Adherence to guideline recommendations for management of clinical T1 renal cancers in the Netherlands: a population-based study

Surgical Management of Renal Cell Carcinoma: Comparisons of open and laparoscopic approaches

Objectives

Renal cell carcinoma (RCC) is a leading urological malignancy with an age-standardised incidence rate of 2.5 per 100,000 per year in Oman. Experts are inclined towards the early detection and use of minimally invasive technology for the treatment of RCC. This study aimed report the shifting trend in the clinical presentation and management of RCC in Oman, comparing the outcomes of laparoscopic and open nephrectomy.

Methods

This retrospective study included adult RCC patients from Sultan Qaboos University Hospital, Muscat, Oman, diagnosed from 2011-2022. Patient biodata, mode of presentation, diagnostic modality, final histopathology and details of treatment received including the perioperative outcomes were analysed.

Results

A total of 56 patients that underwent surgical treatment for RCC, 34 underwent laparoscopic nephrectomy (LN) and 22 underwent open nephrectomy (ON). The mean ages in the LN and ON groups were 53.82 ± 13.44 years and 56.22 ± 15.00 years (P = 0.53), respectively. There were 47 patients of Omani descent and 9 patients were expatiates. The patients' mean tumour size was 6.25 ± 3.16 cm and 9.23 ± 5.20 cm for the LN and ON groups, respectively; 55.35% of the RCC cases were incidentally diagnosed. A trend towards LN was observed.

Conclusion

This study found a trend towards early diagnosis of RCC in Oman, with the majority of cancers being discovered incidentally in the studied period. LN is more commonly used in the surgical management of RCC with acceptable morbidity. These trends remain aligned with those found in the global literature on RCC.

The impact of the COVID-19 pandemic on renal cancer care

PURPOSE

To evaluate the impact of the COVID-19 pandemic on renal cell carcinoma (RCC) care in the Netherlands.

METHODS

Newly diagnosed RCCs between 2018 and 2021 were selected from the Netherlands Cancer Registry; 2020-2021 was defined as COVID period and 2018-2019 as reference period. Numbers of RCCs were evaluated using 3-week-moving averages, overall and by disease stage and age. Changes in treatment were evaluated with logistic regression analyses. To evaluate possible delays in care, time to start of treatment was assessed. The cumulative number of metastatic RCC (mRCC) over time was assessed to evaluate stage shift.

RESULTS

During the 1st COVID wave (weeks 9-22, 2020), the number of new RCC diagnoses decreased with 15%. Numbers restored partially in 2020, but remained 10% lower compared to 2018/2019. The decline was mostly due to a drop in T1a/T1b RCCs and in age > 70 years. 2021 showed similar numbers of new RCC diagnoses compared to 2018/2019 without an increase due to previously missed RCCs. Treatment-related changes during the 1st COVID wave were limited and temporarily; less surgery in T1a RCCs in favor of more active surveillance, and in mRCC targeted therapy was preferred over immunotherapy. Time to start of firstline treatment was not prolonged during the 1st COVID wave. No increase in mRCC was found until the end of 2021.

CONCLUSIONS

The COVID-19 pandemic resulted in fewer RCC diagnoses, especially T1a/T1b tumors. Treatment-related changes appeared to be limited, temporarily and in accordance with the adapted guidelines. The diagnostic delay could lead to more advanced RCCs in later years but there are no indications for this yet.

Trends in the surgical management of kidney cancer by tumor stage, treatment modality, facility type, and location

