Stesura Seveso Archivio Italiano di Urologia e Andrologia 2024; 96(3):12496 1 ORIGINAL PAPER As a result of the extensive utilization of the more available and higher precision imaging techniques, the prevalence of renal cell carcinoma is on the rise, particularly notable in tumors ranging between 2 to 4 cm (2, 3). The RCC’s biol- ogy is intricate, and although nearly 33% of all kidney masses first present signs of systemic disease, yet a signifi- cant number of localized renal masses show a tendency to progress slowly (4). Surgical management is still the pri- mary treatment option. Due to the ongoing evolution of imaging technologies, particularly the enhancements seen in ultrasonography, there has been a discernible augmen- tation in the identification of RCCs at an early stage (5). There are numerous therapeutic options for kidney tumors, including excision via partial nephrectomy (PN) or radical nephrectomy (RN), ablative procedures, or active observation (6). The determination of surgical approaches is substantially impacted by factors such as the volume and precise anatomical location of the neoplasm. Further con- siderations shaping the chosen surgical approach and intervention include the skillset and experience of the sur- geon, the capabilities of the operating facility, and estab- lished procedural norms within the medical practice (7). Increasing evidence implies a link connecting the patho- logical and anatomical characteristics of the renal tumors (8-10), however objective measurements of renal mass anatomy have only recently been described (7, 11-13). In recent times, there has been a discernible demand for pre- cise anatomical characterization of renal masses, prompt- ing the emergence of new scoring systems tailored to offer objective guidance in surgical decision-making processes. Two predominant systems have garnered widespread attention: the RENAL nephrometry score (RNS) which was established by Kutikov and Uzzo (2009) and objectively quantifies relevant kidney tumor anatomy characteristics using a scoring system; the Preoperative Aspects and Dimensions Used for Anatomical Classification (P.A.D.U.A.) approach which was proposed by Ficarra et al. (2009) and closely resembles the RENAL score, offering an alternative anatomical assessment (7, 14, 15). Scoring algorithms have been created and verified to appropriately evaluate the like- lihood of postsurgical adverse events and to reflect the Introduction: The third most prevalent malig- nant neoplasm involving the urinary tract is renal cell carcinoma (RCC), encompassing nearly 3.5% of the entire cancers afflicting the body. The aim of this research was to explore how the R.E.N.A.L. nephrometry score relates to the deci- sions made regarding surgery in individuals with localized RCC. Methods: This prospective study, assessed patients with localized parenchymal renal masses (stages I and II) tentatively diagnosed as RCC. Utilizing preoperative multiphasic renal CT scans and MRI, the R.E.N.A.L. score categorized masses for nephrometry values. Inclusion criteria involved collecting patient data, and data collection utilizing a structured format focusing on the nephrometry grading system. Results: The study included 64 patients aged (Mean ± SD) 49.78 ± 12.35 yrs. Undergoing renal mass surgery, there were 17 (26.5%) low, 28 (43.8%) moderate and 19 (29.7%) high-com- plexity lesions. All patients with a low Nephrometry score (n = 17) underwent partial nephrectomy, and all cases with a high score (n = 19) underwent radical nephrectomy. For those with a moderate Nephrometry score (n = 28), 13 (46.4%) under- went partial nephrectomy, while the remaining 15 (53.6%) cases underwent radical nephrectomy. Morbidity was low, and no mortality occurred at 180 days. Patients who had lesions fully above or below polar lines were less likely to need blood transfu- sions. A trend towards higher Fuhrman grades in patients receiving transfusions suggests a potential link between tumor aggressiveness and bleeding risk Conclusions: Our findings provide insight on the utilization of the R.E.N.A.L. nephrometry score in forecasting perioperative, post-surgical, and