Nephron‐sparing surgery across a nation – outcomes from the British Association of Urological Surgeons 2012 national partial nephrectomy audit

Abstract

ObjectiveTo determine the scope and outcomes of nephron-sparing surgery (NSS), i.e. partial nephrectomy, across the UK and in so doing set a realistic benchmark and identify fresh contemporary challenges in NSS. Patients and MethodsIn 2012 reporting of outcomes of all types of nephrectomy became mandatory in the UK. In all, 148 surgeons in 86 centres prospectively entered data on 6 042 nephrectomies undertaken in 2012. This study is a retrospective analysis of the NSS procedures in the dataset. ResultsA total of 1 044 NSS procedures were recorded and the median (range) surgical volume was 4 (1-39) per consultant and 8 (1-59) per centre. In all, 36 surgeons and 10 centres reported on only one NSS. The indications for NSS were: elective with a tumour of ≤4.5 cm in 59%, elective with a tumour of >4.5 cm in 10%, relative in 7%, imperative in 12%, Von Hippel-Lindau in 1%, and unknown in 11%. The median (range) tumour size was 3.4 (0.8-30) cm. The technique used was minimally invasive surgery in 42%, open in 58%, with conversions in 4%. The histology results were: malignant in 80%, benign in 18%, and unknown in 2%. In patients aged <40 years 36% (36/101) had benign histology vs 17% (151/874) of those aged ≥40 years (P < 0.01). In patients with tumours of <2.5 cm 29% (69/238) had benign histology vs 14% (57/410) with tumours of 2.5-4 cm vs 8% (16/194) with tumours of ≥4 cm (P = 0.02). In patients aged <40 years with of tumours of <2.5 cm 44% (15/34) were benign. The 30-day mortality was 0.1% (1/1 044). There were major complications (Clavien-Dindo grade of ≥IIIa) in 5% (53/1 044). There was an increased risk of complications after extended elective NSS of 19% (19/101) vs elective at 12% (76/621) (relative risk [RR] 1.54; P < 0.01). Margins were recorded in 68% (709/1 044) of the patients, with positive margins identified in 7% (51/709). Positive surgical margins after NSS for pathological T3 (pT3) tumours were found in 47.8% (11/23) vs 6.1% (32/523) for pT1a, tumours (RR 5.61; P < 0.01). In all, 14% (894/6 042) of the patients underwent surgery for T1a tumours: 55% (488/894) by NSS, 42% (377/894) by radical nephrectomy (RN), and in 3% (29/894) the procedure used was unknown. Major complications after occurred in 4.9% (24/488) of NSS vs 1.3% (5/377) of RN (P < 0.01). Limitations included poor reporting of renal function data and no data on tumour complexity. ConclusionsIn its first year, mandatory national reporting has provided several challenging contemporary insights into NSS.

Nomogram for predicting the likelihood of postoperative surgical complications in patients treated with partial nephrectomy: a prospective multicentre observational study (the RECORd 2 project)

“…These results represent a further demonstration of the increasing safety of this procedure over time and slightly exceed the perioperative results of the Italian registry of conservative surgery for renal tumours (RECORd 1 project) from 2008 to 2012, which reported an overall and major complication rate of 13.1% and 3.5%, respectively [4]. The overall and Clavien-Dindo Grade III complication rate reported in the present study was also lower compared to [15]. Indeed, the higher rate of complications in that series could be related to the different era of patients' accrual and to the lower rate of minimally invasive PNs compared to our present study (41.5% vs 65.7%).…”

Surgical treatment of kidney tumors – contemporary trends in clinical practice

“…The median (range) tumor size was 3.4 (0.8–30) cm. The technique used was minimally invasive surgery in 42%, open in 58%, with conversions in 4% [9]. The situation in the whole Czech Republic is documented in a survey performed by the Czech Urological Society and by the National Health Information System (NHIS).…”

“…Indications for surgery strictly follow the European Association of Urology (EAU) guidelines for treatment of renal tumors [2]. Resection is preferred before nephrectomy in all T1 category (≤7 cm) cases [9, 10, 11]. In resection, as well as in nephrectomy, preference is given to the less invasive approach (laparoscopic, even robotically assisted) before open surgery [12].…”

The small renal mass. Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?

“…The perceived wisdom that a small enhancing mass in the kidney represents a surgical lesion that automatically requires excision without the need for a preoperative biopsy has been challenged by Fernando et al [1] in this issue of BJUI.…”

“…The capital costs and extra costs per procedure for robotassisted procedures are well known, but there are limited data on healthcare consumption in the longer term. In this issue of BJUI, a retrospective study investigated the NHS-registered, relevant care activities up to three years after surgery comparing robot-assisted, conventional laparoscopic, and open surgical approaches to radical prostatectomy and partial nephrectomy [1].…”