Increased use of partial nephrectomy to treat high‐risk disease

Abstract

ObjectivesTo evaluate partial nephrectomy (PN) use in patients at higher risk for clinical progression, using a large national database of American patients. Patients and MethodsWe performed a retrospective review of patients with cN0/ cM0 renal cell carcinoma from 2003 to 2011 using the National Cancer Data Base. Our primary endpoint was PN use for high-risk disease, defined as ≥1 adverse pathological features (APF), namely pT3 stage, high grade, or unfavourable histology. Our secondary endpoint was positive surgical margins (PSM) associated with high-risk disease after PN. Time trends were analysed using the asymptotic CochranArmitage trend test. Relationships between patient, provider, and pathological factors and the likelihood of PN were assessed using multivariate logistic regression. ResultsOf 183 886 surgically treated patients, 27.4% underwent PN. Over time, PN use increased overall (17.4-39.7%) and in tumours with ≥1 APF (8.5-24.2%) (P < 0.01). In patients with ≥1 APF, multivariate analysis revealed that academic practice setting and high surgical volume were positively associated with PN use, while increasing tumour size and preoperative biopsy were negatively associated with its use (P < 0.01). The PSM rate after PN also increased significantly over time in all patients and in those harbouring adverse pathology (P < 0.01). Aside from time, older age, larger tumour size, community hospital type, and robotic approach were associated with PSM in the setting of APF (P < 0.01). ConclusionPN use for patients with adverse pathology is increasing and is associated with increasing PSM. The long-term oncological implications of these trends are unclear and warrant further study.

Utilization and quality outcomes of cT1a, cT1b and cT2a partial nephrectomy: analysis of the national cancer database

“…Furthermore, the present study is the first to show a rise in the use of a minimally invasive PN approach for cT2a tumours, which parallels reported trends for increasing use of minimally invasive PN for cT1a and cT1b masses . Although this is encouraging, any enthusiasm generated by these findings must be tempered by the increased risk of PSMs found by both the present authors and Maurice et al . Indeed, while we noted no difference in PSM rates among PN‐treated cT1a, cT1b and cT2a masses, there was an increase in PSMs overall, attributable to the increased use of minimally invasive approaches over time.…”

Survival after partial and radical nephrectomy for high-risk disease: A propensity-matched comparison

“…6 Our results demonstrate superior or at least equivalent survival for patients with high-risk RCC treated with PN. For RCC with HG/UH or T3, PN was an independent significant predictor of improved OS, after adjusting for age, comorbidity burden, tumour size, and other risk factors for all-cause mortality.…”

“…A detailed description of the NCDB has been published previously. 6 We used the NCDB's 2011 participant user file for kidney and renal pelvis cancers. Institutional review board approval was obtained prior to study initiation.…”

“…4,5 Recently, this trend has been associated with increasing PN use for renal cell carcinoma (RCC) with adverse pathologic factors that independently predict cancer-specific death. [6][7][8][9][10] The role of PN for this highrisk RCC is ill-defined. Several retrospective studies have investigated the comparative effectiveness of PN vs. RN for high-risk disease, but have failed to detect a survival difference in this setting.…”

Contemporary Use of Partial Nephrectomy: Are Older Patients With Impaired Kidney Function Being Left Behind?

“…With this growing experience, reports have suggested that partial nephrectomy is being applied to larger and more complex tumors, 8-10 and is being offered to older and multi-morbid patients. 11 While administrative data suggests that partial nephrectomy may improve survival when compared with radical nephrectomy, 12 partial nephrectomy has remained concentrated in high-volume academic centers, and reserved for patients with better insurance and higher socioeconomic status. 13 It is unknown if the increased overall use of partial nephrectomy has benefited patients with impaired pre-operative kidney function, who could benefit most from the procedure.…”