Textbook Outcome in Pediatric Nephroblastoma Surgery After Neoadjuvant Chemotherapy: Defining Standards, Introducing Near-Miss, and Predictors of Failure.
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BACKGROUND: Textbook outcome (TO)-simultaneous achievement of all predefined surgical quality criteria-is established in adult oncological surgery but has never been defined for nephroblastoma surgery after Société Internationale d'Oncologie Pédiatrique (SIOP) neoadjuvant chemotherapy. We defined a nine-criterion TO, reported the TO rate, introduced a near-miss TO (NM-TO) category, and identified predictors of failure. PROCEDURE: Single-center retrospective cohort of pediatric patients below the age of 18 years with nephroblastoma treated at King Hussein Cancer Center between 2015 and 2023. Treatment followed SIOP protocols. The nine TO criteria were as follows: no intraoperative tumor spill, lymph node (LN) harvest ≥7, R0 margin, no major vessel injury, no major organ injury, no Clavien-Dindo ≥3 complication, no unplanned return to the theater within 30 days, adjuvant chemotherapy within 14 days, and estimated blood loss (EBL) <10 mL/kg. NM-TO required exactly 8/9 criteria. RESULTS: Seventy-one patients were analyzed. Full TO was achieved in 35/71 (49.3%); NM-TO in 21 (29.6%), giving a combined rate of 78.9%. The most common NM failures were LN harvest <7 (11 patients) and EBL ≥10 mL/kg (9 patients). Tumor dimension was negatively associated with achieving TO in this univariable, uncorrected analysis (Spearman ρ = -0.405; p < 0.001); stage was not (p = 0.853). Systemic relapse occurred in 12 patients (16.9%); there were no postsurgical local recurrences. CONCLUSIONS: This is the first TO analysis in SIOP nephroblastoma surgery. LN harvest is the main modifiable gap; optimizing this single parameter could raise the institutional TO rate to 64.8%. Weight-adjusted EBL adds a pediatric-specific criterion absent from adult TO frameworks. The NM category identifies which single criterion was missed and where to focus quality improvement.