Practice-setting and surgeon characteristics heavily influence the decision to perform partial nephrectomy among American Urologic Association surgeons

Authors


Correspondence: Bradley C. Leibovich, Department of Urology, Mayo Clinic, 200 First Street SW Gonda 7, Rochester, MN 55905, USA.

e-mail: leibovich.bradley@mayo.edu

Abstract

What's known on the subject? and What does the study add?

  • There is great variability in the utilization of partial nephrectomy, but the causes of these variations are not well understood.
  • The present study underscores the already observed phenomenon of surgical volume influencing surgical planning and outcomes, but it gets at why this might be so. We observe that high-volume renal surgeons have different thresholds of ‘technical feasibility’.

Objective

  • To investigate why there continues to be wide variability in the application of partial nephrectomy (PN) for treating small renal masses despite guidelines in the US and Europe stating that a PN is a standard of care for a patient with a T1 renal mass.

Patients and Methods

  • In June 2009, 764 surgeon-members of the American Urologic Association (AUA) participated in a survey evaluating the management of renal masses.
  • Renal mass complexity was graded by nephrometry score (NS).
  • Multivariable logistic regression models with generalized estimating equations were constructed to evaluate how tumour, surgeon and practice-setting characteristics influence the use of PN.

Results

  • The survey response rate was 19%. Each urological surgeon responded to eight scenarios, providing 6112 evaluable cases.
  • Tumour NS ranged from 4 to 10, and each unit increase in NS was associated with 59% increased likelihood of a surgeon offering RN on multivariable analysis (odds ratio [OR] = 1.59; 95% CI: 1.52–1.64).
  • When holding patient and tumour characteristics constant, the following surgeon and practice-setting characteristics significantly increased the odds of offering a PN: increasing renal case volume (OR = 1.57; 95% CI: 1.27–1.95), academic practice (OR = 1.80; 95% CI: 1.42–2.29), increasing PN % volume (OR = 3.7; 95% CI: 2.46–5.55) and younger surgeon age (≤40 vs >50 years) (OR = 1.64; 95% CI: 1.35–1.96).

Conclusion

  • The characteristics of a surgeon and the setting in which he or she practices influence the utilization of PN, the adherence to professional guidelines, and the threshold of tumour complexity at which a surgeon stops offering PN.

Ancillary