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Beyond traditional nephrometry: a 3D quantitative framework for predicting pentafecta and evaluating mediation
Jia Li1,2, Zhenting Zhang1, Chunsen Yang1
1Department of Genitourinary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy Tianjin, Tianjin, China.
Purpose:
To establish a three-dimensional (3D) quantitative framework for predicting pentafecta achievement and to explore the underlying compensatory associations in nephron-sparing surgery (NSS).
Methods:
We retrospectively analyzed 375 patients undergoing NSS. Preoperative 3D morphometric metrics-specifically contact surface area (CSA) and retained blood-perfused renal volume (RBRV)-were extracted. Pentafecta was strictly defined by optimal perioperative success and 1-year functional preservation (eGFR loss < 10% without chronic kidney disease upstaging). Multivariable logistic regression, quadrant-based phenotypic analysis, and serial mediation modeling were performed to compare predictive performance and explore potential sequential clinical pathways.
Results:
Pentafecta was achieved in 203 patients (54.1%). The 3D quantitative framework, incorporating CSA, RBRV, and their interaction with baseline eGFR, significantly outperformed traditional nephrometry in discrimination (apparent AUC: 0.752, optimism-corrected AUC: 0.729 vs. 0.697; DeLong test, P = 0.004) and clinical net benefit. Quadrant-based analysis revealed a compensatory "Resilience" phenotype, suggesting that preserving substantial RBRV may effectively buffer the detrimental impact of high surgical complexity. Serial mediation analysis revealed a pattern consistent with statistical sequential mediation: the negative association between anatomical complexity (CSA) and pentafecta achievement was not direct (OR = 0.990, P = 0.683), but rather mediated through a potential sequential pathway involving prolonged warm ischemia time and subsequent postoperative day 1 acute kidney injury (AKI) (indirect effect, P = 0.033).
Conclusion:
The 3D quantitative framework demonstrates superior predictive performance compared to traditional nephrometry in predicting pentafecta. Maximizing functional volume retention and preemptively mitigating the risk of ischemia-associated AKI appear paramount for individualized surgical planning and optimal long-term recovery.
