Current Trends in Partial Nephrectomy After Guideline Release: Health Disparity for Small Renal Mass

Abstract

Background: Renal masses can be surgically treated by partial nephrectomy (PN) or radical nephrectomy (RN); however, in 2009 guidelines recommended PN as the standard of care for cT1a renal masses. Objective: To evaluate national trends of surgically appropriate patients using the National Cancer Database (NCDB) for utilization of PN focusing on guideline release, evaluating underlying health disparity. Methods: We identified 99,035 patients from 2004–2015 that underwent surgical resection of cT1a renal masses. We evaluated treatment proportions over time of patients treated with PN or RN. Logistic regression was utilized for multivariable analysis. Results: PN increased from 40.2% in 2004 to 71.3% in 2015 (p < 0.001). Older patients were more likely to be treated with RN (OR 1.018, p < 0.001), as were those with Charlson score 2 or 3+ (OR 1.288 and 2.074, p < 0.001). Patients with lower income were more likely to be treated with RN (OR 1.186, p < 0.001) as were uninsured patients (OR 1.108, p = 0.018) and low volume centers (OR 1.063, p < 0.001). Females were more likely to undergo RN (OR 1.123, p < 0.001) as were black patients (OR 1.339, p < 0.001). While these demographic trends persisted after the release of the guidelines, all associations decreased except for Charlson score and race. Black patients became more likely to undergo RN (pre-guideline OR 1.248 vs post-guideline OR 1.474, p < 0.001). Patients treated with RN had worsened mortality (17.4% vs. 7.3%, p < 0.001). Conclusions: Although use of PN in surgically appropriate patients for cT1a renal masses has increased over time, 30% of patients underwent RN in 2015. Socioeconomic disparities affect treatment decisions and require additional research.