oncological results. Such data might help opti- mize surgical methods and pre-operative patient counseling. KEY WORDS: R.E.N.A.L. nephrometry score; Renal mass complexity; Surgical approach; Hemoglobin drop; Blood transfusion prediction. Submitted 24 March 2024; Accepted 6 April 2024 INTRODUCTION The third most prevalent malignant neoplasm involving the urinary tract is renal cell carcinoma (RCC), encompass- ing nearly 3.5% of the entire cancers afflicting the body (1). The association of anatomical renal mass complexity with surgical approach, Hb drop, and the rate of blood transfusion Shakhawan Hama Amin Said 1, Lusan Abdulhameed Arkawazi Saiwan 1, Mzhda Sahib Jaafar 1, Nadhm Kanabi Majeed 1, Rawa Bapir 2, 3, 4, Ismaeel Aghaways 1, Abdullah A. Qadir 1, 2, Berun A. Abdalla 2, 4, Ayoob Asaad Mohammed Abid 1, Fahmi H. Kakamad 1, 2, 4 1 College of Medicine, University of Sulaimani, Sulaymaniyah, Kurdistan, Iraq; 2 Smart Health Tower, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq; 3 Department of Urology, Sulaymaniyah Teaching Hospital, Sulaymaniyah, Kurdistan, Iraq; 4 Kscien Organization, Hamdi Street, Azadi Mall, Sulaymaniyah, Kurdistan, Iraq. DOI: 10.4081/aiua.2024.12496 Summary Archivio Italiano di Urologia e Andrologia 2024; 96(3):12496 S. Hama Amin Said, L. Abdulhameed Arkawazi Saiwan, M. Sahib Jaafar 2 complexity of renal tumors (16). The aim of this research was to explore how the R.E.N.A.L. nephrometry score relates to the decisions made regarding surgery in individ- uals with localized RCC. METHODS Study design This prospective study design was approved by the Institutional Research Ethics Committee, and all patients were granted informed consent. Preoperative multiphasic renal CT scans with intravenous contrast injection were performed on all patients, with magnetic resonance imaging (MRI) serving as additional imaging. R.E.N.A.L. score was used to assess the kidney tumor. Masses with nephrome- try values of 4 to 6 were categorized as to be mildly com- plicated for resection, those with scores ranging from 7 to 9 were classed as moderate complexity, and those with scores between 10 to 12 were labeled high complexity. The nephrometry score of a kidney tumor might vary from 4a (1+1+1+a+1) to 12ph (3+3+3+ph+3) [1]. In this investigation, the R.E.N.A.L. score was utilized to evalu- ate patients with renal tumors managed at our hospital with radical nephrectomy or partial nephrectomy, con- ducted through both open and laparoscopic approaches. Inclusion and exclusion criteria Data for inclusion criteria regarding clinical features, histopathological specimens, and cross-sectional images, as well as surgical and postsurgical outcomes, were gath- ered from the medical database. Sample size & sampling procedures This study was done prospectively on 64 patients who had localized parenchymal renal mass (stages I and II) that was tentatively diagnosed as RCC and were planned for surgery. Data collection procedures A structured data abstraction format with items targeting the nephrometry grading system was applied. The R.E.N.A.L. score was established in 2009 (7) and is based on the five most repeatable aspects of a solid renal mass's anatomy: (R)adius (the largest diameter of the tumor in cen- timeters) to which points were assigned as 1 (≤ 4 cm), 2 (> 4 but < 7 cm), and 3 (≥ 7 cm); (E)xophytic/endophytic prop- erties (points were designated as 1 in cases where 50% or more of the tumor exhibited exophytic growth, 2 when less than 50% of the tumor demonstrated exophytic character- istics, and 3 in instances where the tumor displayed entire- ly endophytic characteristics); (N) component (nearness) of the tumor to the collecting system or sinus and for which points were assigned as 1 (≥ 7 mm), 2 (> 4 but < 7 mm), and 3 (invading, touching, or within 4 mm); (A) indicates the anterior or posterior location of the tumor which was designated as a non-numerical suffix that describes the location of the tumor with respect to the kid- ney midline plane as assessed on axial images (the tumor is designated with the suffix “x” when it cannot be specified as either anterior or posterior; (L) designates the location