Centralization of Health Care to Facilitate Greater Use of Nephron-Sparing Surgery for Localized Renal Tumors: Identifying Appropriate Health Care Delivery

Jeffrey C. Morrison, Boris Gershman, Badrinath Konety, Nicholas Cost, Simon P. Kim
2020 Annals of Surgical Oncology  
Clinical practice guidelines have endorsed the principles of nephron-sparing surgery (NSS) to achieve comparable oncologic outcomes compared with radical nephrectomy (RN), while minimizing the morbidity from chronic kidney disease. 1-3 Indeed, the American Urological Association (AUA) recently further reinforced 'prioritizing' partial nephrectomy (PN), in particular for clinical T1a (\ 4 cm) renal tumors, and limiting the RN for a specific set of criteria (higher complexity renal tumors with
more » ... ence of pre-existing chronic kidney disease and proteinuria). 2 In response to the greater emphasis in NSS to clinical practice guidelines attributable to the growing evidence regarding similar oncologic control, population-based studies have demonstrated greater use of PN over time. [4] [5] [6] Efforts by key stakeholders, surgeons, and patients have now focused on identifying key characteristics of health care delivery to achieve higher quality, guideline-concordant health care and better patient health outcomes. In this issue of Annals of Surgical Oncology, Flegar et al. elucidated the trends in PN and RN for localized renal tumors in Germany and the US, and identified key hospital-related factors associated with NSS using administrative data from national administrative data and cancer registries from each country. 7 Greater use of NSS for localized renal cell carcinoma (RCC) for both countries represented a key finding from this study, where in fact PN now constitutes a majority of renal surgery for localized T1 renal tumors from the cancer registries. Furthermore, the study also established that hospitals with higher annual surgical volume and access to robotic surgical systems were both clearly associated with NSS for RCC. Against this backdrop, the surgical approach influenced the type of renal surgery performed in Germany and the US, where open PN and RN rapidly declined counterbalanced against an expansion of minimally invasive surgery (MIS). More specifically, robotic surgery to achieve NSS became the predominant approach for localized renal tumors in the US. Although modest adoption of both MIS approaches for localized renal tumors was observed in Germany, approximately 70% and 80% of German patients received open PN and RN for localized RCC, respectively. The central findings from this study have health care policy implications in achieving the goals of identifying and delivering high-quality health care where the appropriately selected patient diagnosed with a T1 renal tumor undergoes NSS. First, it has been well-documented that higher hospital and surgeon volume are clearly associated with greater utilization of appropriate complex cancer surgery, including PN, with better outcomes with less complications and lower health care costs and operative mortality. 5, 8, 9 As a result, efforts to regionalize health care to higher-volume hospitals for patients with localized renal masses have been one consequence of achieving more NSS on a population-level. It is essential to acknowledge that Ó
doi:10.1245/s10434-019-08167-0 pmid:31974706 fatcat:kkyiciugvrdclgdcy5nzxamd6m