Rate Of Partial Nephrectomy Research Articles

PD17-08 THE EFFECT OF THE SURGICAL ROBOT ON THE HOSPITAL-LEVEL UTILIZATION OF PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: The rapid diffusion of the surgical robot has been fraught with controversy because of the technology’s high costs and disputed marginal benefit. Some have suggested that adoption of the surgical robot has facilitated partial nephrectomy (PN), an underutilized procedure considered more challenging yet less morbid than radical nephrectomy. We sought to determine whether institutional acquisition of the robot was associated with a higher rate of PN. METHODS: We used the 2001, 2005 and 2008 Health-care Cost and Utilization Project State In-patient Databases from 7 states to identify 21,569 surgical procedures for renal tumors. These patient-level records were aggregated to the hospital-level then merged with the American Hospital Association Survey and with publicly available data on timing of robot acquisition. We used a difference-in-difference model to assess whether robot acquisition was associated with an increase in the PN rate, adjusting for total nephrectomy rate, year of surgery, year of robot acquisition and several hospital-level factors. We performed two sensitivity analyses to determine whether there was a time lag between robot acquisition and changes in PN utilization (because of a presumed necessity to develop requisite surgical skill) and to ensure no association existed between robot acquisition and performance of an unrelated procedure (the presence of which might suggest an unmeasured confounding characteristic was the actual cause for increased surgical volume). RESULTS: In the multivariable adjusted differences-in-differences model (Figure 1), hospitals acquiring a robot between 2001-2005 performed more PN in both 2005 (30% increase) and 2008 (35% total increase) (p<0.01 for both). Hospitals acquiring a robot in the time period between 2005-2008 also demonstrated higher rates of PN in 2008 (16% increase) (p1⁄40.02). Results of the secondary lag time analysis were not substantially different. There was no association between robot acquisition and utilization of an unrelated surgical procedure. CONCLUSIONS: Hospital acquisition of the robot is associated with increased utilization of PN, a guideline-encouraged procedure. This is one of the few studies to suggest acquisition of the surgical robot was associated with a clear improvement in quality of care.

IJU this issue

This issue deals with a wide range of clinical topics of urology, and contains one Review Article, 12 Original Articles, one Case Report and two Letters to the Editor. Urinary incontinence after radical prostatectomy is a big problem for patients with prostate cancer, and many urologists try to improve postoperative continent rates. Although recent systemic reviews and meta-analyses have shown that robot-assisted radical prostatectomy (RALP) has higher postoperative continence rates than retropubic radical prostatectomy (RRP) and laparoscopic radical prostatectomy (LRP), urinary incontinence has remained one of the most bothersome postoperative complications, even after RARP. The Review Article by Kojima et al. (Fukushima, Japan) showed that the basic concept of the intraoperative technique to improve postoperative urinary continence is to maintain as normal anatomical and functional structure in the pelvis as possible. They precisely reported three processes that consisted of preservation, reconstruction and reinforcement, helping us to modify our technique during RALP. Another topic regarding prostate cancer in this issue is pelvic lymph node dissection for prostate cancer. Mitsuzuka et al. (Sendai, Japan) investigated the role of pelvic lymph node dissection for low-risk prostate cancer using their medical records for 1268 patients undergoing open radical prostatectomy. Their conclusion is that pelvic lymph node dissection can be spared at radical prostatectomy for low-risk disease because of its poor diagnostic and therapeutic value, which is useful information when we carry out radical prostatectomy. Open versus laparoscopic, and partial versus radical nephrectomy (RN) for T1a renal cell carcinoma (RCC) are important topics, because the use of partial nephrectomy (PN) remains low in the community setting despite its established benefits. Bianchi et al. (Milan, Italy) examined the trends of open and laparoscopic PN and RN according to sociodemographic and tumor characteristics, using the USA Surveillance, Epidemiology, and End Results Medicare-linked database. They showed that older and female patients are less likely to undergo nephron-sparing surgery, and are more likely to have a radical nephrectomy by the laparoscopic approach instead, although utilization rates of PN are increasing. Further encouragement is required to increase PN for T1a RCC. Another topic regarding RCC in this issue is RCC extending into the inferior vena cava (IVC). Kondo et al. (Tokyo, Japan) investigated the impact of histological subtypes on the survival of patients presenting with RCC extending into the IVC, using their 68 cases who underwent RN and IVC thrombectomy. Their conclusion is that patients with RCC extending into the IVC with a papillary subtype show a considerably shorter survival compared with those with a clear cell subtype, which is helpful when we decide operative indications for patients with RCC extending into the IVC. Laparoendoscopic single site (LESS) surgery is a technical modification of conventional laparoscopy whereby the entire surgical procedure is carried out through a single abdominal wall incision. Tugcu et al. (Istanbul, Turkey) performed a prospective randomized study of LESS versus conventional transperitoneal laparoscopic pyeloplasty. A total of 39 patients were enrolled in their prospective study, and LESS pyeloplasty could offer faster recovery and higher patient satisfaction than conventional laparoscopic pyeloplasty. However, median operative time was longer in the LESS pyeloplasty group compared with the conventional laparoscopic group. Recently, a reduced port surgery using thin forceps, but not LESS, is increasing with technical advancements. In this sense, a comparison of reduced port pyeloplasty using thin forceps with LESS pyeloplasty would be interesting for evaluating the most minimally-invasive pyeloplasty. None declared.

