Radical nephrectomy including ipsilateral adrenalectomy became standard of care for renal cortical tumors approximately 40 years ago. This was subsequently challenged in the 1980’s by several reports demonstrating favorable results with partial nephrectomy in imperative situations.13, 14
During the last decade, partial nephrectomy has been accepted as a safe and preferable alternative to radical nephrectomy for most small renal tumors even in the setting of a normal contralateral kidney.1–4
However, data from the 2000–2002 SEER cancer registry clearly demonstrates that across the United States, partial nephrectomy is underutilized in the surgical management of renal tumors. With the widespread use of cross-sectional imaging, approximately 2/3 of all renal masses today are small and incidentally detected. Thus, it remains concerning as to why so few patients are treated with partial nephrectomy in the United States.
Our contemporary experience with surgical management of renal tumors demonstrates a few important points. First, the “emerging quality of care concern” reported by Miller et al10
is being addressed as evidenced by the steady increase in the frequency of partial nephrectomy use at our institution. In the year 2007 alone, nearly 90% of patients with T1a tumors were treated with partial nephrectomy despite an elective situation. Furthermore, most (60%) patients with T1b tumors were also treated with partial nephrectomy and we expect these trends to continue to increase for surgically managed patients. Second, we confirm previous population based observations that younger patient age, smaller tumor size, male gender, and more recent diagnostic year are independent determinants of partial nephrectomy use.7, 10
While tumor size and diagnostic year seem logical as predictors of partial nephrectomy, knowledge that females and older patients are at risk for overtreatment should prove helpful in limiting the underutilization of partial nephrectomy. Third, our results suggest that while integration of laparoscopy into renal surgery is initially associated with performing a radical nephrectomy, increased experience facilitates proper patient selection such that surgical approach does not affect the procedure performed.
Recent observations from our institution and others demonstrate a significantly increased risk of chronic renal insufficiency among patients treated with radical compared with partial nephrectomy for renal tumors in elective situations.1, 5
In a graded fashion, chronic renal failure places patients at increased risks of hospitalization, cardiovascular morbidity, and death.15
It is important to emphasize that these risks occur in a graded and escalating fashion beginning when GFR declines below 60. We have previously shown that among all renal mass patients with a “normal” contralateral kidney on imaging and a “normal” serum creatinine, more than 25% actually have baseline chronic kidney disease (GFR <60) if their GFR is estimated using the abbreviated MDRD equation.1
Thus, treatment of contemporary renal mass patients should focus on minimizing the risk of chronic renal disease and not simply attempting to limit the rare progression to dialysis. Additionally, recent observations with mid term clinical follow-up suggest that overall survival is diminished if patients with small renal masses are treated with a radical compared with partial nephrectomy.6, 7
Collectively, these observations suggest that there are serious potential consequences for overutilization of radical nephrectomy for patients with small renal masses. In this report, we demonstrate that this quality of care concern is being addressed at our tertiary care center. We also surmise that our results are applicable to most academic centers, and thus, we believe that the improvement in partial nephrectomy use is likely occurring across the United States and abroad. We also confirm important clinical features that predict for overutilization of radical nephrectomy which should prove useful when additional centers similarly address the national quality of care concern.
This study is not without limitations. Our analysis represents a retrospective, single institution experience that may not be reflective of other institutions. Additionally, we would like to emphasize that the limited number of surgeons who performed laparoscopic surgery at our institution, coupled with the strong preference for open partial nephrectomy by the senior author (who performed 50% of the operations), suggests that the results we observed between surgical approach and type of procedure clearly need external validation or populated based confirmation prior to embracing as a valid association. Furthermore, our results are limited by a referral bias to our tertiary care facility. Patients who request partial nephrectomy or those with imperative indications may be more likely to be referred to our institution. However, we attempted to minimize this bias by limiting the analyses to patients with normal contralateral kidneys and an estimated GFR >45 which we defined as an elective situation. Nonetheless, our results may not be applicable or indicative of all hospitals or surgeons in the United States.
Compared with radical nephrectomy, partial nephrectomy is associated with more procedure related complications; however, the majority of these are minor and there does not appear to be a difference in the frequency of serious complications or the presence of any early complication.16
Additionally, with increasing experience, complications from open partial nephrectomy have significantly decreased to the point where risk of urine leak or hemorrhage are less than 5%.2, 17
In elective situations, health related quality of life is improved with partial compared with radical nephrectomy.18
Hospital costs and length of stay are similar for partial and radical nephrectomy.19, 20
Additionally, laparoscopic partial nephrectomy has now been investigated with excellent mid-term oncologic and functional outcomes.21
Partial nephrectomy reduces the risk of chronic renal failure1, 5
and recent data suggest that partial nephrectomy may reduce the risk of subsequent overall mortality compared with radical nephrectomy.6, 7
Collectively, these observations support that partial nephrectomy is standard of care for most small renal tumors even in the setting of a normal contralateral kidney. Patients with small and often incidental renal tumors should be offered partial nephrectomy or referred to a center that performs the procedure with efficiency. Radical nephrectomy for low grade, indolent, and frequently benign tumors may have long-term adverse consequences including renal failure, cardiovascular morbidity, and death. Our data suggest that these quality of care concerns are currently being addressed to improve the long-term care for renal mass patients.