Trends in the surgical management of localized renal masses: thermal ablation, partial and radical nephrectomy in the USA, 1998–2008
Correspondence: Ithaar H. Derweesh, Division of Urology, Moores UCSD Cancer Center, 3855 Health Sciences Drive, Mail Code: 0987, La Jolla, CA 92093-0987, USA.
What's known on the subject? and What does the study add?
- Treatment options for small renal masses include radical nephrectomy (RN), and nephron sparing modalities (NSM) such as partial nephrectomy (PN), and thermal ablation (Cryo- and radiofrequency ablation, C/RFA). Prior studies had demonstrated gross underutilization of PN; however overall treatment trends for C/RFA had not been well studied using a population-based cohort. In this study, which examined management trends of localized renal masses in the USA, we identified an increased prevalence of RN, PN and C/RFA over the study period, with PN increasing the most rapidly, and with RN continuing to account for the vast majority of procedures.
- This is the first study to examine surgical management of renal masses in patients with non-dialysis dependent chronic renal insufficiency. Although nephron sparing modalities were increasingly utilized over the study period, it is particularly concerning that patients with pre-existing non-dialysis dependent chronic renal insufficiency are receiving less nephron sparing approaches. Further investigations are required to confirm these findings and to identify impediments to the dissemination of nephron sparing modalities.
- To evaluate the diffusion of nephron-sparing modalities (NSM) for the treatment of renal neoplasms in the USA over the last decade and to identify the factors associated with renal procedure selection.
Patients and Methods
- The Nationwide Inpatient Sample was utlized to identify patients undergoing cryo/radiofrequency ablation (C/RFA), radical nephrectomy (RN) and partial nephrectomy (PN) from 1998 to 2008.
- Annual trends in procedure prevalence were determined.
- Multivariate analyses were performed to query the influence of age, race, sex and comorbid disease on surgery selection.
- We identified 443 853 procedures performed during the study period: 25 599 C/RFA, 79 568 PN and 338 687 RN.
- The prevalence per 100 000 hospital admissions in 1998 was 3.7 for C/RFA, nine for PN and 87.1 for RN. All procedures increased over the study period, by 1.05, 3.1 and 2.2/100 000 admissions per year, respectively (all P < 0.001).
- Diabetes, urban, teaching and large capacity hospitals were associated with NSM (either C/RFA or PN) compared to RN (all P ≤ 0.011). Age ≥70 years, female, hypertension, diabetes, chronic kidney disease (CKD) and region outside the Northeast favoured C/RFA over PN (all P ≤ 0.026).
- Compared to those without CKD, patients with CKD had an almost twofold higher probability of undergoing RN than NSM (odds ratio, 1.88; 95% confidence interval, 1.7–2.1). Despite increasing NSM utilization over the study period, most patients with CKD still received RN.
- Although the prevalence of NSM is increasing, RN is more common.
- The low utilization of NSM in patients with pre-existing CKD warrants further investigation.