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whether this is an entirely bad thing. There is no debate that there are real advantages to nephron sparing surgery and that PN is now a standard of care for the treatment of small renal tumors. How- ever, AUA guidelines mention other possible ap- proaches as well, including active surveillance and radical nephrectomy (reference 8 in article). From a quality of care perspective PN in the hands of a surgeon who rarely performs the procedure may re- sult in significantly worse outcomes than the sim- pler radical nephrectomy in the same provider’s hands. While this certainly makes the case for re- gionalization of care to selected centers of excellence in nephron sparing surgery, we must remember that these centers ultimately only have so much band- width and there is a real risk they could exceed their capacity quite quickly, resulting in delays in treat- ment and ultimately worse outcomes. To this end, radical nephrectomy (or, for that matter, active sur- veillance) may still be a reasonable approach in the management of SRMs and perhaps should not be dismissed so quickly. David F. Penson Vanderbilt University Nashville, Tennessee REFERENCE 1. Miller DC, Saigal CS, Banerjee M et al: Diffusion of surgical innovation among patients with kidney cancer. Cancer 2008; 112: 1708. REPLY BY AUTHORS We agree that there likely is a respondent bias in our survey. While we have no way of determining which direction the bias occurred, we suspect there was an overrepresentation from urologists who fa- vor nephron sparing procedures. This suspicion is based on the observations that a disproportionate number of respondents were from academic centers and completed fellowships in oncology or MIS, and the preference for partial nephrectomy seemed to be higher than what we have noted in population based registries. However, most population based regis- tries do not include recently treated patients, and it is not clear if practice patterns in 2002 apply to those in 2010. There have been a plethora of studies in the last 5 years highlighting favorable outcomes associated with partial nephrectomy, and we expect the impact of these findings will only be evident in contemporary practice. It is our hope that the survey responses represent a change of opinion in the uro- logical community but only time will tell. In regard to radical nephrectomy for T1a renal tumors, we believe that indications for this proce- dure are becoming few. Partial nephrectomy for fa- vorably located tumors should be part of the arma- mentarium of all urologists, and referral of “difficult” cases to high volume practices is appropriate. We agree that access to timely and quality care is impor- tant, which highlights the need for efficient referral pathways and continuing education programs to en- sure that urologists are trained to safely perform renal surgery. However, in prior series delayed surgery for 6 months or longer in patients with T1a renal tumors was not associated with significant pathological up staging or change in treatment approach. We agree that ongoing population based assessment of benefit and harm is warranted. SMALL RENAL MASS SURVEY 414
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SMALL RENAL MASS SURVEY414
whether this is an entirely bad thing. There is nodebate that there are real advantages to nephronsparing surgery and that PN is now a standard ofcare for the treatment of small renal tumors. How-ever, AUA guidelines mention other possible ap-proaches as well, including active surveillance andradical nephrectomy (reference 8 in article). From aquality of care perspective PN in the hands of asurgeon who rarely performs the procedure may re-sult in significantly worse outcomes than the sim-pler radical nephrectomy in the same provider’shands. While this certainly makes the case for re-
REFERENCE
1. Miller DC, Saigal CS, Banerjee M et al: Diffusion of surgical innovation among patien
REPLY BY AUTHORS
contemporary practice. It is our hope that the survey
in nephron sparing surgery, we must remember thatthese centers ultimately only have so much band-width and there is a real risk they could exceed theircapacity quite quickly, resulting in delays in treat-ment and ultimately worse outcomes. To this end,radical nephrectomy (or, for that matter, active sur-veillance) may still be a reasonable approach in themanagement of SRMs and perhaps should not bedismissed so quickly.
David F. Penson
Vanderbilt University
gionalization of care to selected centers of excellence Nashville, Tennesseets with kidney cancer. Cancer 2008; 112: 1708.
We agree that there likely is a respondent bias inour survey. While we have no way of determiningwhich direction the bias occurred, we suspect therewas an overrepresentation from urologists who fa-vor nephron sparing procedures. This suspicion isbased on the observations that a disproportionatenumber of respondents were from academic centersand completed fellowships in oncology or MIS, andthe preference for partial nephrectomy seemed to behigher than what we have noted in population basedregistries. However, most population based regis-tries do not include recently treated patients, and itis not clear if practice patterns in 2002 apply tothose in 2010. There have been a plethora of studiesin the last 5 years highlighting favorable outcomesassociated with partial nephrectomy, and we expectthe impact of these findings will only be evident in
responses represent a change of opinion in the uro-logical community but only time will tell.
In regard to radical nephrectomy for T1a renaltumors, we believe that indications for this proce-dure are becoming few. Partial nephrectomy for fa-vorably located tumors should be part of the arma-mentarium of all urologists, and referral of “difficult”cases to high volume practices is appropriate. Weagree that access to timely and quality care is impor-tant, which highlights the need for efficient referralpathways and continuing education programs to en-sure that urologists are trained to safely perform renalsurgery. However, in prior series delayed surgery for 6months or longer in patients with T1a renal tumorswas not associated with significant pathological upstaging or change in treatment approach. We agreethat ongoing population based assessment of benefit
and harm is warranted.
