Comparing Patient-reported Functional Outcomes After Radical Prostatectomy in Historical and Contemporary Practice.

PURPOSE: Modifications to surgical technique, particularly the widespread adoption of robotic surgery, have been proposed to improve functional recovery after prostate cancer surgery. However, rigorous comparison of men in historical vs contemporary practice to evaluate the cumulative effect of these changes on urinary and sexual function after radical prostatectomy is lacking. MATERIALS AND METHODS: We compared prospectively collected patient-reported urinary and sexual function from historical (PROSTQA [Prostate Cancer Outcomes and Satisfaction With Treatment Quality Assessment study], n=235) and contemporary (MUSIC-PRO [Michigan Urological Surgery Improvement Collaborative Patient Reported Outcome] registry, n=1,215) cohorts at the University of Michigan to understand whether modern techniques have resulted in functional improvements for men undergoing prostate cancer surgery. RESULTS: We found significant differences in baseline function, with better urinary (median [IQR]; 100 [93.8-100] vs 93.8 [85.5-100], P < .001) and sexual scores (median [IQR]; 83.3 [66.7-100] vs 74.4 [44.2-87.5], P < .001) prior to treatment in PROSTQA compared to MUSIC-PRO patients, respectively. There was no statistically significant difference in the pattern of urinary incontinence recovery after surgery from 6-24 months between groups (P = .14). However, men in the contemporary MUSIC-PRO group did have significantly better recovery of sexual function compared to men in the historical PROSTQA group (P < .0001). Further, we found that contemporary practice consists of men with more unfavorable demographic and clinical characteristics compared to historical practice. CONCLUSIONS: Our results demonstrate that the widespread alterations in prostate cancer surgery over the past 2 decades have yielded improvements in sexual, but not urinary, function recovery.

Utilization of a Virtual Tumor Board for the Care of Patients With Renal Masses: Experience From a Quality Improvement Collaborative.

INTRODUCTION: Multidisciplinary tumor board meetings are useful sources of insight and collaboration when establishing treatment approaches for oncologic cases. However, such meetings can be time intensive and inconvenient. We implemented a virtual tumor board within the Michigan Urological Surgery Improvement Collaborative to discuss and improve the management of complicated renal masses. METHODS: Urologists were invited to discuss decision-making for renal masses through voluntary engagement. Communication was performed exclusively through email. Case details were collected and responses were tabulated. All participants were surveyed about their perceptions of the virtual tumor board. RESULTS: Fifty renal mass cases were reviewed in a virtual tumor board that included 53 urologists. Patients ranged from 20-90 years old and 94% had localized renal mass. The cases generated 355 messages, ranging from 2-16 (median 7) per case; 144 responses (40.6%) were sent via smartphone. All urologists (100%) who submitted to the virtual tumor board had their questions answered. The virtual tumor board provided suggestions to those with no stated treatment plan in 42% of cases, confirmed the physician's initial approach to their case in 36%, and offered alternative approaches in 16% of cases. Eighty-three percent of survey respondents felt the experience was "Beneficial" or "Very Beneficial," and 93% stated increased confidence in their case management. CONCLUSIONS: Michigan Urological Surgery Improvement Collaborative's initial experience with a virtual tumor board showed good engagement. The format reduced barriers to multi-institutional and multi-disciplinary discussions and improved the quality of care for selected patients with complex renal masses.

Delayed urologic cancer care in the COVID-19 pandemic: Patients' experiences.

OBJECTIVE: To understand experiences of patients with genitourinary cancer who experienced delayed cancer care due to the COVID-19 pandemic. METHODS: We conducted a mixed methods study with an explanatory sequential design. Qualitative findings are reported here. Patients with muscle invasive bladder, advanced prostate or kidney cancer were eligible. Participants were selected for interviews if they self-reported low (0-3/10) or high (6-10/10) levels of distress on a previous survey. Participants were interviewed about their experiences. Interviews were transcribed, coded and categorised using thematic data analysis methodology. RESULTS: Eighteen patients were interviewed. Seven had prostate cancer, six bladder cancer and five kidney cancer. Six themes were derived from the interviews: (1) arriving at cancer diagnosis was hard enough, (2) response to treatment delay, (3) labelling cancer surgery as elective, (4) fear of COVID-19 infection, (5) quality of patient-provider relationship and communication and (6) what could have been done differently. CONCLUSION: These findings offer insight into the concerns of patients with genitourinary cancers who experienced treatment delays due to COVID-19. This information can be applied to support patients with cancers more broadly, should treatment delays occur in the future.