Age Distribution for Partial and Radical Nephrectomy: Whose Nephrons are Being Spared?

Nephron sparing surgery (NSS) is recommended for patients with T1 renal cell carcinoma (RCC) whenever surgically feasible. By analyzing data from all urological clinics in the whole state of Lower Saxony, Germany, regardless of clinic size or level of expertise, we investigated whether current practice reflects the need for NSS in older patients on a broader scale. From 2005 to 2010, more than 100 medical facilities and urological clinics in Lower Saxony, Germany were evaluated for their individual rates of partial nephrectomy (PN) and radical nephrectomy (RN) based on patient's age in 5-year intervals. Sufficient data on age were available for 3,332 out of 3,693 patients with RCC undergoing surgery. PN rates for all patients and for those with T1 RCC were 19.9% and 29.5%, respectively. For all patients with RCC, the rates for PN and RN below the median age (<66.8 years) were 365 (21.9%) and 1,302 (78.1%) and above the median age were 297 (17.8%) and 1,368 (82.2%), respectively (P = 0.003). For patients with T1 RCC, the rates for PN and RN below the median age (<66.5 years) were 341 (32.6%) and 704 (67.4%) and above the median age were 277 (26.4%) and 774 (73.6%), respectively (P = 0.002). The highest rate for each type of surgery was seen in those aged 65-70 years, except for patients with T1 RCC receiving RN who were mostly operated on when aged 70-75 years. The rate of PN for all patients with RCC in this series and especially for patients with T1 RCC is significantly lower in older patients, thereby not reflecting the need and understanding for NSS in the higher age segment. Broader education and teaching of NSS might improve treatment of RCC in the future.

1426 CONTEMPORARY MANAGEMENT OF SMALL RENAL MASSES: PARTIAL NEPHRECTOMY IS ASSOCIATED EXCLUSIVELY WITH TUMOR ANATOMIC COMPLEXITY

