Contemporary management of small renal masses: does practice environment matter?

INTRODUCTION: Population based studies imply underutilization of renal preservation for managing small renal mass (SRMs). Limited information is available regarding the impact of practice environment on SRM treatment. We evaluated practice patterns for SRMs in the context of a urologist's practice environment. MATERIALS AND METHODS: Survey instrument querying practice type (private versus academic/academic affiliation) was distributed to urologists of the Mid-Atlantic section of the American Urological Association. Physicians were presented three case scenarios (exophytic 2.5 cm SRM in a healthy 55-year-old, healthy 75-year-old, and comorbid 75-year-old patient) and were queried on management. RESULTS: Of the 281 respondents who manage kidney cancer, 92 practiced in an academic environment, and 189 were private practitioners. Thirty-four percent had completed residency training within 10 years, 25% between 11-20 years, and 41% over 20 years. For SRMs in a healthy 55-year-old, over 95% of practicing nephrologists advocated nephron-sparing treatments. Nonetheless, private practitioners were more likely to perform a radical nephrectomy (6% versus 0%, p = 0.03) and less likely perform a partial nephrectomy (79% versus 91%, p = 0.01) than academic counterparts. We observed an increase in the percentage of urologists offering thermal ablation (38% versus 12%, p < 0.0001) and observation (29% versus 1%, p < 0.0001) with a corresponding decline in the use of partial nephrectomy (32% versus 83%, p < 0.0001) in the 75-year-old versus 55-year-old patient. When considering management of a SRM in 75-year-old patients (healthy or comorbid), private practitioners were more likely to offer a thermal ablative procedure when compared to academic urologists (41% versus 32%, p = 0.05). CONCLUSIONS: Over 95% of urologists espouse renal preservation strategies for a SRM in a healthy, young patient. Private practitioners are more likely to perform a radical (and less likely a partial) nephrectomy in this cohort. While surveillance is increasingly utilized for SRMs in the elderly patient, private practitioners are more likely to recommend active treatment via thermal ablation when compared to academic counterparts.

Are urology residents adequately exposed to conservative therapies for managing small renal masses?

PURPOSE: Increasing diagnosis of small renal masses (SRMs) necessitates trainees to be familiar with available therapies. We hypothesized that involvement in conservative treatments (ablation and/or active surveillance) occurs infrequently. Therefore, we evaluated resident exposure and participation in treatments as well as proposed management for SRMs. METHODS: A survey was distributed to residents of the American Urologic Association and queried exposure to ablation and surveillance for SRMs. Three case scenarios (SRM in a healthy 55-year-old, healthy 75-year-old, and comorbid 75-year-old patient) were presented for management. RESULTS: Two hundred fifty-seven residents responded to the survey. Two hundred thirty-four (91%) reported ablation was offered at their institution, although only 140 (54%) ever participated in this procedure. Of these, 80 (57%) were involved in fewer than five procedures. Experience with ablation did not increase at higher levels of training (U3-61%, U4-66%, and U5-63%). Two hundred twenty-four (87%) residents noted exposure to surveillance for managing SRMs, increasing from 70% in U1 to 94% in U5. When considering case scenarios, management strategy shifted significantly from extirpation to ablation or surveillance as patient age and comorbidity profile increased. In particular, almost 50% of respondents advocated ablation for SRMs in a comorbid 75-year-old patient. CONCLUSIONS: Although most residents are adequately exposed to surveillance strategies for SRMs, only 54% participated in an ablative procedure. Nonetheless, almost 50% of residents recommended ablation to manage SRMs in the aging, comorbid patient. This suggests a disconnect between training and future practice pattern.