Urologic Oncology: Seminars and Original Investigations
Original articleTrends in management of the small renal mass in renal transplant recipient candidates: A multi-institutional survey analysis
Introduction
The number of patients diagnosed with end-stage renal disease (ESRD) has increased with time [1]. In the United States, more than 100,000 new patients are diagnosed every year [2]. Unless a suitable donor can be found, dialysis is the primary treatment, which has its inherent risks. Acquired renal cystic disease (ARCD) is associated with dialysis and is a predisposing factor to renal cell carcinoma (RCC) in 3% to 7% of patients [3], [4]. Incidence of ARCD increases as the time on dialysis increases [5]. Prevalence increases to 90% 5 years after the initiation of dialysis [4], [5]. In addition, ESRD and renal transplantation are shown to increase the risk of developing RCC regardless of ARCD [3], [6]. Incidence of RCC in native kidneys of hemodialysis patients is 0.5% to 4.2%, [5], [6] and incidence of kidney cancer increases 6-fold after transplantation [7].
There is a lack of high-level evidence to guide treatment of small renal masses (SRM) in the ESRD setting. Partial nephrectomy is the gold standard treatment for SRM (<4 cm) [8], [9]. As kidneys of patients with ESRD are nonfunctional, radical nephrectomy is preferred over partial nephrectomy and laparoscopic radical nephrectomy is a safe technique with excellent oncological outcome for organ-confined disease [9], [10]. However, radical nephrectomy is not without complications, and complications increase significantly in the ESRD setting. These risks include bleeding risk and blood transfusion, increased postoperative complications, prolonged hospitalization, and a 5-fold increased risk of in-hospital mortality [11]. These data beg the question of whether we can offer active surveillance (AS) to patients to avoid or delay surgical morbidity and mortality. We aimed to analyze the practice patterns of transplant surgeons regarding their practice of SRMs in renal transplant candidates.
Section snippets
Materials and methods
The present study used a cross-sectional survey of 21 questions evaluating practice patterns of United States Transplant Centers for renal transplantation candidates with a clinical T1a renal mass. Information on the institution including name of institution, United Network for Organ Sharing (UNOS) regions, estimated years renal transplantation performed, estimated renal transplant volume, and number of transplant surgeons was collected. Additionally, information on practice patterns including
Survey response rate
Overall, there were 101 survey responses. Respondents whose institutions were not in the United States (n = 19), respondents who did not list their institution (n = 19) or were not a Doctor of Medicine or Osteopathic Medicine (n = 1) were excluded from the analysis. Among the 213 United States Transplant Centers to which the survey was sent, there were 62 respondents from 53 US Transplant Centers who responded, resulting in a response rate of 24.9% (n = 53/213).
All 11 UNOS regions were
Discussion
Considering that approximately 19% to 26% of SRMs are benign masses [12], it was a surprise to us that only 14.5% of respondents routinely uses renal biopsy in the evaluation of a SRM renal transplantation candidates. Furthermore, the rate of respondents who preferred AS was higher than (21%) our expectations. Though the majority (59%) preferred radical nephrectomy as the treatment option, most transplant surgeons indicated that they would consider AS and proceed with transplantation if there
Conclusion
There is a lack of evidence and prospective trials regarding treatment of cT1a renal masses in renal transplant recipient candidates. Time to become eligible for transplant in patients with SRM was influenced by treatment modality and tumor size. A high ratio of transplant surgeons who prefer to treat SRMs in renal transplant candidates would be willing to consider AS if there were sufficient data that showed the safety of AS. Future studies with prospective design are needed to validate our
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2021, American Journal of TransplantationEffect of the Need for Preoperative Dialysis on Perioperative Outcomes on Patients Undergoing Laparoscopic Nephrectomy: An Analysis of the National Surgical Quality Improvement Program Database
2019, UrologyCitation Excerpt :A recent survey of active transplant centers in the United States revealed that 59% of participants felt that the preferred treatment entailed a radical nephrectomy followed by active surveillance in 21.3% of the respondents. Of the correspondents whose institutions did not allow active surveillance, 77.4% would monitor small renal masses following transplantation if shown safety of active surveillance.22 There are several limitations to our study.
Active Surveillance of Small Renal Masses
2019, UrologyThe Case for Active Surveillance of Small Renal Masses in Renal Transplant Recipient Candidates
2023, Journal of UrologyRoles for active surveillance in renal cancer
2018, Current Opinion in Urology