There is no question in the urologic literature that partial nephrectomy (PN), particularly for renal masses ¡Ü 4cm, has demonstrated oncologic equipoise with radical nephrectomy (RN).
While more technically challenging, there is general agreement among experts that normal renal tissue should be conserved, when feasible, through nephron sparing approaches. A recent article by Miller and colleagues out of Michigan published in the March 2006 issue of Journal of Urology would suggest, however, that partial nephrectomy rates are no where near what they should be for patients that present with small localized renal masses.
Using the SEER database from 1988 ¨C 2001, the authors identified 14,647 patients with primary renal tumors ¡Ü 7cm who were treated surgically for locoregional kidney cancer. Of these, 1401 patients were treated with partial nephrectomy (PN) (9.6%). Looking at the utilization of PN over time, rates significantly increased from 1988 (4.6%) to 2001 (17.6%) (p<0.001). In a subset analysis, the authors noted that in patients with tumors <2cm, 14% were treated with PN in 1988, which increased to 42% in 2001 (p<0.001). In patients with tumors 2-4cm, 5% were treated with PN in 1988, which increased to 20% in 2001 (p<0.001). Looking at determinants that predicted whether or not a patient would receive PN, the authors noted that younger age, smaller tumor size, and more recent diagnostic year (p<0.05) were all predictive.
This study documents the underutilization of PN in the United States. While renal conservation is espoused as beneficial in the literature, it does not appear to be practiced in reality. It is amazing that in 2001, 80% of tumors 2-4 cm and 58% of tumors <2cm were treated with radical nephrectomy. Whether this phenomenon relates to lack of training in the procedure, lack of hospital infrastructure to support the more technically challenging operation, the increased use of laparoscopic nephrectomy, or the lack of acceptance of the procedure as an oncologically viable option remains speculative.
By Christopher G. Wood, MD
Reference :
J Urol 175: 853-858, 2006.