of tumor in relation to polar lines. Standardized points (1-3 points per descriptor) were given to each parameter, excluding the anterior or posterior component. An addi- tional suffix “h” is used to highlight a hilar tumor. The literature review was done by carefully selecting papers from reputable journals and omitting those from predatory sources based on predetermined criteria of Kscien’s list (17). RESULTS In this study, a total of 64 patients were included, encom- passing 28 males and 36 females. The patients had the surgery through an open approach except for five (7.8%) Table 1. Presents clinical characteristics of the 64 patients enrolled in this study. Variables N. patients (%) Demographics Age (Mean ± SD) 49.78 ± 12.35 yrs. Sex Male 28 (43.8%) Female 36 (56.2%) Tumors side Right 28 (43.8%) Left 36 (56.2%) Past medical history No 38 (59.4%) HTN 16 (25%) DM 4 (6.3%) HTN+DM 6 (9.4%) BMI < 18.5 0 (0%) 18.5-24.9 20 (31.3%) 25-29.9 30 (46.9%) > 30 14 (21.9%) Blood transfusion Yes 16 (25%) No 48 (75%) Type of management Radical 34 (53.1%) Partial 30 (46.9%) Presentation on symptomatic Incidental 41 (64.1%) Symptomatic 23 (35.9%) Symptom of presentation Asymptomatic 39 (60.9%) Right loin pain 8 (12.5%) Left loin pain 10 (15.6%) Anemia 2 (3.1%) Hematuria 5 (7.8%) ASA 1 29 (45.3%) 2 25 (39.1%) 3 9 (14.1%) 4 1 (1.6%) Stage 1 50 (78.1%) 2 14 (21.9%) Nephrometry score Low 17 (26.5%) Middle 28 (43.8%) High 19 (29.7%) Archivio Italiano di Urologia e Andrologia 2024; 96(3):12496 3 Anatomical renal mass complexity and surgery patients who had laparoscopic surgery. Among them 30 (46.9%) patients underwent partial nephrectomy, while 34 patients (53.1%) underwent radical nephrectomy. Among these patients, 41 (64.1%) had an incidental find- ing of a renal tumor, while 23 (35.9%) presented with symptoms. Of these, 28 (43.8%) had a right-sided renal tumor, while 36 (56.2%) had a left-sided renal tumor. Most of our patients were diagnosed with clear-cell RCC on final histopathology (n = 60). The remaining cases con- sisted of multilocular cystic RCC (n = 1), renal oncocy- toma (n = 2), and renal angiomyolipoma (n = 1). Sixteen patients (25%) received perioperative blood transfusions, while 48 (75%) did not (Table 1). The general 180-day morbidity in the current investigation was low, including pleural injury (n = 3), urinary leakage (n = 1), and patients requiring postoperative blood transfusion (n = 6). The mortality rate was zero after 180 days of follow-up. There were 17 (26.5%) low, 28 (43.8%) moderate and 19 (29.7%) high-complexity lesions (Table 1). All patients with a low Nephrometry score (n = 17) underwent partial nephrectomy, and all cases with a high score (n = 19) underwent radical nephrectomy. For those with a moderate Nephrometry score (n = 28), 13 (46.4%) underwent partial nephrectomy, while the remaining 15 (53.6%) cases under- went radical nephrectomy (Table 2). Additionally, Table 2 provides post-operative follow-up data, examining the connections between Hb- drop and postoperative creatinine change with different nephrometry scores. The Nephrometry scores were categorized as low, moderate, and high, and the data are reported as mean ± SD. For the variable "Hb drop", the following values were observed: for low Nephrometry score: 1.02 ± 0.65, for moderate Nephrometry score 1.50 ± 0.83; for high Nephrometry score 1.53 ± 0.78 (with a p-value of 0.093). For the variable “postoperative creatinine change", the data aer as follows: for low Nephrometry Score 0.14 ± 0.19; for moderate Nephrometry score 0.12 ± 0.20; for high Nephrometry score 0.08 ± 0.21 (with a p-value of 0.705 ) (Table 2). The anatomical location data based on the nephrometry score reveals important details about the renal masses under study. The mean maximum dimension and stan- dard deviation (SD) was measured at 1.96 ± 0.73. The nature of the masses is described in terms of endophytic and exophytic characteristics, with 37.5% of the masses being predominantly exophytic, 48.5% showing a 50% exophytic nature, and 14.1% being primarily endophytic (Table 3). Regarding their location, 31.3% of the masses are prioritized anteriorly [designated