National Trends in the Utilization of Partial Nephrectomy Before and After the Establishment of AUA Guidelines for the Management of Renal Masses

Abstract

Objective-To assess the impact of the American Urological Association guidelines advocating partial nephrectomy for T1 tumors guidelines on the likelihood of undergoing partial nephrectomy.Materials and Methods-We analyzed the Nationwide Inpatient Sample, a dataset encompassing 20% of all United States inpatient hospitalizations, from 2007 through 2010. Our dependent variable was receipt of radical vs. partial nephrectomy (55.50, 55.51, 55.52, and 55.54 vs. 55.4) for a renal mass (ICD-9 code 189.0). The independent variable of interest was time of surgery (before or after the establishment of AUA guidelines); covariates included a diagnosis of chronic kidney disease (CKD), overall comorbidity, age, race, gender, geographic region, income, and hospital characteristics. Bivariate and multivariable adjusted logistic regression was used to determine the association between receipt of partial nephrectomy and time of guideline establishment. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Their data shows indeed an association between the increasing use of PN and the AUA guideline and a statistically significant increase in the likelihood of PN after AUA guideline publication. However association does not necessarily mean causality. In fact their study can neither rule-out the influence of other factors in the increasing use of PN nor exclude the logical implementation of a surgical technique. Furthermore, although statistically significant, the magnitude of the difference before and after AUA guideline publication is small and a net increment of 5% through 4 years might be considered marginally clinically relevant and similar to the increments described previously to the publication of the AUA guideline [3][4][5]. Results-We Conflicts of interest: NoneThese reflections do not discredit the value of the AUA guidelines for the Management of Renal Masses and the effort of Bjurlin and cols. On the contrary, this excellent document is more than adequate to improve process and structure of care and the present report opens a line of future investigation. It is likely that a longer period of time will be necessary to measure its effects on patients health outcomes otherwise scarcely studied [6]. Multiple barriers modulate the adherence to guidelines and there is a high level of variation in effects across recommendations [7].Guidelines on the other hand are not documents ahead of their time. More frequent than not, both technical implementation and development of comprehensive guidelines are parallel phenomena. Consequently a strong association is not strange but causality ...

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

“…Prior reports using data from the Nationwide Inpatient Sample from 2007 to 2010 also found that pre-operative claims for chronic kidney disease were not associated with higher odds of receipt of partial nephrectomy. 20 “Renalism” is a term previously used to describe inappropriately low rates of coronary angiography in patients with impaired kidney function. 22 Here we find evidence of renalism – an aversion to perform a potentially more complex partial nephrectomy surgery in patients with impaired kidney function – despite the historical presumption that these patients derive the most benefit from partial nephrectomy.…”

The Adoption of Nephron-Sparing Surgery in Europe - A Trend Analysis in Two Referral Centers from Austria and Germany

“…While RN was the standard of care for all tumors in the first EAU guideline in 2001 [18], PN was established as recommended treatment in the updated 2007 EAU RCC guidelines [19]. Likewise, the American Urological Association RCC guideline of 2009 recommends PN when feasible, but early evaluations could not yet show a substantial increase in PN usage [20,21]. The lack of adoption was observed despite a stage migration from T1b to T1a tumors due to rising numbers and the widespread use of radiological imaging [22].…”

International Variations and Trends in Renal Cell Carcinoma Incidence and Mortality

“…Because radical nephrectomy often results in impairment of function or failure of the contralateral kidney, the preferred procedure for small kidney cancers is partial nephrectomy. This procedure has now been included in both the US and European urology society guidelines, but it is still not widely implemented, even in the USA [36,37]. The currently observed disparities in reducing renal cell cancer mortality are likely to increase even further following the introduction of targeted therapies with tyrosine kinase and mTOR inhibitors since the mid-2000s [34].…”