Partial nephrectomy (PN) is an alternative to radical nephrectomy (RN) in the appropriate localized renal tumor. The scope of PN has expanded over time and, since the advent and proliferation of minimally invasive surgery, more surgeons have access to and have been trained in laparoscopic and robotic technology. Amid the changing surgical landscape, we sought to characterize the trends in management by cancer stage, institution type, and geographic location using the National Cancer Database (NCDB). We queried the NCDB for patients with kidney cancer from 2004 to 2019. Overall, 241,311 patients who underwent PN or RN were included in the study. The nephrectomy approach was categorized as robotic partial (RPN), robotic radical (RRN), laparoscopic partial (LPN), laparoscopic radical (LRN), open or unspecified partial (OPN), and open or unspecified radical (ORN). The categorical variables were presented as frequency and percentages. Overall, there was an increase in the utilization of robotic approaches from 2010 to 2019. For cT1 tumors, the use of RPN and RRN increased from 14.27 to 33.06% and 5.24% to 19.63%, respectively. The use of ORN for cT2 and cT3 tumors declined, with rates dropping from 54.71 to 10.76% and 64.71 to 46.64%, respectively. Conversely, the utilization of RRN rose during this period. However, ORN remained the most common approach for cT3 tumors. The use of RPN increased across different facility types, with the highest utilization observed in academic/research programs. The use of ORN for cT2 and cT3 tumors declined across facility types, although it remained most prevalent in community cancer programs. The use of robot-assisted surgery to treat localized renal cancer increased in the US between 2010 and 2019 across all stages of disease. RPN became the most used approach for cT1 disease, while LRN was preferred for cT2 disease. ORN remained the approach of choice for cT3 disease throughout the study period. Trends in facility type and geographic location largely mirrored the overall trends.

Variation in the management of cT1 renal cancer by surgical hospital volume: A nationwide study

Objectives

To analyse variation in clinical management of cT1 renal cell carcinoma (RCC) in the Netherlands related to surgical hospital volume (HV).

Materials and methods

Patients diagnosed with cT1 RCC during 2014-2020 were identified in the Netherlands Cancer Registry. Patient and tumour characteristics were retrieved. Hospitals performing kidney cancer surgery were categorised by annual HV as low (HV < 25), medium (HV = 25-49) and high (HV > 50). Trends over time in nephron-sparing strategies for cT1a and cT1b were evaluated. Patient, tumour and treatment characteristics of (partial) nephrectomies were compared by HV. Variation in applied treatment was studied by HV.

Results

Between 2014 and 2020, 10 964 patients were diagnosed with cT1 RCC. Over time, a clear increase in nephron-sparing management was observed. The majority of cT1a underwent a partial nephrectomy (PN), although less PNs were applied over time (from 48% in 2014 to 41% in 2020). Active surveillance (AS) was increasingly applied (from 18% to 32%). For cT1a, 85% received nephron-sparing management in all HV categories, either with AS, PN or focal therapy (FT). For T1b, radical nephrectomy (RN) remained the most common treatment (from 57% to 50%). Patients in high-volume hospitals underwent more often PN (35%) for T1b compared with medium HV (28%) and low HV (19%).

Conclusion

HV is related to variation in the management of cT1 RCC in the Netherlands. The EAU guidelines have recommended PN as preferred treatment for cT1 RCC. In most patients with cT1a, nephron-sparing management was applied in all HV categories, although differences in applied strategy were found and PN was more frequently used in high HV. For T1b, high HV was associated with less appliance of RN, whereas PN was increasingly used. Therefore, closer guideline adherence was found in high-volume hospitals.

Effects of race and socioeconomic status on treatment for localized renal masses in New York City

INTRODUCTION

Partial nephrectomy (PN) is the preferred treatment for localized renal masses (LRM), however its use is not uniform across patient socioeconomic (SES) factors. Our hypothesis is that the effect of increased SES on surgical management of LRMs in New York City (NYC) will not be the same for Black and White patients.

PATIENTS AND METHODS

Patients were identified from the New York State Cancer Registry (NYSPACED) treated for LRMs with PN or radical nephrectomy from 2004 to 2016. We identified patients' home neighborhoods through Public Use Microdata Areas (PUMA) in NYSCAPED and used a US Census SES index. Logistic regression was used to determine the association of race and SES on receipt of PN, controlling for age, ethnicity, gender, and diagnosis year.

RESULTS

On unadjusted analyses, patients from higher PUMA SES quartiles were more likely to receive PN (OR = 1.07, P < 0.05), while Black patients were less likely to receive PN as compared to White patients (OR = 0.66, P < 0.001). Multivariable analysis showed a significant interaction between race and SES quartile (interaction P = 0.005) such that the effect of PUMA SES on receipt of PN was modified by race. PN receipt for Black vs. White patients was significantly different within the highest SES quartile (OR = 0.44, P < 0.001), but not within the lowest.

