title: Increased use of partial nephrectomy to treat high-risk disease.
abstract: OBJECTIVE
  To evaluate partial nephrectomy (PN) use in patients at higher risk for clinical progression, using a large national database of American patients.
  
  
  METHODS
  We performed a retrospective review of patients with cN0/cM0 renal cell carcinoma from 2003 to 2011 using the National Cancer Data Base. Our primary endpoint was PN use for high-risk disease, defined as ≥1 adverse pathological features (APF), namely pT3 stage, high grade, or unfavourable histology. Our secondary endpoint was positive surgical margins (PSM) associated with high-risk disease after PN. Time trends were analysed using the asymptotic Cochran-Armitage trend test. Relationships between patient, provider, and pathological factors and the likelihood of PN were assessed using multivariate logistic regression.
  
  
  RESULTS
  Of 183 886 surgically treated patients, 27.4% underwent PN. Over time, PN use increased overall (17.4-39.7%) and in tumours with ≥1 APF (8.5-24.2%) (P < 0.01). In patients with ≥1 APF, multivariate analysis revealed that academic practice setting and high surgical volume were positively associated with PN use, while increasing tumour size and preoperative biopsy were negatively associated with its use (P < 0.01). The PSM rate after PN also increased significantly over time in all patients and in those harbouring adverse pathology (P < 0.01). Aside from time, older age, larger tumour size, community hospital type, and robotic approach were associated with PSM in the setting of APF (P < 0.01).
  
  
  CONCLUSIONS
  PN use for patients with adverse pathology is increasing and is associated with increasing PSM. The long-term oncological implications of these trends are unclear and warrant further study.
authors: Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.|Division of Urology, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.
authors: Matthew J
authors: MJ
authors: Maurice
authors: Division of Urology, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.|Glickman Urologic and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
authors: Hui
authors: H
authors: Zhu
authors: Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
authors: Simon P
authors: SP
authors: Kim
authors: Urology Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
authors: Robert
authors: R
authors: Abouassaly
mesh_terms: D000328:Adult; D000368:Aged; D001706:Biopsy; D002292:Carcinoma, Renal Cell / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D007668:Kidney / Q000473:pathology*; D007680:Kidney Neoplasms / Q000473:pathology / Q000601:surgery*; D008297:Male; D000072662:Margins of Excision; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods* / Q000706:statistics & numerical data; D011300:Preoperative Care / Q000379:methods; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
keywords: nephrectomy; pathology; renal cell carcinoma; trends; utilisation