Almost 5% of Patients Undergo Incomplete Procedure to Remove Kidney and Nearby Tissue for Upper Tract Urothelial Carcinoma

April 13, 2021
Darlene Dobkowski, MA

Several factors were associated with patients undergoing radical nephrectomy compared with radical nephroureterectomy including Black race, large tumors, advanced tumor stage and high-grade tumors.

Unintentional radical nephrectomy, or the surgical removal of the entire kidney, nearby lymph nodes and adrenal gland and surrounding tissue, occurs in nearly 5% of patients with upper tract urothelial carcinoma, according to a study published in Urology.

"The important thing is that sometimes in clinical practice, there's a misdiagnosis, as these masses that arise from the inner lining of the kidney from the pelvic side, they masquerade or look as if they are coming from the cortex of the kidney," said Dr. Bashir Al Hussein Al Awamlh, urology resident at Weill Cornell Medicine in New York, New York, in an interview with CURE®. "Physicians tend to get confused by them, would assume that these are the masses that are coming from the cortex and just operate on them as if that's the case. These are not so common events, and there's very little literature on them."

Researchers also found that patients who underwent radical nephrectomy had significantly worse overall survival compared with those treated with radical nephroureterectomy, or the surgical removal of a kidney and its ureter.

To compare overall survival in patients who underwent radical nephrectomy with those who underwent radical nephroureterectomy, researchers analyzed data from patients with upper tract urothelial carcinoma in the National Cancer Database. In particular, 820 patients were originally diagnosed with renal cortical tumors, underwent radical nephrectomy and were then confirmed to have urothelial carcinoma, whereas 16,464 patients were diagnosed with renal pelvis tumors and underwent appropriate radical nephroureterectomy.

Of the patients in this study, 4.7% underwent inappropriate radical nephrectomy.

Now, the percentage ... we found (of) 5%, it may not be very accurate because this is a large data set that is dependent on human coding errors, etc.," said Al Hussein Al Awamlh. "It is a rough estimate, but it's out there."

Compared with radical nephroureterectomy, several factors were associated with radical nephrectomy including larger tumors 55 millimeters versus 33 millimeters, Black race (7.5% versus 4.3%), high-grade tumors (69% versus 58.4%) and advanced tumor stage (56.3% versus 31.5% with T3 or T4).

Patients who underwent surgery at a facility that performs a higher number of radical nephroureterectomy per year were less likely to undergo radical nephrectomy.

The five-year overall survival for patients who underwent radical nephrectomy was 39.9% compared with 49.9% in those who underwent radical nephroureterectomy.

"The other important takeaway is that (poorer outcomes were) associated with centers with less experience, which is what you expect; people who are less experienced in managing these kinds of cancers tend to perform this misdiagnosis or ‘mistake," said Al Hussein Al Awamlh.

He added some important reassurance for patients in this particular scenario. "Medical mistakes do happen, unfortunately, and I think the governing bodies in urology do underscore the importance of diagnosis," said Al Hussein Al Awamlh. "If there's a small fraction of these mistakes (that) do happen, ... I think the one takeaway that can help reassure patients in these situations is if it's not an obvious mass — which a clinician can tell if it's an obvious mass — or it's equivocal, the data seem to suggest that it's probably better for patients to be referred to someone who's a little bit more seasoned in these complex cases and complex masses to avoid missing that diagnosis."

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