You have accessJournal of UrologyKidney Cancer: Localized III1 Apr 20121426 CONTEMPORARY MANAGEMENT OF SMALL RENAL MASSES: PARTIAL NEPHRECTOMY IS ASSOCIATED EXCLUSIVELY WITH TUMOR ANATOMIC COMPLEXITY Gregory Broughton, Peter Clark, Daniel Barocas, Pamela Krajewski, Rodney Davis, Joseph Smith, Michael Cookson, S. Duke Herrell, and Sam Chang Gregory BroughtonGregory Broughton Nashville, TN More articles by this author , Peter ClarkPeter Clark Nashville, TN More articles by this author , Daniel BarocasDaniel Barocas Nashville, TN More articles by this author , Pamela KrajewskiPamela Krajewski Nashville, TN More articles by this author , Rodney DavisRodney Davis Nashville, TN More articles by this author , Joseph SmithJoseph Smith Nashville, TN More articles by this author , Michael CooksonMichael Cookson Nashville, TN More articles by this author , S. Duke HerrellS. Duke Herrell Nashville, TN More articles by this author , and Sam ChangSam Chang Nashville, TN More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1899AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Partial nephrectomy (PN) is the standard of care for small renal masses (SRM), though its underuse is suggested. We reported previously that the decision to perform PN is associated with both tumor complexity (represented by the Renal Nephrometry Score [RENAL-NS] and tumor size) and surgical approach (i.e. open versus minimally-invasive [MIS]). With increased experience and the maturation of MIS at our hospital (including the mid-2008 introduction of robotic renal surgery) we sought to reexamine the factors associated with PN use in a contemporary cohort. METHODS We identified 126 patients who underwent PN or RN between 2/2009 and 8/2011 for a solitary clinical T1a SRM and in whom there were no relative or imperative indications for PN. Patients were categorized into PN and RN groups based on preoperative treatment plan. Patient, procedure, and tumor variables, along with RENAL-NS, were evaluated for their association with planned PN versus RN. Chi-square and Fisher's exact tests were used to identify differences between the two groups. Multivariable logistic regression was then performed to identify independent correlates of PN use. RESULTS Mean patient age was 54.9 years (range 24-88 years) and tumor size 2.6 cm (range 0.8 to 4.0 cm). No patient factor differed significantly between the PN and RN groups. In an intention-to-treat analysis the rate of PN in this contemporary cohort was 115/126 (91%), with the overall rate of PN decreasing slightly to 112/126 (89%) after 3 intraoperative conversions from PN to RN. MIS was used in 91/126 (72%) of all cases overall, in 81/115 (70%) of PN cases, and in 10/11 (91%) of RN cases. There was no difference between the PN and RN groups with regard to planned approach (open vs. MIS, p = 0.288). Mean tumor size was smaller in the group undergoing PN compared to RN (2.6 vs. 3.2 cm, p = 0.003). Mean RENAL-NS was lower in the PN group compared to the RN cohort (6.2 vs. 8.7, p <0.001). In multivariable logistic regression only RENAL-NS was independently associated with PN (each 1 point decrease in RENAL-NS associated with PN OR 3.0, 95%CI 1.5 to 6.0, p = 0.001), while tumor size (OR 2.4, 95%CI 0.77 to 7.6, p = 0.131) and surgical approach (univariate p = 0.288) were not significant. CONCLUSIONS The decision to perform PN versus RN for SRM is associated exclusively with tumor anatomic complexity (RENAL-NS). Surgical approach and tumor size no longer correlate with nephrectomy type in this contemporary cohort. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e579 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gregory Broughton Nashville, TN More articles by this author Peter Clark Nashville, TN More articles by this author Daniel Barocas Nashville, TN More articles by this author Pamela Krajewski Nashville, TN More articles by this author Rodney Davis Nashville, TN More articles by this author Joseph Smith Nashville, TN More articles by this author Michael Cookson Nashville, TN More articles by this author S. Duke Herrell Nashville, TN More articles by this author Sam Chang Nashville, TN More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1845 NATIONAL SURVEY ON THE USE OF PARTIAL NEPHRECTOMY IN FRANCE. DATA FROM THE MULTICENTER PROSPECTIVE NEPHRON STUDY