as 'Priority (a)'], while the same percentage is located posteriorly ['Priority (p)']. An additional 37.4% of the masses are categorized as 'Uncertain (x).' The proximity of the masses to the renal hilum is also noted, with 12.5% located at or above 7 units away, 15.6% situated between 4 and 7 units, and the majority, 71.9%, being located within 4 units of the hilum (Table 3). Polar relationships further characterized the masses, with 53.1% positioned exclusively under or upwards of the polar lines. Another 20.3% of the masses crossed the polar line, while the remaining 26.6% were distributed such that 50% of the mass either crosses the polar line, extends across the axial renal midline, or is fully situated amidst the polar lines. These factors collectively provide insights into the lesion's size, endophytic or exophytic nature, its specific location, proximity to the hilum, and its relationship to the polar lines. This data distribution is detailed in Table 3. A comparative analysis was conducted between patients who received blood transfusions and those who did not. The mean maximum diameter for patients receiving blood transfusions was 2.25 ± 0.77, while those who did not receive transfusions had a mean diameter of 1.87 ± 0.70 (p = 0.077). Patients with tumors ≥ 50% exophytic nature received transfusion in 4/24, those with < 50% exophytic nature tumors received in 7/32, and patients with endo- phytic tumors on 5/9 (p = 0.065). Patients with tumors in anterior location had transfusion in 5/20, patients with tumors in posterior location in 5/20 and patients with tumors in unknown location in 6/24 (p =1.00). In regards to the nearness with hilum, patients with a distance ≥ 7 units received blood in 1/8, and those with distances > 4 but < 7 units in 1/10, and for distances ≤ 4 units, 14/46 received blood (p = 0.274). In regard to polar relation, the Table 3. Anatomical characteristics of dimension nephrometry scores. Variables N (%) Maximum diameter (Mean ± SD) 1.96 ± 0.73 Endophytic/exophytic >= 50% exophytic 24 (37.5%) < 50% exophytic 31 (48.5%) Endophytic 9 (14.1%) Location Anterior (a) 20 (31.3%) Posterior (p) 20 (31.3%) Unknown (x) 24 (37.4%) Nearness to Hilum >= 7 8 (12.5%) >4 BUT < 7 10 (15.6%) <= 4 46 (71.9%) Polar relation Entirely above the upper or below the lower polar 34 (53.1%) lesion crosses polar line 13 (20.3%) > 50% of mass is across polar line, or mass crosses 17 (26.6%) the axial renal midline, or mass is entirely between the polar lines Table 2. Surgical approach stratified by nephromtery score and relationships between Hb-drop and postoperative creatinine change with Nephrometery score. Variables Nephromtery score - N (%), SD, Mean P-value Types of management Low Moderate High Partial 17 (56.6%) 13 (43.3%) 0 (0%) < 0.001 Radical 0 (0%) 15 (44.1%) 19 (55.8%) Post-operative value Hb drop 1.02 ± 0.65 1.5 ± 0.83 1.53 ± 0.78 0.093 Postoperative creatinine change 0.14 ± 0.19 0.12 ± 0.20 0.08 ± 0.21 0.705 Archivio Italiano di Urologia e Andrologia 2024; 96(3):12496 S. Hama Amin Said, L. Abdulhameed Arkawazi Saiwan, M. Sahib Jaafar 4 analysis showed that 5/34 of the cases with mass entirely above or below the polar lines received a blood transfusion, whereas transfusion were received in 3/13 of those with lesions that crossed polar lines (p = 0.042). The results from this comparative evaluation are summa- rized (Table 4). The number of patients by type of man- agement, radical or partial, revealed that the type of surgery was based on the anatomical scores (Table 5). An investigation was conducted to explore the association between nephrometry scores and hemoglobin decline in the context of blood transfu- sion. The transfusion rate was correlat- ed with Nephrometry score (Table 6). Patients with low, moderate, and high nephrometry scores had transfusions in 2/15, 6/28, and 8/19, respectively (p = 0.093. Additionally, mean ± SD values for Hb drop for those who received a blood transfusion or not are presented in (Table 6). Furthermore, Table 6 delved into the investigation of the rela- tionship between blood transfusion and Fuhrman grade, with information pre- sented as counts and