CONCLUSION

In NYC, patients from higher SES quartile neighborhoods had significantly increased odds for receipt of PN for LRMs. As neighborhood SES quartile increased, White patients were significantly more likely to receive PN, while Black patients were not.

Trends in the surgical management of renal cell carcinoma in a contemporary tertiary care setting

Background

In the last three eras, the incidence of renal cell carcinoma (RCC) has increased, due to increased radiological studies. The expected 5-year survival rate has become better, associated with the identification of small size renal masses. However, this survival improvement may be secondary to improved surgical techniques and medical therapies for these malignancies.

Objectives

The objective was to report the trends of clinical presentation, peri-operative, oncological outcomes, and surgical management trends for RCCs over the period.

Methods

After Institutional Review Board approval, a retrospective study for adult patients was conducted, who presented with renal mass and were managed between 2008 and 2019. Variables, including demographics, perioperative and pathological outcomes analyzed using descriptive statistics for continuous variables reported as mean ± standard deviation and categorical variables values compared by Chi-square test. Survival Analysis calculated using the Kaplan-Meier method. The level of significance is set at P-value < 0.05.

Results

A total of 588 patients underwent surgical treatment for kidney cancer from January 2008 to January 2019. 237 (40.30%) were females and 351 (59.69%) males. The clinical presentation was higher as an incidental diagnosis of 58.67%. 71.25% of patients were from outside Riyadh city. Pathology was mostly clear cell RCC 61.22% and grade 2 (57.48%). Tumor size, surgery time, and length of hospital stay showed a significant difference between the three periods (both P > 0.05). Robotic surgery performed more than open (P < 0.0001). There was no significant difference in the survival time, when compared to patients by the regions and when compared by the primary tumors (Log-Rank P = 0.4821). Patients from the Riyadh region (median = 54.0) had a significantly higher recurrence time (Log-Rank P < 0.0001).

Conclusion

There was a rising trend in the incidence of RCC associated with comorbidities and incidental diagnosis. In our study period we found increase in the trend of minimal invasive approach. The size of the tumor, blood loss and operative time decreases over the period of time. The Robotic assisted nephrectomy approach has become increased over the period of time duration in present study.

Implementing Continuous Quality Improvement in an Integrated Community Urology Practice: Lessons Learned

OBJECTIVE

To determine the effectiveness of 2 different continuous quality improvement interventions in an integrated community urology practice. We specifically assessed the impact of audited physician feedback on improving physicians' adoption of active surveillance for low-risk prostate cancer (CaP) and adherence to a prostate biopsy time-out intervention.

MATERIALS AND METHODS

The electronic medical records of Genesis Healthcare Partners were analyzed between August 24, 2011 and September 30, 2020 to evaluate the performance of 2 quality interventions: audited physician feedback to improve active surveillance adoption in low-risk CaP patients, and audited physician feedback to promote adherence to an electronic medical records embedded prostate biopsy time-out template. Physician and Genesis Healthcare Partners group adherence to each quality initiative was compared before and after each intervention type using ANOVA testing.

RESULTS

For active surveillance, we consistently saw an increase in active surveillance adoption for low risk CaP patients in association with continuous audited feedback (P < .001). Adherence to the prostate biopsy time-out template improved when audited feedback was provided (P < .001).

CONCLUSION

The implementation of clinical guidelines into routine clinical practice remains challenging and poses an obstacle to the improvement of United States healthcare quality. Continuous quality improvement should be a dynamic process, and in our experience, audited feedback coupled with education is most effective.

Guideline adherence for the surgical treatment of T1 renal tumours correlates with hospital volume: an analysis from the British Association of Urological Surgeons Nephrectomy Audit

OBJECTIVE

To assess European Association of Urology guideline adherence on the surgical management of patients with T1 renal tumours and the effects of centralisation of care.

PATIENTS AND METHODS

Retrospective data from all kidney tumours that underwent radical nephrectomy (RN) or partial nephrectomy (PN) in the period 2012-2016 from the British Association of Urological Surgeons Nephrectomy Audit were retrieved and analysed. We assessed total surgical hospital volume (HV; RN and PN performed) per centre, PN rates, complication rates, and completeness of data. Descriptive analyses were performed, and confidence intervals were used to illustrate the association between hospital volume and proportion of PN. Chi- squared and Cochran-Armitage trend tests were used to evaluate differences and trends.