1845 NATIONAL SURVEY ON THE USE OF PARTIAL NEPHRECTOMY IN FRANCE. DATA FROM THE MULTICENTER PROSPECTIVE NEPHRON STUDY

Evolving practice patterns for the management of small renal masses in the USA

What's known on the subject? and What does the study add? Treatment options for small renal masses include radical nephrectomy (RN), partial nephrectomy (PN), ablation, and surveillance. PN provides equivalent oncological as RN for small tumours, but long-term outcomes for ablation and surveillance are poorly defined. Due to changing techniques and technology, treatment patterns for small renal masses are rapidly developing. Prior studies had analysed utilisation trends for PN and RN to 2006, revealing a relative rise in the rate of PN. However, overall treatment trends including surveillance and ablation had not been studied using a population-based cohort. It has become increasingly clear that RN is associated with greater renal and cardiovascular deterioration than nephron-sparing treatments. Thus, it is important to understand current population-based practice patterns for the treatment of small renal masses to assess whether practitioners are adhering to ever-changing principles in this field. The present study provides up-to-date treatment trends in the USA using a large population-based cohort. To describe the changing practice patterns in the management of small renal masses, including the use of surveillance and ablative techniques. All patients in the Surveillance, Epidemiology and End Results (SEER) registry treated for renal masses of ≤7 cm in diameter, from 1998 to 2008, were included for analysis. Annual trends in the use of surveillance, ablation, partial nephrectomy (PN), and radical nephrectomy (RN) were calculated. Multinomial logistic regression was used to determine the association of demographic and clinical characteristics with treatment method. In all, 48 148 patients from 17 registry sites with a mean age of 63.4 years were included for analysis. Between 1998 and 2008, for masses of <2 cm and 2.1-4 cm, there was a dramatic increase in the proportion of patients undergoing PN (31% vs 50%, 16% vs 33%, respectively) and ablation (1% vs 11%, 2% vs 9%, respectively). In multivariable analysis, later year of diagnosis, male gender, being married, clinically localised disease, and smaller tumours were associated with increased use of PN vs RN. Later year of diagnosis, male gender, being unmarried, smaller tumour, and the presence of bilateral masses were associated with increased use of ablation and surveillance vs RN. PN is now used in half of all patients with the smallest renal masses, and its use continues to increase over time. Ablation and surveillance are less common overall, but there is increased usage over time in select populations.

1483 THE RATES OF PARTIAL NEPHRECTOMY IN PATIENTS WITH SMALL RENAL MASSES ARE INCREASING: A POPULATION-BASED STUDY

You have accessJournal of UrologyKidney Cancer: Localized V1 Apr 20101483 THE RATES OF PARTIAL NEPHRECTOMY IN PATIENTS WITH SMALL RENAL MASSES ARE INCREASING: A POPULATION-BASED STUDY Claudio Jeldres, Giovanni Lughezzani, Lars Budäus, Rodolphe Thuret, Daniel Liberman, Maxine Sun, Shahrokh F. Shariat, Paul Perrotte, Hartwig Huland, Markus Graefen, Francesco Montorsi, and Pierre I. Karakiewicz Claudio JeldresClaudio Jeldres Montreal, Canada More articles by this author , Giovanni LughezzaniGiovanni Lughezzani Milan, Italy More articles by this author , Lars BudäusLars Budäus Hamburg, Germany More articles by this author , Rodolphe ThuretRodolphe Thuret Rennes, France More articles by this author , Daniel LibermanDaniel Liberman Montreal, Canada More articles by this author , Maxine SunMaxine Sun Montreal, Canada More articles by this author , Shahrokh F. ShariatShahrokh F. Shariat Montreal, Canada More articles by this author , Paul PerrottePaul Perrotte Montreal, Canada More articles by this author , Hartwig HulandHartwig Huland Hamburg, Germany More articles by this author , Markus GraefenMarkus Graefen Hamburg, Germany More articles by this author , Francesco MontorsiFrancesco Montorsi Milan, Italy More articles by this author , and Pierre I. KarakiewiczPierre I. Karakiewicz Montreal, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1199AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Partial nephrectomy (PN) represents the treatment modality of choice for patients with small renal masses. We examined the rates of PN in patients with histologically proven small renal masses within a large population-based tumor registry. METHODS Within the 17 registries from the Surveillance, Epidemiology and End Results database between the years 1988 and 2006, we identified 20880 patients treated with either a partial or radical nephrectomy for T1aN0M0 histologically proven renal cell carcinoma. Trends, proportions, and multivariable logistic regression models were generated to assess the use of partial versus radical nephrectomy in this cohort. RESULTS Overall, 30.1% of patients underwent a PN between 1988 and 2006. The annual rates of PN use increased from 7.0 to 42.1% throughout the entire study period (relative increase: 6.0%, X2 trend: p<0.001). For tumors smaller or equal to 2.0 centimeters, the use of PN increased from 14.0 to 58.3% (relative increase: 4.2%, X2 trend: p<0.001) vs. 5.1 to 35.5% (relative increase: 7.0%, X2 trend: p<0.001) in tumors sized between 2.1 to 4.0 centimeters within the study period. Of all patients who received a PN, most were Caucasian (84.0%) and male (63.0%). PNs were more frequent in patients aged between 60-69 years old (27.8%) and least common in octogenarians (3.9%). Metropolitan areas showed the highest rate of PN being performed (91.0%). Additionally, most PN were performed in counties where the estimated median family income ranged between 45 to 75 thousand dollars (72.7%) vs. lower median family income counties (range 18 to 35 thousand dollars). Finally, most PN were performed in the most contemporary year quartile (37.2%). Multivariable models revealed that males were 1.2 times more likely to undergo a PN relative to female gender vs. 1.2 times for Caucasians compared to African Americans and 2.3 times in patients aged less than 50 years old relative to octogenarians (all p<0.001). Moreover, PN are 2.7 times more likely used in tumors sized less or equal to 2.0 centimeters relative to those larger than 2.0 centimeters (p<0.001). Finally, PN was up to 4 times higher in more contemporary years (p<0.001). CONCLUSIONS The rate of PN increased over the study period. As many as 48.1% of small renal masses less or equal to 2.0 centimeters were treated with PN. Only 24.4% of tumors sized from 2.1 to 4.0 centimeters were treated with a PN. Despite a clear increase in the rates of PN use over time, more emphasis needs to be placed on its benefit over radical nephrectomy to further encourage its use in clinical practice. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e571-e572 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Claudio Jeldres Montreal, Canada More articles by this author Giovanni Lughezzani Milan, Italy More articles by this author Lars Budäus Hamburg, Germany More articles by this author Rodolphe Thuret Rennes, France More articles by this author Daniel Liberman Montreal, Canada More articles by this author Maxine Sun Montreal, Canada More articles by this author Shahrokh F. Shariat Montreal, Canada More articles by this author Paul Perrotte Montreal, Canada More articles by this author Hartwig Huland Hamburg, Germany More articles by this author Markus Graefen Hamburg, Germany More articles by this author Francesco Montorsi Milan, Italy More articles by this author Pierre I. Karakiewicz Montreal, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1364 HOW OFTEN ARE PATIENTS WITH DIABETES OR HYPERTENSION BEING TREATED WITH PARTIAL NEPHRECTOMY FOR RCC? A POPULATION-BASED ANALYSIS

