Positive Surgical Margins in Partial Nephrectomy: A Collaborative Effort to Maintain Quality

What is it about?

Partial nephrectomy (PN) is the gold standard for managing small renal masses, with similar oncological outcomes and better functional outcomes compared to radical nephrectomy. However, PN carries a risk of positive surgical margin (PSM), which can affect oncological and survival outcomes. The Michigan Urological Surgery Improvement Collaborative-Kidney mass (MUSIC-KIDNEY) is a statewide quality improvement (QI) initiative focused on improving care for patients with clinical stage T1 renal masses. The aim of this study was to investigate the influence of practice-level variation, patient, and tumour factors on PSM rates in the MUSIC-KIDNEY cohort. A total of 1142 patients underwent PN in 14 MUSIC-KIDNEY practices for cT1RM. The overall rate of PSM in the MUSIC-KIDNEY practices was 6.7%. The endophytic component (E) of the R.E.N.A.L. nephrometry score, surgical approach, and annual practice volume of ≤20 were independently associated with PSM. On multivariable analysis, only annual practice volume was significantly associated with PSM.

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Why is it important?

This research is important because it provides valuable insights into the rates of positive surgical margins (PSM) in patients undergoing partial nephrectomy (PN) and identifies factors associated with PSM rates. The study highlights the impact of practice-level variation, patient, and tumor factors on PSM rates, emphasizing the significance of high-volume centers and the expertise of surgeons in achieving better outcomes. The study findings are crucial for several reasons: They corroborate prior literature demonstrating that high-volume centers have lower rates of PSM following PN. The research is unique in describing current practice patterns and outcomes in an entire state across academic, hybrid, and community institutions. The study emphasizes the importance of access to tertiary care centers and centralization of care to high-volume centers, which may lead to improved patient outcomes. Key Takeaways: 1. The overall rate of PSM in the MUSIC-KIDNEY practices was 6.7%. 2. The endophytic component (E) of the R.E.N.A.L. nephrometry score, surgical approach, and annual practice volume of ≤20 were independently associated with PSM. 3. Only annual practice volume was significantly associated with PSM on multivariable analysis. 4. High-volume centers have lower rates of PSM following PN. 5. The study is unique in describing current practice patterns and outcomes across an entire state. 6. Access to tertiary care centers and centralization of care to high-volume centers may lead to improved patient outcomes.