Urologic oncology patient perspectives during COVID-19 treatment delays.

PURPOSE: We sought to describe patient experiences during COVID-19 related delays in urologic cancer treatment. METHODS: We conducted a mixed methods study with an explanatory-sequential design. Survey findings are presented here. Patients from a Midwestern Cancer Center and the Bladder Cancer Advocacy Network (BCAN) self-reported via survey their experience of treatment delay, patient-provider communication, and coping strategies. We quantified patient distress with an ordinal scale (0-10), based on the National Comprehensive Cancer Network Distress Thermometer (NCCN-DT). RESULTS: Forty-four patients with bladder, prostate, and kidney cancers consented to the survey. Most individuals were male (n = 29; 66%) and older than 61 years of age (n = 34; 77%). Median time since diagnosis was 6 months. Dominant reactions to treatment delay included fear that cancer would progress (n = 22; 50%) and relief at avoiding COVID-19 exposure (n = 19; 43%). Most patients reported feeling that their providers acknowledged their emotions (n = 31; 70%), yet 23 patients (52%) did not receive follow-up phone calls and only 24 (55%) felt continually supported by their providers. Patients' median distress level was 5/10 with 68% (n = 30) of patients reaching a clinically significant level of distress (≥ 4). Thematically grouped suggestions for providers included better communication, more personalized support, and better patient education. CONCLUSION: During the COVID-19 pandemic, a high proportion of urologic cancer patients reached a clinically significant level of distress. While they felt concern from providers, they desired more engagement and personalized care.

The added influence of genomics and post-MRI confirmatory biopsy results to MRI results alone on medical decision making for men with favorable risk prostate cancer being considered for active surveillance.

BACKGROUND: We examined how the results of genomic classifier (GC) or post-magnetic resonance imaging confirmatory biopsy (pMRI-CBx) influenced management strategy for men with an MRI considering active surveillance (AS). METHODS: We reviewed the Michigan Urological Surgery Improvement Collaborative registry for men with favorable-risk prostate cancer. Among men with an MRI after the diagnostic biopsy (n = 1162) a subset also had GC (n = 126) or pMRI-CBx (n = 309). Results of MRI, GC, and pMRI-CBx were deemed reassuring (RA) or non-reassuring (Non-RA). We assess the association of the combination of test results obtained with the selection of AS. Proportions were compared with the Fisher's exact test. Multivariable logistic regression models were fit for an association of test results with the selection of AS. RESULTS: The results of pMRI-CBx tended to influence management decisions greater than that of GC, especially in situation where testing results were discordant with the MRI result. Fewer men with a RA MRI and non-RA pMRI-CBx where managed with AS compared with RA MRI alone (31% vs. 86%, p < 0.001). non-RA genomics did not seem to have the same influence on management as non-RA pMRI-CBx as a similar proportion of men with RA MRI and non-RA genomics were managed with AS compared with RA MRI alone (85% vs. 86%, p = 0.753). More men with non-RA MRI and RA pMRI-CBx were managed with AS compared with non-RA MRI alone (89% vs. 40%, p < 0.001). Alternatively, a similar proportion of men with non-RA MRI and RA genomics were managed with AS compared with non-RA MRI alone (42% vs. 40%, p > 0.999). In the multivariable models, pMRI-CBx results influenced the decision for AS versus treatment. CONCLUSIONS: In men with newly diagnosed prostate cancer and an MRI, the additional information provided by pMRI-CBx influenced the decision of AS versus treatment, while the addition of GC results were less influential.

Assessing the Impact of Decision Aid Use on Post Prostatectomy Patient Reported Outcomes.

