title: Evaluation of renal mass biopsy risk stratification algorithm for robotic partial nephrectomy--could a biopsy have guided management?
abstract: OBJECTIVE
  We evaluated a published biopsy directed small renal mass management algorithm using a large cohort of patients who underwent robotic partial nephrectomy for tumors 4 cm or smaller.
  
  
  METHODS
  A simplified algorithm of biopsy directed small renal mass management previously reported using risk stratified biopsies was applied to 1,175 robotic partial nephrectomy cases from 5 academic centers. A theoretical assumption was made of perfect biopsies that were feasible for all patients and had 100% concordance to final pathology. Pathology risk groups were benign, favorable, unfavorable and intermediate. The algorithm assigned favorable or intermediate tumors smaller than 2 cm to active surveillance and unfavorable or intermediate 2 to 4 cm tumors to treatment. Higher surgical risk patients were defined as ASA® 3 or greater and age 70 years or older.
  
  
  RESULTS
  Patients were assigned to the pathology risk groups of benign (23%), favorable (13%), intermediate (51%) and unfavorable (12%). Patients were also assigned to the management groups of benign pathology (275, 23%), active surveillance (336, 29%) and treatment (564, 48%). Most of the 611 (52%) patients in the benign or active surveillance groups were low surgical risk and had safe treatment (2.6% high grade complications). A biopsy may not have been feasible or accurate in some tumors that were anterior (378, 32%), hilar (93, 7.9%) or less than 2 cm (379, 32%). Of 129 (11%) high surgical risk patients the biopsy algorithm assigned 70 (54%) to benign or active surveillance groups.
  
  
  CONCLUSIONS
  The theoretical application of a biopsy driven, risk stratified small renal mass management algorithm to a large robotic partial nephrectomy database suggests that about half of the patients might have avoided surgery. Despite the obvious limitations of a theoretical assumption of all patients receiving a perfect biopsy, the data support the emerging role of renal mass biopsies to guide management, particularly in high surgical risk patients.
authors.affiliation: Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan.
authors.forename: Haider
authors.initials: H
authors.lastname: Rahbar
authors.affiliation: Division of Urologic Surgery, Washington University School of Medicine, Saint Louis, Missouri.
authors.forename: Sam
authors.initials: S
authors.lastname: Bhayani
authors.affiliation: Department of Urology, New York University Langone Medical Center, New York, New York.
authors.forename: Michael
authors.initials: M
authors.lastname: Stifelman
authors.affiliation: The Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Jihad
authors.initials: J
authors.lastname: Kaouk
authors.affiliation: James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Mohamad
authors.initials: M
authors.lastname: Allaf
authors.affiliation: Department of Urology, New York University Langone Medical Center, New York, New York.
authors.forename: Susan
authors.initials: S
authors.lastname: Marshall
authors.affiliation: The Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Homayoun
authors.initials: H
authors.lastname: Zargar
authors.affiliation: James Buchanan Brady Urological Institute, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors.forename: Mark W
authors.initials: MW
authors.lastname: Ball
authors.affiliation: Division of Urologic Surgery, Washington University School of Medicine, Saint Louis, Missouri.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Larson
authors.affiliation: Vattikuti Urology Institute, Henry Ford Hospital, Detroit, Michigan. Electronic address: crogers2@hfhs.org.
authors.forename: Craig
authors.initials: C
authors.lastname: Rogers
mesh_terms: D000465:Algorithms; D001706:Biopsy / Q000379:methods*; D002292:Carcinoma, Renal Cell / Q000453:epidemiology / Q000473:pathology* / Q000601:surgery; D003937:Diagnosis, Differential; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007680:Kidney Neoplasms / Q000453:epidemiology / Q000473:pathology* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging / Q000379:methods*; D009392:Nephrectomy / Q000379:methods*; D015203:Reproducibility of Results; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012371:Robotics; D014481:United States / Q000453:epidemiology
keywords: biopsy; carcinoma; kidney neoplasms; renal cell