You have accessJournal of UrologyKidney Cancer: Localized IV1 Apr 20101364 HOW OFTEN ARE PATIENTS WITH DIABETES OR HYPERTENSION BEING TREATED WITH PARTIAL NEPHRECTOMY FOR RCC? A POPULATION-BASED ANALYSIS Robert Abouassaly, Shabbir M.H. Alibhai, and Antonio Finelli Robert AbouassalyRobert Abouassaly More articles by this author , Shabbir M.H. AlibhaiShabbir M.H. Alibhai More articles by this author , and Antonio FinelliAntonio Finelli More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.992AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Compared to radical nephrectomy (RN), partial nephrectomy (PN) leads to improved renal function preservation. This is particularly important in patients at risk of renal disease, such as patients with diabetes mellitus (DM) and hypertension (HTN), the two most frequent causes of end-stage renal disease. However, few data exist on PN use in these susceptible groups of patients. METHODS We conducted a population-based, retrospective, observational study using the Canadian Institute for Health Information Discharge Abstract Database. This contains data from all hospitals in 8 of 10 provinces and all 3 territories in Canada. All patients treated for RCC with either RN or PN from April 1, 1998 to March 31, 2008 were included in the analysis. Patients with DM and HTN were identified using specific diagnosis codes, and comorbidity was determined using the Deyo modification of the Charlson Index. The proportions of patients treated with PN were compared in patients with and without DM and HTN using the chi-square test and using a multivariable logistic regression adjusting for age, gender, year of surgery, and Charlson score. RESULTS A total of 20,226 patients were treated for RCC during the observation period. The median (interquartile range) age was 62 years (53-72 years), and 12,541 (62%) were men. Overall, 3,101 (15.3%) patients were treated with PN. The Charlson score (excluding DM) was 0, 1 and ≥2 in 83.6%, 8.9%, and 7.5%, respectively. In our sample, 2,370 (11.7%) were identified as having DM, 2,248 (11.1%) as having HTN, and 509 (2.5%) as having both. PN was used in 17.2% of patients with DM, compared to 15.1% of those without DM (p<0.01), whereas in patients with HTN, PN was used in 12.7% of patients compared to 15.7% of patients without HTN (p<0.01). However, after adjusting for covariates, both HTN and DM were found to be independently associated with increased PN use, OR 1.19 (95% CI 1.04-1.38) and OR 1.16 (95% CI 1.03-1.30) respectively. CONCLUSIONS Using population-based data, patients with HTN and DM appear to be treated by PN slightly more often than normotensives and non-diabetics. However, in this contemporary analysis PN continues to be underutilized and although statistically significant, the rate of PN in DM and HTN was less than expected given their known relationship to chronic renal failure. Further study is needed to elucidate the specific factors contributing to PN underutilization in these susceptible patients. Toronto, Canada© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e527 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Robert Abouassaly More articles by this author Shabbir M.H. Alibhai More articles by this author Antonio Finelli More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