RESULTS

In total, 13 045 surgically treated T1 tumours were included in the analyses. Over time, there was an increase in PN use (39.7% in 2012 to 44.9% in 2016). Registration of the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) complexity score was included in March 2016 and documented in 39% of cases. Missing information on postoperative complications appeared constant over the years (8.5-9%).  A clear association was found between annual HV and the proportion of T1 tumours treated with PN rather than RN (from 18.1% in centres performing <25 cases/year [lowest volume] to 61.8% in centres performing ≥100 cases/year [high volume]), which persisted after adjustment for PADUA complexity. Overall and major (Clavien-Dindo grade ≥III) complication rate decreased with increasing HV (from 12.2% and 2.9% in low-volume centres to 10.7% and 2.2% in high-volume centres, respectively), for all patients including those treated with PN.

CONCLUSION

Closer guideline adherence was exhibited by higher surgical volume centres. Treatment of T1 tumours using PN increased with increasing HV, and was accompanied by an inverse association of HV with complication rate. These results support the centralisation of kidney cancer specialist cancer surgical services to improve patient outcomes.

Relationship of surgeon/hospital volume with outcomes in uro-oncology surgery

PURPOSE OF REVIEW

Hospital and surgical volumes, as well as complications, are considered to influence intra and postoperative results in most surgical operations. This trend is also seen in uro-oncologic surgery. The objective of this review is to critically analyze the most recent literature to give a comprehensive overview on whether surgical and hospital volumes have an impact, and whether regionalization of the procedure should be advised.

RECENT FINDINGS

Uro-oncologic surgery has recently become more regionalized, and data coming from different population-based analyses appear to support this trend. Recent data suggest that the most beneficial procedures could be radical cystectomy, radical prostatectomy, and partial nephrectomy. For radical cystectomy, even considering different cut-off values, saw better results for postoperative complications, mortality and long-term oncological and functional outcomes in patients treated in high-volume institutions. Centralization of radical prostatectomy seems to affect short-term outcomes and costs related to prostate cancer treatment, with high-volume institutions providing more affordable treatments reducing cancer recurrence and progression. Partial nephrectomy is more frequently performed in cT1-b cancer in high-volume than low-volume institutions. Additionally, in this setting it has a higher success rate and lower complications, shorter operative time, and fewer prolonged hospital stays.

SUMMARY

Regionalization of the procedure in high-volume centers seems to have impact on postoperative morbidity and mortality for the most frequent major uro-oncological procedures: radical prostatectomy, radical cystectomy, and partial nephrectomy; but there are insufficient data available on other procedures.

National Norwegian Practice Patterns for Surgical Treatment of Kidney Cancer Tumors ≤7cm: Adherence to Changes in Guidelines May Improve Overall Survival

BACKGROUND

Guidelines on surgical treatment for kidney cancer (KC) have changed over the last 10 yr. We present population-based data for patients with KC tumors ≤7cm from 2008 to 2013 to investigate whether surgical practice in Norway has changed according to guidelines.

OBJECTIVE

To assess the predictors of treatment and survival after KC surgery.

DESIGN, SETTING, AND PARTICIPANTS

We identified all surgically treated KC patients with tumors ≤7cm without metastasis diagnosed during 2008-2013 (2420 patients) from the Cancer Registry of Norway.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Relationships with outcomes were analyzed using joinpoint regression, multivariate logistic regression, Kaplan-Meier survival estimates, Cox regression, relative survival (RS), and competing-risk analyses.

RESULTS AND LIMITATIONS

The mean follow-up was 5.2 yr. There was a 28% increase in the number of patients undergoing surgical treatment over the study period. Joinpoint regression revealed a significant annual increase in partial nephrectomy (PN) and a small reduction in radical nephrectomy (RN). PN increased from 43% to 66% for tumors ≤4cm and from 10% to 18% for tumors of 4.1-7cm. Minimally invasive (MI) RN increased from 53% to 72% and MI PN from 25% to 64%, of which 55% of procedures were performed with robotic assistance in 2013. The geographical distribution of treatment approaches differed significantly. Both PN and MI approaches were more frequent in high-volume hospitals. Cox regression analysis revealed that PN, age, and Fuhrman grade and stage were independent predictors of survival. There were no significant differences in cancer-specific survival (p=0.8). The 5-yr RS for T1a disease was higher after PN than after RN.

