The Temporal Association of Robotic Surgical Diffusion with Overtreatment of the Small Renal Mass

To evaluate contemporary practice patterns in the management of small renal masses.

We identified 52,804 patients within the National Cancer Database diagnosed with a small renal mass (≤4cm) between 2010-2014. Utilization trends for active surveillance, ablation, and robotic, laparoscopic, and open surgical techniques were compared among all-comers, elderly patients (≥75 years) and individuals with competing health risks (Charlson index ≥2). Multivariable logistic regression models were used to assess factors associated with use of robotic renal surgery and active surveillance.

Surgery remained the primary treatment modality across all years studied, utilized in 75.0% and 74.2% of cases in 2010 and 2014, respectively. Although increases in both active surveillance (4.8% in 2010 to 6.0% in 2014;P<0.001) and robotic renal surgery (22.1% in 2010 to 39.7% in 2014;P<0.001) were observed, the increase in the proportion of small renal masses treated by robotic partial (82.0%) and radical (63.0%) nephrectomy was greater than that for active surveillance (25.0%). Subgroup analyses in individuals ≥75 years or with Charlson index ≥2 likewise revealed preferential increases in robotic surgery versus active surveillance. On multivariable analysis, later year of diagnosis was associated with increased utilization of robotic renal surgery compared to active surveillance (2014 versus 2010 OR 1.44; 95%CI 1.20-1.72;P<0.001) and non-robotic procedural interventions (2014 versus 2010 OR 2.59; 95%CI 2.30-2.93;P<0.001).

Utilization of robotic surgical extirpation has outpaced adoption of active surveillance for small renal masses, raising concern that diffusion of robotic technology propagates the practice of overtreatment, particularly among elderly and comorbid individuals.

The Journal of urology. 2018 May 21 [Epub ahead of print]

Paras H Shah, Manaf A Alom, Bradley C Leibovich, R Houston Thompson, Robert G Uzzo, Louis R Kavoussi, Lee Richstone, Bimal Bhindi, Elizabeth B Habermann, Vidhu Joshi, Stephen A Boorjian

Department of Urology, Mayo Clinic, Rochester, MN., Division of Urology, Fox Chase Cancer Center, Philadelphia, PA., Department of Urology, Northwell Health, New Hyde Park, NY., Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN., Department of Urology, Mayo Clinic, Rochester, MN. Electronic address: .