percentages (N%). For patients who did not receive blood, Fuhrman Grade 1 accounted for 60.9% (28 cases), Fuhrman Grade 2 for 37% (17 cases), and Fuhrman Grade 3 for 2.1% (1 case). Patients who received blood were 5/33 in Fuhrman grade 1 group, 11/28 in Fuhrman grade 2 group and 0/1 in Fuhrman grade 3 group (p = 0.094). These findings are comprehen- sively presented in (Table 6), contribut- ing to the insight into the interplay between nephrometry scores, hemoglo- bin decline, and Fuhrman grade in the studied cohort. DISCUSSION The third most prevalent malignant neoplasm involving the urinary tract is RCC, encompassing nearly 3.5% of the entire cancers afflicting the body (1). An approximate 54.390 new diagnoses and 13.010 mortalities in 2008 were attrib- uted to RCC (18). Most diagnoses nowadays are unintentional. In the past, symptoms such as weight loss, hema- turia, or a palpable flank bulge would indicate the condition. The reason for this change is because more cross-sec- tional diagnostic imaging is being used. As a result, at least 48-66% of RCC diag- noses have been established based on asymptomatic, incidental renal masses Table 4. Comparison of clinical features in blood transfusion groups. Blood transfusion Yes No P-value Maximum diameter (Mean ± SD) 2.25 ± 0.77 1.87 ± 0.70 0.077 Endophytic/exophytic 0.065 >= 50% exophytic 4 (16.6) 20 (83.4) < 50% exophytic 7 (21.9) 25 (78.1) Endophytic 5 (55.5) 4 (44.5) Location 1.000 Anterior (a) 5 (25) 15 (75) Posterior (p) 5 (25) 15 (75) Unknown (x) 6 (25) 18 (75) Nearness to Hilum 0.274 >= 7 1 (6.3) 7 (14.6) > 4 BUT < 7 1 (6.3) 9 (18.8) <= 4 14 (87.4) 32 (66.7) Polar Relation 0.042 Entirely above the upper or below the lower polar 5 (14.7) 29 (85.3) lesion crosses polar line 3 (23) 10 (77) > 50% of mass is across polar line, or mass crosses the axial renal midline, 8 (47.1) 9 (52.9) or mass is entirely between the polar lines Table 5. Surgical approach of renal cell carcinoma. Blood transfusion Yes No P-value Maximum diameter (Mean ± SD) 1.53 ± 0.57 2.35 ± 0.64 < 0.001 Endophytic/exophytic < 0.001 >= 50% exophytic 19 (63.3%) 5 (14.7%) < 50% exophytic 11 (36.7%) 20 (58.8%) Endophytic 0 (0%) 9 (26.5%) Location 0.199 Anterior (a) 10 (33.3%) 10 (29.4%) Posterior (p) 12 (40%) 8 (23.5%) Unknown (x) 8 (26.7%) 16 (47.1%) Nearness to Hilum < 0.001 >= 7 8 (26.7%) 0 (0%) > 4 BUT < 7 10 (33.3%) 0 (0%) <= 4 12 (40%) 34 (100%) Polar Relation < 0.001 Entirely above the upper or below the lower polar 25 (83.3%) 9 (26.5%) lesion crosses polar line 3 (10%) 10 (29.4%) > 50% of mass is across polar line, or mass crosses the axial renal midline, 2 (6.7%) 15 (44.1%) or mass is entirely between the polar lines Table 6. Relationship between Nephrometry score and Hb drop with blood transfusion and Relationship of blood transfusion with Fuhrman grade. P-value Blood transfusion N (%) Variables No Yes 0.093 Nephrometry score 15 (31.3%) 2 (12.5%) low 22 (45.8%) 6 (37.5%) moderate 11 (22.9%) 8 (50%) high 0.479 1.34 ± 0.79 ± 0.80 1.50 Hb drop (Mean ± SD) 0.094 Furhman grade 28 (60.9%) 5 (31.2%) 1 17 (37%) 11 (68.8%) 2 1 (2.1%) 0 (0%) 3 Archivio Italiano di Urologia e Andrologia 2024; 96(3):12496 5 Anatomical renal mass complexity and surgery (19). Both the incidence of RCC and the rate of RCC ther- apies have risen consistently over the last three decades with lower-stage migration (20). The treatment of local- ized RCC is a therapeutic challenge due to the diversity of tumor appearances and unique patient circumstances. Surgical management, such as PN and RN, is the main treatment option for localized RCC. A number of factors, including the size, location, and intricacy of the tumor, influence the decision to perform a particular surgery (21). The R.E.N.A.L. nephrometry score employs imag- ing-derived characteristics of kidney tumors to measure tumor complexity objectively, facilitating decisions regarding the selected technique and strategy. Postoperative results in individuals receiving open or minimally invasive PN have been correlated with the R.E.N.A.L score. The current study underscores the effec- tiveness of the R.E.N.A.L nephrometry score in forecast- ing surgical complexity and