826 THE EFFECT OF RADICAL VERSUS PARTIAL NEPHRECTOMY ON OTHER-CAUSE MORTALITY IN PATIENTS WITH T1A RENAL CELL CARCINOMA: RESULTS FROM THE SURVEILLANCE, EPIDEMIOLOGY AND END RESULTS DATABASE

You have accessJournal of UrologyKidney Cancer: Localized I1 Apr 2010826 THE EFFECT OF RADICAL VERSUS PARTIAL NEPHRECTOMY ON OTHER-CAUSE MORTALITY IN PATIENTS WITH T1A RENAL CELL CARCINOMA: RESULTS FROM THE SURVEILLANCE, EPIDEMIOLOGY AND END RESULTS DATABASE Giovanni Lughezzani, Claudio Jeldres, Lars Budaus, Shahrokh F. Shariat, Daniel Liberman, Rodolphe Thuret, Hugues Widmer, Philippe Arjane, Jean-Jacques Patard, Paul Perrotte, Francesco Montorsi, and Pierre I. Karakiewicz Giovanni LughezzaniGiovanni Lughezzani Milano, Italy More articles by this author , Claudio JeldresClaudio Jeldres Montreal, Canada More articles by this author , Lars BudausLars Budaus Hamburg, Germany More articles by this author , Shahrokh F. ShariatShahrokh F. Shariat Montreal, Canada More articles by this author , Daniel LibermanDaniel Liberman Montreal, Canada More articles by this author , Rodolphe ThuretRodolphe Thuret Montpellier, France More articles by this author , Hugues WidmerHugues Widmer Montreal, Canada More articles by this author , Philippe ArjanePhilippe Arjane Montreal, Canada More articles by this author , Jean-Jacques PatardJean-Jacques Patard Rennes, France More articles by this author , Paul PerrottePaul Perrotte Montreal, Canada More articles by this author , Francesco MontorsiFrancesco Montorsi Milano, Italy More articles by this author , and Pierre I. KarakiewiczPierre I. Karakiewicz Montreal, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1527AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Partial nephrectomy (PN) is frequently used. However, its rates could still be increased, especially in patients with T1a renal cell carcinomas (RCC). The rationale for maximizing PN rates may reside in the protective effect of PN on non-RCC related events. We tested this hypothesis in a large population-based cohort. METHODS Between 1988 and 2006, 23613 patients underwent a PN (n=7048; 29.8%) or a radical nephrectomy (RN) (n=16565; 70.2%) for pT1apN0M0 RCC within 17 Surveillance, Epidemiology and End Results (SEER) registries. Cumulative incidence plots addressed other-cause mortality (OCM) rates of PN vs. RN patients after accounting for cancer-specific mortality. Finally, multivariable competing-risks regression models addressed OCM after PN vs. RN after adjusting for age, gender, race, tumor size, histological subtype, tumor grade and year of diagnosis. RESULTS Overall, cardiovascular disease, cerebrovascular disease and lung cancer were the three most frequent non-RCC related causes of death. In univariable analyses, RN was associated with a 1.52 (95% CI: 1.40-1.66; p<0.001) increase in OCM relative to PN, which translated into a 5.01% and 8.63% absolute increase in mortality at 5 and 10 years after surgery respectively. In multivariable competing-risks regression models RN was still associated with a statistically significant increase in OCM rates relative to PN (HR: 1.29; 95% CI: 1.18-1.41; p<0.001). CONCLUSIONS Patients treated with RN for T1a RCC have higher OCM rates than PN patients even after adjustment for various patient and tumor characteristics. In consequence, PN should be attempted whenever technically feasible in order to decrease non-RCC related deaths. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e323 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Giovanni Lughezzani Milano, Italy More articles by this author Claudio Jeldres Montreal, Canada More articles by this author Lars Budaus Hamburg, Germany More articles by this author Shahrokh F. Shariat Montreal, Canada More articles by this author Daniel Liberman Montreal, Canada More articles by this author Rodolphe Thuret Montpellier, France More articles by this author Hugues Widmer Montreal, Canada More articles by this author Philippe Arjane Montreal, Canada More articles by this author Jean-Jacques Patard Rennes, France More articles by this author Paul Perrotte Montreal, Canada More articles by this author Francesco Montorsi Milano, Italy More articles by this author Pierre I. Karakiewicz Montreal, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1367 SURGICAL MANAGEMENT OF T1A LESIONS IN THE 21ST CENTURY: A POPULATION-BASED STUDY

