Partial Nephrectomy Remains Underutilized, Despite AUA Endorsement

Although the 2009 American Urological Association (AUA) guidelines cite “compelling data” for consideration of nephron-sparing surgery in all patients, partial nephrectomy remains underutilized for small renal masses, according to a new analysis.

At the 2012 Society of Urologic Oncology (SUO) annual meeting in Bethesda, Maryland, Marc Bjurlin, MD, clinical instructor in the Department of Urology at New York University, reported findings from an analysis of the use of partial nephrectomy before and after issuance of the 2009 AUA guidelines. For management of clinical stage 1 renal masses, the guidelines state that partial nephrectomy provides equivalent oncologic outcomes for the treatment of small renal masses and minimizes the risk for chronic kidney disease, associated cardiovascular disease, and mortality over the longer term.

Bjurlin and colleagues analyzed data from the Nationwide Inpatient Sample between 2007 and 2010. The dataset includes a 20% sample of all US inpatient hospitalizations.

The investigators identified 26,224 patients with renal tumors who underwent surgery. Prior to the guidelines, 27% (4033) of patients underwent partial nephrectomy. After the guidelines were issued in 2009, 32% (3560) received partial nephrectomy for small renal masses. On multivariate analysis, undergoing surgery after the issuance of the AUA guidelines was an independent predictor of partial nephrectomy (odds ratio [OR] =1.28; 95% CI, 1.21-1.36; P <.01).

Other factors associated with use of partial nephrectomy included urban location, surgery that was conducted at a teaching hospital, large-hospital status, location in the Northeast, and black race. Gender and chronic kidney disease were not associated with partial nephrectomy.

Figure. Partial Nephrectomy Use Before and After the Introduction of the 2009 AUA Guidelines

Although the study did not look at barriers to partial nephrectomy, several have been suggested, Bjurlin said, including patient decision, tumor characteristics, the hospital where the surgery is performed, and surgeon characteristics. Increased comorbidities have also been shown to reduce the likelihood of choosing a partial nephrectomy. “Tumor size and complexity often drive a decision for a partial nephrectomy,” he said. The investigators also observed that age was a barrier.

A suboptimal adoption trend following a clinical guideline change could be overemphasized, however. Other surgical disciplines have had less success with the impact of their guidelines— cardiology and obstetrics/gynecology, for example, Bjurlin said. Even so, he suggested that the barriers need to be individually addressed in order to bring about wider adoption of use of partial nephrectomy in the urology community.

“The take-home message is that even though the adoption of partial nephrectomy increased after the establishment of the AUA guidelines for renal masses, partial nephrectomy remains underutilized,” Bjurlin said. “Our focus now needs to be on these barriers to adoption of partial nephrectomy and how to overcome them.”