BERKELEY, CA (UroToday.com) - In 1933, the surgeon Joseph Lazarus remarked that “there are few chapters in urology that are quite as discouraging to the surgeon as the chapter dealing with malignant tumors of the kidney.”
In the eighty years since, various strategies to treat kidney cancer have flourished, yet often the urologist is no less perplexed as to which strategy might be most beneficial to the patient’s survival and quality of life. This balance of treatment and quality of life is particularly important for the older urology patient.
As the field of urology confronts the aging population, there are two reasonable approaches to managing the geriatric urologic patient. The first approach is to treat a disease process in an older patient differently from that of a younger patient. An example of where this might be appropriate is in the screening and subsequent management of prostate cancer. An 85-year-old with an elevated PSA is surely different from a 55-year-old. A second approach to managing the elderly urologic patient is to view their pathology as no different from that of a younger person. In our study, we demonstrated that patients over the age of 75 with the smallest of renal masses (<2cm) are at nearly a 20% increased chance of receiving a radical nephrectomy vs. partial nephrectomy when compared to their younger counterparts. This trend, which was present across the entire U.S., did improve over the past 10 years. Because there are no evidence-based reasons why a more radical surgery in the elderly is preferential, this trend suggests that our field is taking the first approach to elderly patients with renal masses. Whether this is correct or not remains to be seen.
Since 2007 (the final year of this study period), several important developments have occured in the management of small renal masses. The first is new evidence suggesting that many of these very small masses can safely be managed with active-surveillance, particularly in the elderly. As a result, if an 80-year-old patient is incidentally found to have a 1.5cm renal mass, there are now a plethora of management strategies: active surveillance, local cryotherapy or radio-frequency ablation, partial nephrectomy, and finally, as a last resort comes radical nephrectomy. As we continue to study and compare these treatment options, radical nephrectomy for a 2cm incidental carcinoma will hopefully disappear from the urologic armamentarium.
Of course, a patient’s treatment in kidney cancer surgery is often a reflection of the surgeon’s comfort level with the various treatment modalities. An open partial nephrectomy may appear like a more detrimental operation in comparison to a laparoscopic radical nephrectomy, despite the evidence that suggests that a patient benefits by preserving as many nephrons as possible. It is thus important to note the increased adoption of minimally invasive partial nephrectomy in the four years since our study concluded. It will be interesting to see if minimally invasive partial nephrectomy replaces open partial nephrectomy in a manner similar to the trend that has been observed in radical prostatectomy. If it does, than we may see a shift towards partial nephrectomy, which will not necessarily be based on the evidence at hand, but on a shifting set of surgical skills among urologists.
Max Kates and James M. McKiernan, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Columbia University Medical Center, Department of Urology, New York, NY USA