Increased Use of Partial Nephrectomy to Treat High-risk Disease

Objectives: To evaluate partial nephrectomy (PN) use in patients at higher risk for clinical progression, using a large national database of American patients.

Patients And Methods: We performed a retrospective review of patients with cN0/cM0 renal cell carcinoma from 2003 to 2011 using the National Cancer Data Base. Our primary endpoint was PN use for high-risk disease, defined as ≥1 adverse pathological features (APF), namely pT3 stage, high grade, or unfavourable histology. Our secondary endpoint was positive surgical margins (PSM) associated with high-risk disease after PN. Time trends were analysed using the asymptotic Cochran-Armitage trend test. Relationships between patient, provider, and pathological factors and the likelihood of PN were assessed using multivariate logistic regression.

Results: Of 183 886 surgically treated patients, 27.4% underwent PN. Over time, PN use increased overall (17.4-39.7%) and in tumours with ≥1 APF (8.5-24.2%) (P < 0.01). In patients with ≥1 APF, multivariate analysis revealed that academic practice setting and high surgical volume were positively associated with PN use, while increasing tumour size and preoperative biopsy were negatively associated with its use (P < 0.01). The PSM rate after PN also increased significantly over time in all patients and in those harbouring adverse pathology (P < 0.01). Aside from time, older age, larger tumour size, community hospital type, and robotic approach were associated with PSM in the setting of APF (P < 0.01).

Conclusion: PN use for patients with adverse pathology is increasing and is associated with increasing PSM. The long-term oncological implications of these trends are unclear and warrant further study.