You have accessJournal of UrologyKidney Cancer: Localized IV1 Apr 20101367 SURGICAL MANAGEMENT OF T1A LESIONS IN THE 21ST CENTURY: A POPULATION-BASED STUDY Giovanni Lughezzani, Claudio Jeldres, Lars Budaus, Rodolphe Thuret, Daniel Liberman, Maxine Sun, Shahrokh F. Shariat, Philippe Arjane, Hugues Widmer, Wassim Kassouf, Jean-Jacques Patard, Francesco Montorsi, Giorgio Guazzoni, Paul Perrotte, and Pierre I. Karakiewicz Giovanni LughezzaniGiovanni Lughezzani Milano, Italy More articles by this author , Claudio JeldresClaudio Jeldres Montreal, Canada More articles by this author , Lars BudausLars Budaus Hamburg, Germany More articles by this author , Rodolphe ThuretRodolphe Thuret Montpellier, France More articles by this author , Daniel LibermanDaniel Liberman Montreal, Canada More articles by this author , Maxine SunMaxine Sun Montreal, Canada More articles by this author , Shahrokh F. ShariatShahrokh F. Shariat Montreal, Canada More articles by this author , Philippe ArjanePhilippe Arjane Montreal, Canada More articles by this author , Hugues WidmerHugues Widmer Montreal, Canada More articles by this author , Wassim KassoufWassim Kassouf Montreal, Canada More articles by this author , Jean-Jacques PatardJean-Jacques Patard Rennes, France More articles by this author , Francesco MontorsiFrancesco Montorsi Milano, Italy More articles by this author , Giorgio GuazzoniGiorgio Guazzoni Milano, Italy More articles by this author , Paul PerrottePaul Perrotte Montreal, Canada More articles by this author , and Pierre I. KarakiewiczPierre I. Karakiewicz Montreal, Canada More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.995AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES According to the National Comprehensive Cancer Network guidelines, partial nephrectomy (PN) should be the standard of care in patients with T1a renal cell carcinoma (RCC) and normal contralateral kidney. Conversely, local tumor ablation (LTA) represents a treatment option for patients with multiple comorbidities or for those with limited life expectancy. METHODS Within the Surveillance, Epidemiology and End Results database, 15785 individuals treated with LTA, PN and RN for histologically proven stage T1a RCC were identified within 17 registries between 2001 and 2006. Trends, proportions, and multivariable logistic regression models assessed patient characteristics and predictors of LTD or PN in this patient population. RESULTS Overall 3.8, 35.0 and 61.2% of patients respectively underwent LTA, PN or RN. The rate of LTA use increased from 1.1 to 7.1% within the studied years of interest (chi-square trend, p<0.001). Similarly, the rate of PN increased from 26.6 to 39.3% within the study period (chi-square trend, p<0.001). In multivariable logistic regression models, the independent predictors of LTA were more advanced age (p<0.001), male gender (p=0.01), and more favorable tumor grade (p<0.001). The independent predictors of PN were younger age (p<0.001), male gender (p=0.008), more favorable tumor grade (p<0.001), and higher socioeconomic status (p=0.001). CONCLUSIONS Local tumor ablation represents a treatment option for highly select patient subgroup and is predominantly offered to elderly individuals with low grade tumors. Surprisingly, its increase (6.5-fold) significantly exceeded that of PN (1.5-fold) between 2001 and 2006. Finally, the use of PN should be encouraged as only 39% of individuals benefitted of this nephron-sparing treatment option in the most recent study year. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e528 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Giovanni Lughezzani Milano, Italy More articles by this author Claudio Jeldres Montreal, Canada More articles by this author Lars Budaus Hamburg, Germany More articles by this author Rodolphe Thuret Montpellier, France More articles by this author Daniel Liberman Montreal, Canada More articles by this author Maxine Sun Montreal, Canada More articles by this author Shahrokh F. Shariat Montreal, Canada More articles by this author Philippe Arjane Montreal, Canada More articles by this author Hugues Widmer Montreal, Canada More articles by this author Wassim Kassouf Montreal, Canada More articles by this author Jean-Jacques Patard Rennes, France More articles by this author Francesco Montorsi Milano, Italy More articles by this author Giorgio Guazzoni Milano, Italy More articles by this author Paul Perrotte Montreal, Canada More articles by this author Pierre I. Karakiewicz Montreal, Canada More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A comparative population‐based analysis of the rate of partial vs radical nephrectomy for clinically localized renal cell carcinoma

