Contemporary Use of Partial Nephrectomy at a Tertiary Care Center in the United States

Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
The Journal of urology (Impact Factor: 4.47). 03/2009; 181(3):993-7. DOI: 10.1016/j.juro.2008.11.017
Source: PubMed


The use of partial nephrectomy for renal cortical tumors appears unacceptably low in the United States according to population based data. We examined the use of partial nephrectomy at our tertiary care facility in the contemporary era.
Using our prospectively maintained nephrectomy database we identified 1,533 patients who were treated for a sporadic and localized renal cortical tumor between 2000 and 2007. Patients with bilateral disease or solitary kidneys were excluded from study and elective operation required an estimated glomerular filtration rate of 45 ml per minute per 1.73 m(2) or greater. Predictors of partial nephrectomy were evaluated using logistic regression models.
Overall 854 (56%) and 679 patients (44%) were treated with partial and radical nephrectomy, respectively. In the 820 patients treated electively for a tumor 4 cm or less the frequency of partial nephrectomy steadily increased from 69% in 2000 to 89% in 2007. In the 365 patients treated electively for a 4 to 7 cm tumor the frequency of partial nephrectomy also steadily increased from 20% in 2000 to 60% in 2007. On multivariate analysis male gender (p = 0.025), later surgery year (p <0.001), younger patient age (p = 0.005), smaller tumor (p <0.001) and open surgery (p <0.001) were significant predictors of partial nephrectomy. American Society of Anesthesiologists score, race and body mass index were not significantly associated with treatment type.
The use of partial nephrectomy is increasing and it is now performed in approximately 90% of patients with T1a tumors at our institution. For reasons that remain unclear certain groups of patients are less likely to be treated with partial nephrectomy.

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    • "The utility of NSS has increased accordingly at many high volume centers over the past decade, approaching 90% for T1a tumors at some centers [4]. The more popular trend has been to perform NSS by minimally invasive approaches, which is a considerable challenge given concern about margin status and ischemia times [5, 6]. "
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    • "In the 365 patients with a renal tumor from 4 to 7 cm, the frequency of PN increased from 20% in 2000 to 60% in 2007. Despite a commitment to kidney sparing operations during this time frame by the MSKCC group, multivariate analysis indicated that PN was a significantly favored approach for males, younger patients, smaller tumors, and open surgeons (Thompson et al., 2009). "
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    ABSTRACT: There is a well known association between end stage renal disease and the development of kidney cancer in the native kidney of patients requiring renal replacement therapy. There is now emerging evidence that lesser degrees of renal insufficiency (chronic kidney disease, CKD) are also associated with an increased likelihood of cancer in general and kidney cancer in particular. Nephropathological changes are commonly observed in the non-tumor bearing portions of kidney resected at the time of partial and radical nephrectomy (RN). In addition, patients with renal cancer are more likely to have CKD at the time of diagnosis and treatment than the general population. The exact mechanism by which renal insufficiency transforms normal kidney cells into tumor cells is not known. Possible mechanisms include uremic immune inhibition or increased exposure to circulating toxins not adequately cleared by the kidneys. Surgeons managing kidney tumors must have an increased awareness of their patient's renal functional status as they plan their resection. Kidney sparing approaches, including partial nephrectomy (PN) or active surveillance in older and morbidly ill patients, can prevent CKD or delay the further decline in renal function which is well documented with RN. Despite emerging evidence that PN provides equivalent local tumor control to RN while at the same time preventing CKD, this operation remains under utilized in the United States and abroad. Increased awareness of the bi directional relationship between kidney function and kidney cancer is essential in the contemporary management of kidney cancer.
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    • "62.8 (13.3) [30] [31] [32] [33] [34] [35] [36] [37] [38] 5.3 (2.8) [1.7–15] "
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