Effect of Renal Mass Biopsy on Subsequent Nephrectomy Outcomes: A Population-based Assessment

TY - JOUR

T1 - Effect of Renal Mass Biopsy on Subsequent Nephrectomy Outcomes

T2 - A Population-based Assessment

AU - Wallis, Christopher J.D.

AU - Garbens, Alaina

AU - Klaassen, Zachary

AU - Kodama, Ronald T.

AU - Herschorn, Sender

AU - Nam, Robert K.

N1 - Funding Information: Christopher J.D. Wallis a b 1 Alaina Garbens a 1 Zachary Klaassen c d Ronald T. Kodama a Sender Herschorn a Robert K. Nam a ⁎ robert.nam@utoronto.ca a Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada Division of Urology Department of Surgery University of Toronto Toronto Canada b Department of Urology, Vanderbilt University Medical Center, Nashville, TN, USA Department of Urology Vanderbilt University Medical Center Nashville TN USA c Department of Surgery, Division of Urology, Medical College of Georgia at Augusta University, Augusta, GA, USA Department of Surgery Division of Urology Medical College of Georgia at Augusta University Augusta GA USA d Georgia Cancer Center, Augusta University, Augusta, GA, USA Georgia Cancer Center Augusta University Augusta GA USA ⁎ Corresponding author. Division of Urology, Department of Surgery, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada. Tel.: +1 416 4805075; Fax: +1 416 4806934. Division of Urology Department of Surgery University of Toronto 2075 Bayview Avenue Toronto Ontario M4N 3M5 Canada 1 These authors contributed equally to this work. Reported outcomes following renal mass biopsy (RMB) have, to date, been limited to single-center studies reporting diagnostic rates and immediate post-procedural outcomes [1–3] . We assessed the effect of RMB on subsequent partial (PN) or radical nephrectomy (RN) outcomes using population-based data from the Institute for Clinical Evaluative Sciences. Using a protocol approved by Sunnybrook Research Ethics Board, we identified adults who underwent PN or RN from January 1, 2003 to March 31, 2015 in Ontario, Canada and stratified patients on the basis of RMB in the 6 mo preceding surgery (varied between 3 and 12 mo in sensitivity analyses). Outcomes included 30-d rates of any-cause mortality, reoperation (any intra-abdominal operation), renal angioembolization, percutaneous drain insertion, cystoscopic stent insertion, emergency department visits, and hospital admissions, as well as hospital length of stay (LOS), total operative time, and the proportion of patients diagnosed with renal cancer following nephrectomy using the Ontario Cancer Registry. Owing to confounding by surgical modality, analysis was stratified by the operative approach (PN vs RN). We compared medians and proportions using a Wilcoxon rank-sum test and χ 2 test, respectively. We used multivariable generalized estimating equations to assess the association between preoperative RMB and postoperative complications (logistic model) and hospital LOS and operative time (negative binomial models), while accounting for patient, physician and hospital-level characteristics and clustering at the level of nephrectomy institution. Statistical significance was set at p  < 0.05 for two-tailed comparison. All analyses were performed using SAS Enterprise Guide 7.1 (SAS Institute, Cary, NC, USA). We compared 679 patients who underwent PN and 984 who underwent RN following RMB to contemporaneous patients who underwent PN ( ). Multivariable analysis showed no significant association between history of RMB and aggregate postoperative complications. The median operative time was longer for patients who underwent biopsy before surgery (PN: 5.3 vs 4.8 h; n  = 5499) or RN ( n  = 18 219) without RMB. RMB receipt was not associated with rates of mortality, operative and non-operative interventions, hospitalization, or emergency department visits within 30 d of surgery for PN patients, while RN patients had a higher likelihood of requiring a nonoperative intervention or hospitalization ( Table 1 p  < 0.001; RN: 5.2 vs 4.8 h; p  < 0.001). Patients who underwent RMB were significantly less likely to have benign disease on final pathology ( Table 1 ), with an absolute difference of 22% (95% confidence interval [CI] 19–25%) in the PN and 12% (95% CI 9.0–15%) in the RN group. Sensitivity analyses in which the exposure window was varied did not significantly change the study results (data not shown). A history of RMB is associated with a small but significant increase in operative time for subsequent PN and RN. With rare exceptions, we found no significant differences in postoperative complications. RMB may decrease the likelihood of undergoing surgical intervention for benign lesions. These data support the use of RMB where clinically appropriate [4] , with ongoing assessment of the long-term implications of RMB. Limitations include selection bias, as the underlying reason for biopsy could not be assessed, the surrogacy of complications captured and lack of causal attribution, lack of surgical details, and lack of radiographic data including renal mass size, location, and complexity. Conflicts of interest: The authors have nothing to disclose. Acknowledgments: Robert K. Nam is supported by the Ajmera Family Chair in Urologic Oncology. This study used deidentified data from the ICES Data Repository, which is managed by the Institute for Clinical Evaluative Sciences with support from its funders and partners: Canada’s Strategy for Patient-Oriented Research (SPOR), the Ontario SPOR Support Unit, the Canadian Institutes of Health Research, and the Government of Ontario. The opinions, results, and conclusions reported are those of the authors. No endorsement by ICES of any of its funders or partners is intended or should be inferred. The authors would like to thank Lesley Plumptre and Refik Saskin, senior analysts at ICES, for their assistance in the preparation of this manuscript.

PY - 2020/1

Y1 - 2020/1

UR - http://www.scopus.com/inward/record.url?scp=85075914389&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85075914389&partnerID=8YFLogxK

U2 - 10.1016/j.eururo.2019.09.025

DO - 10.1016/j.eururo.2019.09.025

M3 - Letter

C2 - 31585679

AN - SCOPUS:85075914389

SN - 0302-2838

VL - 77

SP - 136

EP - 137

JO - European urology

JF - European urology

IS - 1

ER -