Concordance of surgical treatment selection with the AUA guidelines for localized renal masses.

Abstract

Objective: To examine and evaluate guideline concordance of surgical treatment selection at a community-based health system. The AUA guidelines provide specific guidance regarding appropriate utilization of radical nephrectomy (RN) and partial nephrectomy (PN). However, nearly 40% of patients did not fit a guideline-specified scenario in a prior report.

Methods: Retrospective review of consecutive surgical patients (7/2019-9/2022) identified indications for RN/PN relative to 3 criteria: tumor complexity (RENAL ≥ 9), oncologic risk (size ≥ 7cm, cT3a, infiltrative features, and/or renal mass biopsy with high-risk features), and renal function (preoperative GFR ≥ 60 ml/min/1.73m²; predicted GFR following RN ≥ 45 ml/min/1.73m²).

Results: Of 372 surgeries for cT1a-cT3aN0M0 renal masses, 138 were RN (37%) and 234 were PN (63%). Overall, 247 patients (66%) fit a guideline-specified scenario: 35 (9%) had a strong indication for RN of whom 34 underwent RN (97%) and 212 (57%) had a strong indication for PN of whom 191 underwent PN (90%). Of 125 patients (34% of total) that did not fit guidelines scenarios, 83 underwent RN (66%) and 42 underwent PN (34%). Oncologic risk was the most influential factor in both guideline-specified and non-specified cases with 96% of patients with high-oncologic risk undergoing RN whether renal function was adequate or impaired. Fellowship-trained urologic-oncologists were more likely to perform PN than general urologists for non-specified cases (47% vs. 28%, P < 0.001).

Conclusion: We found strong AUA guideline compliance for RN and PN with some over-utilization of RN. Our results confirm that more than one third of cases are uncategorized. Subsequent iterations of guidelines could incorporate more cases by expanding indications for appropriate RN. Regardless, complex cases may benefit from tumor boards and multidisciplinary review.