CONCLUSIONS

The rate of PN for tumors ≤7cm increased in the 6-yr study period. MI approaches increased for both RN and PN. This treatment shift coincides with the new guideline recommendations in 2010. The possible better survival for patients undergoing PN compared to RN indicates the importance of following evidence-based guidelines.

PATIENT SUMMARY

The use of partial nephrectomy and minimally invasive surgery for kidney cancer tumors increased in Norway from 2008 to 2013 according to population-based data, coinciding with guideline changes. The study illustrate that adherence to guidelines may improve patient outcomes.

Kidneys with small renal masses: Can they be utilized for kidney transplantation in the era of partial nephrectomy?

OBJECTIVE

To retrospectively evaluate our database to determine our partial nephrectomy and radical nephrectomy rates and to see percentage of the discarded kidneys which were suitable for transplantation after radical nephrectomy.

MATERIAL AND METHODS

Patients who underwent radical or partial nephrectomy between January 2000 and December 2016 were identified. Only stage I tumors according to tumor, node, metastasis classification were included in this review. Tumor size, location, proximity to renal collecting system and hilum were considered while deciding the suitability of a kidney for transplantation.

RESULTS

A statistically significant gradual increase in the number of patients treated with partial nephrectomy was observed (p=0.00001). Only 17 out of 181 kidneys with a tumor size smaller than 3 cm could be an appropriate candidate for a renal transplantation if they were to be transplanted.

CONCLUSION

Exact number of the discarded kidneys with small renal masses which can be used for kidney transplantation should be determined by large scale studies. A national or governmental policy may only be developed to utilize these discarded organs after the magnitude of the wasted kidneys can be determined.

Surgical treatment of kidney tumors - contemporary trends in clinical practice

INTRODUCTION

The aim of this article is to generally describe the roles of main surgical modalities in treatment of renal tumors, especially in the CT1a category in clinical practice. Surgical modalities include the following: laparoscopic or open resection (LR, OR) and laparoscopic or open nephrectomy (LN, ON). Representation of these methods has been changing over years due to improved operative skills and equipment and due to a shift of tumors to the lower T categories.

MATERIAL AND METHODS

The sources of data were surgeries performed for renal tumors at the institution of the main author during the period 2002 to III/2016, reaching a total of 2204 cases (546 ONs, 647 LNs, 668 ORs and 343 LRs). Patients indicated for percutaneous ablative therapy or active surveillance were not included.

RESULTS

During the whole period, the proportions of methods were: ONs 24.8%, LNs 29.4%, ORs 30.3%, LRs 15.6%. But during the years 2014 - III/2016, these changed to 12.6%:26.3%:31.6%:29.4% (in cT1a 1.7%:8.3%:37.8%:52.2%). Category cT1a constitutes in the years 2007 - III/2016 41.3%, in 2014 - III/2016 50.9%.

CONCLUSIONS

Resections and minimally invasive approaches are being performed more frequently and are the preferred methods in surgical treatment of kidney tumors. Resection is now indicated in about 60% of cases (open vs. laparoscopic resection are used nearly equally with a slight tendency for laparascopic predomination). In the cT1a category (amounting to approximately 50% of all surgically treated tumors), resection is possible in about 85-90% of cases.

[Guideline adherence - is more always better?]

Guidelines play an increasing role in the health system. Guidelines are intended to provide guidance in the sense of ‟corridors for action and decision", whereby in certain justified cases actions can - or even must - deviate from them. "Cookbook medicine" is not the aim of guidelines.Guideline adherence can not necessarily be equated with guideline conformity. Adherence presumes an agreed treatment goal between patient and physician and focuses the behavior of the patient. Based on current studies on guideline adherence, the use of the term in studies on urological tumors is analyzed.