postsurgical morbidity. The results of this investigation correspond with past studies that have highlighted the connection between sur- gical technique selection and tumor architecture. One standardized and objective tool for preoperative decision- making is the R.E.N.A.L-NS. It gives urologists a useful tool for determining the optimal surgical approach and evaluating the complexity of renal masses. These findings provide credence to the hypothesis that anatomically- based tailored renal mass surgery might lead to improved clinical outcomes (22). According to this study, anatomic tumor features like size and location have a profound effect on preoperative outcomes and the prognosis that follows surgery. According to our findings, renal masses' preoperative radiographic and anatomic characteristics can predict the mass's pathologic characteristics. The R.E.N.A.L. Nephrometry score, as the primary rating algo- rithm established to gauge renal tumor architecture con- cerning surgical resectability, was utilized in this study. Excision is the usual course of treatment for individuals with a solid renal tumor. Active observation, operative excision, and thermal ablative procedures are all effective therapeutic options for suitably chosen individuals with a clinical stage T1 kidney tumor, as new American Urological Association guidelines have shown (23). R.E.N.A.L nephrometry scores range through 4 to 12 points. Lesions that have a collective score of 4, 5, or 6 on nephrometry are classified as low complexity. Meanwhile tumors with cumulative points of 7 to 9 points are con- sidered intermediate complexity, and masses scored between 10 to 12 are classified as high complexity lesions. A suffix of a or p, and x adds a descriptive com- ponent to the system, signifying the anterior or posterior location of the mass, whereas a h is used for hilar tumors (7). Of the 68 patients in the current study, 34 (53.1%) underwent RN and 30 (46.9%) underwent PN based on their nephrometry scores: 17 (26.5%) were low complex- ity, followed by 28 (43.8%) intermediate complexity and 19 (29.7%) high complexity. Haidar et al. found a relationship connecting R.E.N.A.L score and surgical technique choice. PN was done in 75.6% of cases with low score, 54.6% of instances with moderate level (p = 0.004), and only 11.7% of those with high score (p < 0.001) (24). In our study, 46.9% of 68 patients underwent partial nephrectomy, with 56.6% having a low score and 43.3% having a moderate score. The remaining patients underwent radical nephrectomy, with 44.1% and 55.8% having intermediate and high scores, respectively. To define the anatomical aspects of a kidney mass, anoth- er approach called Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) was established. With the exception of defining the sinus lines and assessing the physical connection between the tumor and the renal sinus, or urine collecting system, this system is compara- ble to the nephrometry score. The C-Index Method was finally presented to ascertain the centrality of a tumor. The distance separating the mass and the kidney centers must be calculated using a sophisticated geometric approach utilizing cross-sectional imaging (25, 26). Whenever medically feasible, most globally recognized standards recommend doing a partial nephrectomy for T1a tumors. Approaches to solid renal tumor care include deciding whether to remove the entire kidney or only the tumor with a clean surgical margin, as well as whether to use an open or laparoscopic surgical technique. It was demonstrated that tumor volume increases the likelihood of malignant vs benign pathology, high-grade versus low- grade illness, and clear cell versus papillary histology (27). In our study, all patients with a low Nephrometry score got partial nephrectomy, while all patients with a high score had radical nephrectomy. Those with a mod- erate score (46.4%) got partial nephrectomy, while the rest (53.6%) had radical nephrectomy. One of the most difficult components of RCC therapy is preventing perioperative problems while maintaining patient safety (28). The study identified just a few cases of pleural injury, urinary