The decline of radical nephrectomy: Contemporary trends in the treatment of T1 renal cell carcinoma

TL;DR

This study shows that partial nephrectomy and ablation are increasingly used instead of radical nephrectomy for small kidney tumors in the US.

Contribution

The paper presents the largest series to date on treatment trends for T1 renal cell carcinoma and identifies predictors for ablative therapy use.

Findings

Partial nephrectomy increased from 16% to 57% while radical nephrectomy decreased from 84% to 33% between 2000 and 2021.

Ablation use grew from 1% to 11%, with most procedures performed on tumors <4 cm.

Cryoablation saw the most significant increase among ablative techniques.

Abstract

The diagnosis of small renal masses is becoming increasingly common. Management recommendations are shifting from radical nephrectomy (RN) toward nephron‐sparing options such as partial nephrectomy (PN), thermal ablation (TA), and active surveillance (AS). This study aims to present current treatment trends in the USA for treating clinical stage T1 renal cell carcinoma in the largest series to date. Additionally, we sought to identify predictors linked to the receipt of ablative treatments.

We conducted a retrospective cohort study using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) 22 Registries from 2000 to 2021. Adults (≥18 years) with unilateral, primary cT1 renal cortical renal cell carcinoma were included. Treatments analysed were RN, PN, and ablative therapies (radiofrequency, cryoablation, and laser). Annual trends were assessed, and multinomial logistic regression identified demographic and clinical predictors of treatment selection.

A total of 86 642 patients were included. Between 2000 and 2021, PN increased from 16% to 57% and ablation from 1% to 11%, while RN decreased from 84% to 33% (p < 0.001). Overall, 6138 ablative treatments were performed, with the majority (n = 5623, 92%) conducted on renal masses <4 cm. The most substantial growth was for tumours <2 cm, with a 17.2% increase in ablation compared to a 3.4% increase for masses >4 cm. Among ablative techniques, cryoablation's utilization increased most dramatically from 0% to 7% during the study period. Multivariable analysis indicated that predictors for choosing ablation over RN included older age, later year of diagnosis, smaller tumours, and higher income. Conversely, Hispanic ethnicity, marital status, and non‐classic RCC subtypes were linked to a higher likelihood of receiving RN versus ablation.

Over the past two decades, PN and ablation have increasingly replaced RN in the management of cT1 renal masses, particularly for tumours <4 cm. As technology advances, ablation is likely to expand further, reinforcing the shift toward nephron‐sparing strategies.

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