OBJECTIVE: To evaluate whether completing a decision aid, Personal Patient Profile - Prostate (P3P), prior to prostatectomy, affects self-reported bother from post-prostatectomy urinary incontinence and erectile dysfunction. MATERIALS AND METHODS: This retrospective analysis included data from men with newly diagnosed clinically localized, very low to intermediate risk prostate cancer who elected for prostatectomy within the Michigan Urological Surgery Improvement Collaborative between 2018-2021. Multivariable logistic regression models were used to estimate the association between P3P use and bother from post prostatectomy erectile dysfunction and urinary incontinence as measured by the Expanded Prostate Cancer Index Composite (EPIC-26). RESULTS: Among the 3987 patients included, 7% used P3P (n = 266). Men who used P3P reported significantly less bother from erectile dysfunction at 6 months vs non-users (aOR 0.42 [95% CI 0.27-0.66]). At 12 months, the effect of P3P on bother from erectile dysfunction was not statistically significant (aOR 0.62 [95% CI 0.37-1.03]). Men who used P3P did not have a statistically significant difference in bother from urinary incontinence (3-month: aOR 0.56 [95% CI 0.30-1.06]; 6-month; aOR 0.79 [95% CI 0.31-1.97]). CONCLUSION: Within the stated limitations of this study, we find that use of a decision aid for localized prostate cancer was associated with decreased odds of men being bothered from sexual dysfunction but not urinary incontinence at 6 months post prostatectomy.

Delayed radical prostatectomy after a period of active surveillance is not associated with the use of secondary treatments compared with immediate prostatectomy.

BACKGROUND: We evaluated the use of secondary treatments in men with grade group (GG) 1 PC following a period of active surveillance (AS) compared with men undergoing immediate radical prostatectomy (RP) to evaluate what is potentially lost in terms of cancer control, if a patient trials AS and transitions to treatment. METHODS: We reviewed the Michigan Urological Surgery Improvement Collaborative (MUSIC) registry for men with GG1 PC undergoing RP from April 2012 to July 2018. Men were classified into groups based on time from diagnosis to RP: immediate (surgery within 1 year of diagnosis) and delayed RP (surgery >1 year after initiation of AS). Time to secondary treatment was estimated using Kaplan-Meier curves and compared using the log-rank test. A multivariable Cox proportional hazards model was fit to assess the association between timing of RP and use of secondary treatments. A chi-squared test was used to assess the association between delayed RP and adverse pathology. RESULTS: We identified 1878 men that underwent an RP during the study period, of which 1489 (79%) underwent immediate RP and 389 (21%) underwent delayed RP. The incidence of adverse pathology was higher in men with delayed versus immediate RP (49% vs. 36%, p < 0.0001, respectively). However, we noted only a small absolute difference in the estimated 24-month secondary treatment-free probability between men with delayed versus immediate RP (93% and 96%, respectively). On multivariable analysis, delayed RP was associated with increased use of secondary treatments (hazard ratio = 1.94, 95% confidence interval = 1.23-3.06, p = 0.004). CONCLUSIONS: The use of secondary treatment after RP in men with GG1 PC undergoing immediate or delayed prostatectomy was rare. These data suggest that the burden of treatment is near equivalent in patients who progress to treatment on AS compared with those who underwent immediate RP.

Patient Preferences and Treatment Decisions for Prostate Cancer: Results From A Statewide Urological Quality Improvement Collaborative.

OBJECTIVES: To examine the relationship between influential factors and treatment decisions among men with newly diagnosed prostate cancer (PCa). METHODS: We identified men in the Michigan Urological Surgery Improvement Collaborative registry diagnosed with localized PCa between 2018-2020 who completed Personal Patient Profile-Prostate. We analyzed the proportion of active surveillance (AS) between men who stated future bladder, bowel, and sexual problems (termed influential factors) had "a lot of influence" on their treatment decisions versus other responses. We also assessed the relationship between influential factors, confirmatory testing results and choice of AS. RESULTS: A total of 509 men completed Personal Patient Profile-Prostate. Treatment decisions aligned with influential factors for 88% of men with favorable risk and 49% with unfavorable risk PCa. A higher proportion of men who identified bladder, bowel and sexual concerns as having "a lot of influence" on their treatment decision chose AS, compared with men with other influential factors, although not statistically significant (44% vs 35%, P = .11). Similar results were also found when men were stratified based on PCa risk groups (favorable risk: 78% vs 67%; unfavorable risk: 17% vs 9%, respectively). Despite a small sample size, a higher proportion of men with non-reassuring confirmatory testing selected AS if influential factors had "a lot of influence" compared to "no influence" on their treatment decisions. CONCLUSION: Men's concerns for future bladder, bowel, and sexual function problems, as elicited by a decision aid, may help explain treatment selection that differs from traditional clinical recommendation.

Implementation of prostate cancer treatment decision aid in Michigan: a qualitative study.