incontinence, and the need for postoperative blood transfusions. The lack of mortality throughout the 180-day follow-up period is reassuring, showing that anatomically complex surgical decisions do not threaten patient safety. In terms of perioperative blood transfusions, the study revealed that a quarter of the patients needed them, although the rest did not. This study stresses the need of accurately calculating perioperative blood loss, which can affect surgical technique and postoperative therapy. In challenging cases, efforts to decrease blood loss and the need for transfusions, such as precision surgical tech- niques and advanced hemostatic therapies, should be considered. Haider et al. revealed that individuals with an elevated R.E.N.A.L. score experienced more adverse peri- operative results in comparison to those with a lower score. Subjects with a high R.E.N.A.L score (19.4% vs 6.3%, p = 0.018) were three folds more likely to get blood transfusions than those with a low score (24). Out of the 68 patients in the current study, 16 had blood transfu- sions, the majority, 8 (50%) had high scores, followed by 6 (37.5%) with moderate scores and 2 (12.5%) with low scores. There is ongoing debate regarding the ability of the R.E.N.A.L. nephrometry scoring technique to reliably forecast malignancy and high histopathological grades in small kidney tumors. Osawa et al. found that despite the fact that R.E.N.A.L. nephrometry scores were effective in distinguishing the benign and malignant kidney masses, as well as low- and high-grade kidney tumors, histopatho- Archivio Italiano di Urologia e Andrologia 2024; 96(3):12496 S. Hama Amin Said, L. Abdulhameed Arkawazi Saiwan, M. Sahib Jaafar 6 logical examination yielded superior performance in this regard (29). Further investigations have demonstrated a profound relationship between the R.E.N.A.L. score and both tumor grade (p < 0.0001) and histology (p < 0.0001). This suggests that as tumor volume rises, there is a higher probability of malignancy, particularly high- grade and clear-cell tumors, upon histological examina- tion (30). The consequence of RCC tumor complexity on oncologic results remains to be definitively made. This current research revealed that the R.E.N.A.L. score played a predictive role in key oncologic outcomes. For instance, individuals exhibiting lower R.E.N.A.L. scores demon- strated markedly higher survival rates in contrast to those presenting higher nephrometry scores. Similarly, tumors with elevated R.E.N.A.L. scores showed more likelihood of experiencing recurrence and progression. CONCLUSIONS The R.E.N.A.L. nephrometry scoring system offers a ver- satile, advantageous, and replicable tool for quantifying the key aspects of renal anatomy. The cumulative nephrometry score was shown to be linked with opera- tive decision-making. 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Surgical man- agement of renal cell carcinoma. Semin Intervent Radiol. 2014; Vol. 31, No. 01, pp. 027-032. Thieme Medical Publishers. Archivio Italiano di Urologia e Andrologia 2024; 96(3):12496 7 Anatomical renal mass complexity and surgery 29. Osawa T, Hafez KS, Miller DC, et al. Comparison of percuta- neous renal mass biopsy and RENAL nephrometry score nomograms for determining benign vs malignant disease and low-risk vs high-risk renal tumors. Urol. 2016; 96:87-92. 30. Kutikov A, Smaldone MC, Egleston BL, et al. Anatomic features of enhancing renal masses predict malignant and high-grade pathol- ogy: a preoperative nomogram using the RENAL Nephrometry score. Eur Urol. 2011; 60:241-8. Correspondence Shakhawan Hama Amin Said Lusan Abdulhameed Arkawazi Saiwan Mzhda Sahib Jaafar Nadhm Kanabi Majeed Ismaeel Aghaways Abdullah A. Qadir Ayoob Asaad Mohammed Abid College of Medicine, University of Sulaimani, Sulaymaniyah, Kurdistan, Iraq Rawa Bapir Berun A. Abdalla berun.anwer95@gmail.com Smart Health Tower, Madam Mitterrand Street, Sulaymaniyah, Kurdistan, Iraq Fahmi H. Kakamad (Corresponding Author) fahmi.hussein@univsul.edu.iq Doctors City, Building 11, Apartment 50, Sulaimani, Iraq Conflict of interest: The authors declare no potential conflict of interest.