Prevalence (prospective cohort with good follow up). 1a. To examine contemporary (1989-2004) trends in partial nephrectomy (PN) within the Surveillance, Epidemiology and End Results (SEER) database, as among other considerations, a survival benefit due to avoidance of surgically induced renal insufficiency distinguishes PN from radical nephrectomy (RN). Diagnostic, stage and surgical codes of patients with T1-2N0M0 renal cell carcinoma treated with either PN or RN were assessed. Proportions, trends and multivariable logistic regression models tested the predictors of the use of PN. Of 19 733 assessable patients, 2614 (13.2%) and 17 119 (86.8%), respectively, had PN or RN. The use of PN decreased with increasing tumour size, was more frequent in younger patients and increased with more contemporary years of surgery (all P < 0.001). Intriguingly, there was important geographical variability (P < 0.001), e.g. in the San Francisco-Oakland Metropolitan Area the absolute PN rate was 16.4%, vs 7.6% in New Mexico (P < 0.001). In multivariable analyses, tumour size, age, year of surgery, gender and SEER registries were independent predictors of PN use. Although as expected the rate of PN use increased over time, unexplained variability remained. For example, gender and SEER registries affected the likelihood of PN. These variables warrant further analyses to reduce unnecessary variability and to maximize PN use and its benefit.

Does Laparoscopy Beget Underuse of Partial Nephrectomy for T1 Renal Masses? Competing Treatment Decision Pathways May Influence Utilization

It has been suggested that renal laparoscopy has resulted in an underuse of partial nephrectomy (PN) for small renal masses in the U.S. In the absence of evidence-based medicine (EBM) guide-lines, multiple-perspective reasoning is required where complete v partial nephrectomy and the laparoscopic v the open surgical approach must be considered. We report on the PN rate in a contemporary laparoscopicera series of patients with T(1) renal masses and examine the potential influence of the management decision tree on the PN rate. An actively managed database of referred patients with T(1) renal masses was utilized retrospectively. All patients were evaluated by a single fellowship-trained urologic oncologist with formal laparoscopic training. Patients were presented with a management decision tree in which PN v total nephrectomy (TN) was the first decision node, laparoscopy v open surgery was the second decision node, and the actual PN rate was reported. We then constructed a hypothetical decision tree in which the first and second decision nodes were reversed and the criteria for performing laparoscopic nephrectomy remained constant. Seventy consecutive patients were entered during a 36-month period (July 2002-June 2005). The actual PN rate was 60%: 91% for lesions <2.0 cm, 68% for lesions 2.1 to 4.0 cm, and 33% for lesions 4.1 to 7.0 cm; and 62% of patients were treated laparoscopically. When the first and second decision nodes were reversed and this hypothetical model was applied to the study cohort, the projected PN rate was 23%, and 96% of the patients were treated laparoscopically. In the hypothetical model, the PN rate fell when patients who chose laparoscopy at the first decision node were excluded from PN at the second decision node if the criteria for laparoscopic PN were not met. Laparoscopy did not appear to result in underuse of PN. We explain this by suggesting that the PN rate may be influenced by variation in the decision tree itself. Such variation is inherent in complex clinical decision making where EBM guidelines are lacking.