BACKGROUND: The American Urological Association White Paper on Implementation of Shared Decision Making (SDM) into Urological Practice suggested SDM represents the state of the art in counseling for patients who are faced with difficult or uncertain medical decisions. The Michigan Urological Surgery Improvement Collaborative (MUSIC) implemented a decision aid, Personal Patient Profile-Prostate (P3P), in 2018 to help newly diagnosed prostate cancer patients make shared decisions with their clinicians. We conducted a qualitative study to assess statewide implementation of P3P throughout MUSIC. METHODS: We recruited urologists and staff from 17 MUSIC practices (8 implementation and 9 comparator practices) to understand how practices engaged patients on treatment discussions and to assess facilitators and barriers to implementing P3P. Interview guides were developed based on the Tailored Interventions for Chronic Disease (TICD) Framework. Interviews were transcribed for analysis and coded independently by two investigators in NVivo, PRO 12. Additionally, quantitative program data were integrated into thematic analyses. RESULTS: We interviewed 15 urologists and 11 staff from 16 practices. Thematic analysis of interview transcripts indicated three key themes including the following: (i) P3P is compatible as a SDM tool as over 80% of implementation urologists asked patients to complete the P3P questionnaire routinely and used P3P reports during treatment discussions; (ii) patient receptivity was demonstrated by 370 (50%) of newly diagnosed patients (n = 737) from 8 practices enrolled in P3P with 78% completion rate, which accounts for 39% of all newly diagnosed patients in these practices; and (iii) urologists' attitudes towards SDM varied. Over a third of urologists stated they did not rely on a decision aid. Comparator practices indicated habit, inertia, or concerns about clinic flow as reasons for not adopting P3P and some were unconvinced a decision aid is needed in their practice. CONCLUSION: Urologists and staff affiliated with MUSIC implementation sites indicated that P3P focuses the treatment discussion on items that are important to patients. Experiences of implementation practices indicate that once initiated, there were no negative effects on clinic flow and urologists indicated P3P saves time during patient counseling, as patients were better prepared for focused discussions. Lack of awareness, personal habits, and inertia are reasons for not implementing P3P among the comparator practices.

Delayed Urological Cancer Care during the COVID-19 Pandemic: Urologists' Experience.

INTRODUCTION: The arrival of coronavirus disrupted health care systems and forced delays in cancer treatment. We explored the experience of urologists who had to delay their patients' cancer care. METHODS: Urologists who treat prostate, bladder, and renal cancers, selected through purposive sampling, responded to a survey about cancer treatment delay. They were asked about their practice setting, decision making and interactions with patients, and they were asked to reflect on their personal experience. A 0 to 10 point scale, modeled on the National Comprehensive Cancer Network' Distress Thermometer (NCCN-DT), validated for cancer patients with cancer, was used to estimate physician distress. We used descriptive statistics to analyze survey results. RESULTS: Of the 64 participating urologists, 98% delayed surgical treatment; fewer delayed cases of advanced cancers (42% for ≥T3/T4 or Gleason ≥8 prostate cancers, 58% for muscle invasive bladder cancer, 61% for ≥T2 renal cancers). They reported feeling anxious (44%) and helpless (29%), and their median distress score was 5 (range 0-10). They relied on their own risk assessments (67%) and consulted colleagues (56%) and national guidelines (53%) when making treatment deferral decisions. They identified a number of concerns as they resumed surgeries. CONCLUSIONS: Based on a comparison to the NCCN-DT clinical cutoff distress level of 4, urologists experienced moderately high levels of distress as they delayed cancer care during the COVID-19 pandemic and expressed concerns going forward. While the focus on patient care is paramount in a pandemic, it is important to recognize physician distress and develop practical and psychological strategies for distress mitigation.

Limitations of abdominopelvic CT and multiparametric MR imaging for detection of lymph node metastases prior to radical prostatectomy.

