To evaluate partial nephrectomy use in patients at higher risk for clinical progression, using a large national database of American patients.
We performed a retrospective review of patients with cN0/cM0 renal cell carcinoma from 2003-2011 using the National Cancer Data Base.
Our primary endpoint was partial nephrectomy use for high-risk disease, defined as ≥1 adverse pathologic feature(s), namely pT3 stage, high grade, or unfavorable histologic subtype). Our secondary endpoint was positive surgical margins associated with high-risk disease after partial nephrectomy. Time trends were analyzed using the asymptotic Cochran-Armitage trend test. Relationships between patient, provider, and pathologic factors and the likelihood of partial nephrectomy were assessed using multivariate logistic regression.
Of 183,886 surgically treated patients, 27.4% underwent partial nephrectomy. Over time, partial nephrectomy use increased overall (17.4-39.7%) and in tumors with ≥1 adverse pathologic feature(s) (8.5-24.2%) (p<0.01). In patients with ≥1 adverse pathologic feature(s), multivariate analysis revealed that academic practice setting and high surgical volume were positively associated with partial nephrectomy use, while increasing tumor size and preoperative biopsy were negatively associated with its use (p<0.01). The positive margin rate after partial nephrectomy also increased significantly over time in all patients and in those harboring adverse pathology (p<0.01). Aside from time, older age, larger tumor size, community hospital type, and robotic approach were associated with positive margins in the setting of adverse pathologic features (p<0.01).
Partial nephrectomy use for patients with adverse pathology is increasing and is associated with increasing positive surgical margins. The long-term oncologic implications of these trends are unclear and warrant further study. This article is protected by copyright All rights reserved.
BJU international 2015 Aug 25 [Epub ahead of print]
Matthew J Maurice, Hui Zhu, Simon P Kim, Robert Abouassaly
Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA , Division of Urology, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA , Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA , Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA