A More Rational Approach To Renal Mass Surgery
Robert G. Uzzo, MD, FACS
In the absence of level I evidence, physician treatment recommendations are subject not only to the objective (interpretations of the cohort literature and practice guidelines) but also the subjective (training patterns, comfort levels, biases and individual experiences).
Such is the case for management of the incidental renal mass where multiple therapeutic options exist (J Urol. 2008;179:1227-1233). This is well highlighted in recently released guidelines from the American Urological Association (J Urol. 2009;182:1271-1279; www.auanet.org/guidelines).
When considering how best to excise a renal tumor (laparoscopic/robotic or open/partial or radical), the decision is profoundly affected by the surgeon's subjective assessment of the anatomical attributes of the renal tumor in the context of his/her experience.
A lesion that one clinician may deem “inappropriate” or even “impossible” for a partial nephrectomy due to its “central”, “hilar,” or “endophytic” location, may be “standard” for another clinician. This has resulted in overutilization of radical nephrectomy with profound implications for the development of CKD (Lancet Oncol.2006;7:735-740).
Equally importantly, comparing outcomes and developing metrics from retrospective localized renal cancer cohort studies in the literature are currently impossible due to the lack of a standard nomenclature to quantitate differences in renal mass anatomy.
Recently a scoring system (Nephrometry) has been proposed to objectify the difficulties of renal mass excision (J Urol. 2006;175:853-857; www.nephrometry.com). It is the first of what may be several systems aimed at quantitative surgical decision making processes in kidney cancer.
Not everything in medicine in quantifiable. Experience and “gestalt” remain relevant clinical tools. Nonetheless, hepatic surgeons all understand that a lesion in segment 1 or 8 is technically difficult while another in segment 2 or 3 is straight forward.
Interpretation of a retrospective or prospective series of hepatic resections is based on this understanding. Similarly, BI-RADS (Breast Imaging-Reporting and Data Systems) has been used as a quality control system for concise and unambiguous understanding of patients mammogram between multiple doctors, facilities and publications. Objective parameters such as nephrometry encourage consistency in clinical decision making and allow relevant comparisons—goals that remain elusive in much of the surgical literature.
Dr. Uzzo is the G. Willing "Wing" Pepper Chair in Cancer Research and Professor and Chairman, Department of Surgery, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia. He is the Renal & Urology News Medical Director for Nephrology.