PURPOSE: To investigate the performance of pre-surgery CT and multiparametric MRI (mpMRI) to identify lymph node (LN) metastases in the Michigan Urological Surgery Improvement Collaborative (MUSIC). Abdominopelvic CT and mpMRI are commonly used for intermediate- and high-risk prostate cancer (PCa) staging. METHODS: Retrospective analysis of the MUSIC registry identified patients undergoing robot-assisted radical prostatectomy (RP) between 3/2012 and 7/2018. Patients were classified according to pre-surgery imaging modality. Primary outcomes were operating characteristics of CT and mpMRI for detection of pathologic LN involvement (pN1). RESULTS: A total of 10,250 patients underwent RP and 3924 patients (38.3%) underwent CT and/or mpMRI prior to surgery. Suspicion for LN involvement was identified on 2.3% CT and 1.9% mpMRI. Overall, 391 patients were pN1(3.8%), including 0.1% low-, 2.1% intermediate-, and 10.9% high-risk PCa patients. Of 235 pN1 patients that underwent CT prior, far more had negative (91.1%) than positive (8.9%) findings, yielding sensitivity: 8.9%, specificity: 98.3%, negative predictive value (NPV): 92.1%, and positive predictive value (PPV): 32.3% for CT with regard to LN metastases. Similarly, more patients with pN1 disease had negative mpMRI (81.0%) then suspicious or indeterminate MRI (19.0%), yielding sensitivity: 19.0%, specificity: 97.3%, NPV: 95.9%, and PPV: 26.7%. CONCLUSIONS: Abdominopelvic CT and mpMRI have clear limitations in identifying LN metastases. Additional clinicopathologic features should be considered when making management decisions, as 2.1% and 10.9% with intermediate-and high-risk cancer had metastatic LNs. The majority of pN1 patients had a negative CT or a negative/indeterminate mpMRI prior to RP. Pelvic LN dissection should be performed in RP patients with intermediate- or high-risk PCa, independent of preoperative imaging results.

Impact of Early Confirmatory Tests on Upgrading and Conversion to Treatment in Prostate Cancer Patients on Active Surveillance.

OBJECTIVES: To assess the impact of confirmatory tests on active surveillance (AS) biopsy disease reclassification and progression to treatment in men with favorable risk prostate cancer (FRPC). METHODS: We searched the MUSIC registry for men with FRPC managed with AS without or with a confirmatory test. Confirmatory tests included (1) repeat prostate biopsy, (2) genomic tests, (3) prostate magnetic resonance imaging (MRI), or (4) MRI followed by a post-MRI biopsy. Confirmatory test results were deemed reassuring (RA) or nonreassuring (nonRA) according to predefined criteria. Kaplan-Meier curves and multivariable Cox regression models were used to compare surveillance biopsy disease reclassification-free survival and treatment-free survival. RESULTS: Of the 2,514 men with FRPC who were managed on AS, 1211 (48%) men obtained a confirmatory test. We noted differences in the 12-month unadjusted surveillance biopsy disease reclassification-free probability (68%, 83%, and 90%, P < .0001) and 24-month unadjusted treatment-free probability (55%, 81%, and 79%, P < .0001), for men with nonRA confirmatory tests, no confirmatory test, and RA confirmatory tests, respectively. Excluding patients with genomic confirmatory tests, men with RA confirmatory tests were associated with a lower hazard (hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.38-0.84, P = .005) and men with nonRA confirmatory tests had an increased hazard (HR 1.97, 95% CI 1.22-3.19, P = .006) of surveillance disease reclassification compared with men without confirmatory tests in the multivariable model. CONCLUSION: These data suggest men with RA confirmatory tests have less surveillance biopsy reclassification and remain on AS longer than men with nonRA test results. Confirmatory tests may help risk stratify men considering active surveillance.

Overtreatment and Underutilization of Watchful Waiting in Men With Limited Life Expectancy: An Analysis of the Michigan Urological Surgery Improvement Collaborative Registry.

OBJECTIVE: To determine rates of watchful waiting (WW) vs treatment in prostate cancer (PCa) and limited life expectancy (LE) and assess determinants of management. MATERIALS AND METHODS: Patients diagnosed with PCa between 2012 and 2018 with <10 years LE were identified from the Michigan Urologic Surgery Improvement Collaborative registry. Multinomial logistic regression models were used to identify factors associated with management choice among NCCN low-risk PCa patients. Data from high-volume practices were analyzed to understand practice variation. RESULTS: Total 2393 patients were included. Overall, WW was performed in 8.1% compared to 23.3%, 25%, 11.2%, and 3.6% who underwent AS, radiation (XRT), prostatectomy (RP), and brachytherapy (BT), respectively. In men with NCCN low-risk disease (n = 358), WW was performed in 15.1%, compared to AS (69.3%), XRT (4.2%), RP (6.7%), and BT (2.5%). There was wide variation in management among practices in low-risk men; WW (6%-35%), AS (44%-81%), and definitive treatment (0%-30%). Older age was associated with less likelihood of undergoing AS vs WW (odds ratio [OR] 0.88, P < .001) or treatment vs WW (OR 0.83, P < .0001). Presence of ≥cT2 disease (OR 8.55, P = .014) and greater number of positive biopsy cores (OR 1.41, P = .014) was associated with greater likelihood of treatment vs WW and Charlson comorbidity score of 1 vs 0 (OR 0.23, P = .043) was associated with less likelihood of treatment vs WW. CONCLUSION: Wide practice level variation exists in management for patients with low- and favorable-risk PCa and <10-year LE. Utilization of WW is poor, suggesting overtreatment in men who will experience little benefit.

