Four Management Options For Small Kidney Masses Interview with:

Hiten D. Patel, MD, MPH Resident, Urological Surgery James Buchanan Brady Urological Institute The Johns Hopkins Medical Institutions Baltimore, Maryland 21287

Dr. Hiten Patel

Hiten D. Patel, MD, MPH
Resident, Urological Surgery
James Buchanan Brady Urological Institute
The Johns Hopkins Medical Institutions
Baltimore, Maryland 21287 What is the background for this study?

Dr. Patel: The study reports results of a systematic review contracted by the Agency for Healthcare Research and Quality based on input from stakeholders. Part of the motivation was due to the American Urological Association’s desire to use the results as a basis to update relevant clinical guidelines.

There are four major management options for clinically localized small renal masses diagnosed on imaging including active surveillance, thermal ablation, partial nephrectomy, and radical nephrectomy. The body of research evaluating these management options is broad, but many of the studies performing comparative analyses have limitations. Therefore, the systematic review aimed to evaluate a number of outcomes (e.g. overall survival, cancer specific survival, local recurrence, metastasis, renal function, complications, and perioperative outcomes) based on available comparative studies in the literature. What are the main findings?

Dr. Patel: The main findings note excellent and comparable cancer-specific survival among management strategies for appropriately selected patients. Overall survival varied based on the comorbidities of the patient population. Local recurrence free survival was worse for thermal ablation compared to partial or radical nephrectomy. Radical nephrectomy led to the largest decline in estimated glomerular filtration rate and had the highest incidence of chronic kidney disease, but the rate of end stage renal disease did not differ from the available literature. Perioperative outcomes were somewhat better for thermal ablation but postoperative harms were similar between options. There were very few comparative studies that included active surveillance, but the non-comparative studies showed appropriately selected patients have excellent outcomes. What should readers take away from your report?

Dr. Patel: There are multiple considerations when advising patients on the best management strategy for a localized renal mass suspicious for renal cell carcinoma. For young, healthy patients or patients not willing to consider less invasive options, partial and radical nephrectomy offer excellent outcomes with differences in postoperative renal function and complication rates that should be discussed. Older patients with significant comorbidities may opt to consider less invasive management strategies including an initial period of active surveillance or undergoing thermal ablation based on perioperative outcomes and surgical risk. There are also a number of opportunities for further research that could help fill the gaps in our knowledge or evidence base. What recommendations do you have for future research as a result of this study?

Dr. Patel: Better prospective evaluation of management strategies is needed. Although randomized controlled trials might be difficult in this clinical situation, with only one performed in the past, prospective evaluations with patients that could meeting inclusion criteria for more than one management strategy may provide stronger evidence on differences in outcomes. Standardized definitions and follow-up are also needed given the high level of variation between investigators. Is there anything else you would like to add?

Dr. Patel: We thank the Evidence-Based Practice Center at Johns Hopkins and the Agency for Healthcare Research and Quality for supporting and conducting the legwork to perform this analysis. We also look forward to the upcoming guidelines update from the American Urological Association based on our the up-to-date systematic review of the literature. Thank you for your contribution to the community.


Management of Renal Masses and Localized Renal Cancer: Systematic Review and Meta-analysis

Pierorazio, Phillip M. et al.
The Journal of Urology , Volume 0 , Issue 0

Published Online:May 05, 2016

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on May 11, 2016 by Marie Benz MD FAAD