Contemporary management of small renal masses: does practice environment matter?

Population based studies imply underutilization of renal preservation for managing small renal mass (SRMs). Limited information is available regarding the impact of practice environment on SRM treatment. We evaluated practice patterns for SRMs in the context of a urologist's practice environment.

Survey instrument querying practice type (private versus academic/academic affiliation) was distributed to urologists of the Mid-Atlantic section of the American Urological Association. Physicians were presented three case scenarios (exophytic 2.5 cm SRM in a healthy 55-year-old, healthy 75-year-old, and comorbid 75-year-old patient) and were queried on management.

Of the 281 respondents who manage kidney cancer, 92 practiced in an academic environment, and 189 were private practitioners. Thirty-four percent had completed residency training within 10 years, 25% between 11-20 years, and 41% over 20 years. For SRMs in a healthy 55-year-old, over 95% of practicing nephrologists advocated nephron-sparing treatments. Nonetheless, private practitioners were more likely to perform a radical nephrectomy (6% versus 0%, p = 0.03) and less likely perform a partial nephrectomy (79% versus 91%, p = 0.01) than academic counterparts. We observed an increase in the percentage of urologists offering thermal ablation (38% versus 12%, p < 0.0001) and observation (29% versus 1%, p < 0.0001) with a corresponding decline in the use of partial nephrectomy (32% versus 83%, p < 0.0001) in the 75-year-old versus 55-year-old patient. When considering management of a SRM in 75-year-old patients (healthy or comorbid), private practitioners were more likely to offer a thermal ablative procedure when compared to academic urologists (41% versus 32%, p = 0.05).

Over 95% of urologists espouse renal preservation strategies for a SRM in a healthy, young patient. Private practitioners are more likely to perform a radical (and less likely a partial) nephrectomy in this cohort. While surveillance is increasingly utilized for SRMs in the elderly patient, private practitioners are more likely to recommend active treatment via thermal ablation when compared to academic counterparts.