Do patients who undergo multiparametric MRI for prostate cancer benefit from additional staging imaging? Results from a statewide collaborative.

OBJECTIVES: Prostate cancer (CaP) staging traditionally includes computed tomography (CT) and technetium-99m bone scintigraphy (BS) for assessment of lymph node (LN) and bone metastases, respectively. In recent years, multiparametric magnetic resonance imaging (mpMRI) has been used in diagnostic assessment of CaP. We sought to compare the accuracy of mpMRI to CT and BS for pretreatment staging. MATERIALS AND METHODS: Using the Michigan Urological Surgery Improvement Collaborative registry, we identified men undergoing pretreatment mpMRI in addition to CT and/or BS in 2012 to 2018. Imaging reports were classified as positive, negative, or equivocal for detection of LN and bone metastases. A best value comparator (BVC) was used to adjudicate metastatic status in the absence of pathologic data. mpMRI accuracy was calculated using pessimistic (equivocal=positive) and optimistic (equivocal = negative) interpretations. We compared the diagnostic performance of mpMRI, CT, and BS in detecting metastases. RESULTS: In total, 364 men underwent CT and mpMRI, and 646 underwent BS and mpMRI. Based on the BVC, 52 men (14%) harbored LN metastases and 38 (5.9%) harbored bone metastases. Sensitivity of mpMRI for LN metastases was significantly higher than CT (65-73% vs 38%, P < 0.005), and specificity of mpMRI and CT were 97% to 99% and 99% (P = 0.2-0.4), respectively. For bone metastases, BS sensitivity was 68% as compared to 42% to 71% (P = 0.02-0.83) for mpMRI. Specificity for bone metastases was 95% to 99% across all modalities. CONCLUSIONS: Using statewide data, mpMRI appears superior to CT and comparable to BS for detection of LN and bone metastases, respectively. Pretreatment mpMRI may obviate the need for additional staging imaging.

Quality of Care for Renal Masses: The Michigan Urological Surgery Improvement Collaborative-Kidney Mass: Identifying & Defining Necessary Evaluation & Therapy (MUSIC-KIDNEY).

INTRODUCTION: We describe the establishment of the Michigan Urological Surgery Improvement Collaborative-Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) to improve the quality of care that patients in Michigan receive for localized, 7 cm or smaller (T1) renal masses. METHODS: The MUSIC-KIDNEY collaborative is comprised of 45 urologists from 8 group practices. From June 2017 to November 2018 surgeons collected data for 821 patients with newly diagnosed T1 renal masses. Goals are to reduce the overall burden of treatment for T1 renal masses specifically by avoiding treatment when a noninterventional approach is appropriate, reducing the treatment of benign renal masses, preventing radical nephrectomy when a kidney sparing approach is appropriate, and decreasing length of hospitalization and readmission rates. RESULTS: Median age at diagnosis was 66 years, 56.8% of patients were male and 83.8% were Caucasian. The patient populations differed across practice sites for age (p <0.001), tumor size (p=0.002), race (p <0.001), Charlson comorbidity index and insurance type (p <0.001). Tumor complexity was infrequently reported (35.1%). Initial management included surveillance/repeat imaging (45.1%), biopsy (15.4%), intervention (39.1%) and second opinion (0.6%). No treatment at initial presentation (0% to 74.5%) and nephron sparing treatment (0% to 100%) varied significantly among practices (p <0.001). Of 133 patients with T1 renal masses who underwent radical nephrectomy (39.8%) 53 had tumors smaller than 4 cm and/or surgical findings without malignancy. Readmission or emergency department visit within 30 days after renal surgery occurred in 7.6%. CONCLUSIONS: Initial findings of MUSIC-KIDNEY indicate practice level variation and several quality improvement opportunities. Focusing on these goals may optimize practice patterns and surgical outcomes across Michigan.