski MK, Park CH, Gill IS (2010) Kidney tumor location measurement using the C index method. J Urol 183(5):1708–1713PubMedGoogle Scholar
  5. 5.
    Tobert CM, Kahnoski RJ, Thompson DE, Anema JG, Kuntzman RS, Lane BR (2012) RENAL nephrometry score predicts surgery type independent of individual surgeon’s use of nephron-sparing surgery. Urology 80(1):157–161. doi: 10.1016/j.urology.2012.03.025 CrossRefPubMedGoogle Scholar
  6. 6.
    Simhan J, Smaldone MC, Tsai KJ, Canter DJ, Li T, Kutikov A, Viterbo R, Chen DY, Greenberg RE, Uzzo RG (2011) Objective measures of renal mass anatomic complexity predict rates of major complications following partial nephrectomy. Eur Urol 60(4):724–730. doi: 10.1016/j.eururo.2011.05.030 PubMedCentralPubMedGoogle Scholar
  7. 7.
    Canter D, Kutikov A, Manley B, Egleston B, Simhan J, Smaldone M, Teper E, Viterbo R, Chen DY, Greenberg RE, Uzzo RG (2011) Utility of the R.E.N.A.L. nephrometry scoring system in objectifying treatment decision-making of the enhancing renal mass. Urology 78(5):1089–1094. doi: 10.1016/j.urology.2011.04.035 CrossRefPubMedCentralPubMedGoogle Scholar
  8. 8.
    Kopp RP, Mehrazin R, Palazzi KL, Liss MA, Jabaji R, Mirheydar HS, Lee HJ, Patel N, Elkhoury F, Patterson AL, Derweesh IH (2013) Survival outcomes after radical and partial nephrectomy for clinical T2 Renal tumors categorized by RENAL nephrometry score. BJU Int. doi: 10.1111/bju.12580 Google Scholar
  9. 9.
    Okhunov Z, Rais-Bahrami S, George AK, Waingankar N, Duty B, Montag S, Rosen L, Sunday S, Vira MA, Kavoussi LR (2011) The comparison of three renal tumor scoring systems: C-Index, P.A.D.U.A., and R.E.N.A.L. nephrometry scores. J Endourol 25(12):1921–1924PubMedGoogle Scholar
  10. 10.
    Hew MN, Baseskioglu B, Barwari K, Axwijk PH, Can C, Horenblas S, Bex A, Rosette JJ, Pes MP (2011) Critical appraisal of the PADUA classification and assessment of the R.E.N.A.L. nephrometry score in patients undergoing partial nephrectomy. J Urol 186(1):42–46. doi: 10.1016/j.juro.2011.03.020 PubMedGoogle Scholar
  11. 11.
    Lavallee LT, Desantis D, Kamal F, Blew B, Watterson J, Mallick R, Fergusson D, Morash C, Cagiannos I, Breau RH (2012) The association between renal tumour scoring systems and ischemia time during open partial nephrectomy. Canadian Urological Association journal = Journal de l’Association des urologues du Canada:1–8. doi: 10.5489/cuaj.11202
  12. 12.
    Simmons MN, Hillyer SP, Lee BH, Fergany AF, Kaouk J, Campbell SC (2012) Diameter-axial-polar nephrometry: integration and optimization of R.E.N.A.L. and centrality index scoring systems. J Urol 188(2):384–390. doi: 10.1016/j.juro.2012.03.123 PubMedGoogle Scholar
  13. 13.
    Mehrazin R, Palazzi KL, Kopp RP, Colangelo CJ, Stroup SP, Masterson JH, Liss MA, Cohen SA, Jabaji R, Park SK, Patterson AL, L’Esperance JO, Derweesh IH (2013) Impact of tumour morphology on renal function decline after partial nephrectomy. BJU Int 111(8):E374–E382. doi: 10.1111/bju.12149 PubMedGoogle Scholar
  14. 14.
    Kolla SB, Spiess PE, Sexton WJ (2011) Interobserver reliability of the RENAL nephrometry scoring system. Urology 78(3):592–594CrossRefPubMedGoogle Scholar
  15. 15.
    Montag S, Waingankar N, Sadek MA, Rais-Bahrami S, Kavoussi LR, Vira MA (2011) Reproducibility and fidelity of the R.E.N.A.L. nephrometry score. J Endourol 25(12):1925–1928PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Massimiliano Spaliviero
    • 1
  • Bing Ying Poon
    • 2
  • Omer Aras
    • 3
  • Pier Luigi Di Paolo
    • 3
  • Giuliano B. Guglielmetti
    • 1
  • Christian Z. Coleman
    • 1
  • Christoph A. Karlo
    • 3
  • Melanie L. Bernstein
    • 1
  • Daniel D. Sjoberg
    • 2
  • Paul Russo
    • 1
  • Karim A. Touijer
    • 1
  • Oguz Akin
    • 3
  • Jonathan A. Coleman
    • 1
    • 4
    Email author
  1. 1.Department of Surgery, Urology ServiceMemorial Sloan Kettering Cancer CenterNew YorkUSA
  2. 2.Department of Epidemiology and BiostatisticsMemorial Sloan Kettering Cancer CenterNew YorkUSA
  3. 3.Department of RadiologyMemorial Sloan Kettering Cancer CenterNew YorkUSA
  4. 4.Department of Surgery, Sidney Kimmel Center for Prostate and Urologic CancersMemorial Sloan Kettering Cancer CenterNew YorkUSA

Personalised recommendations