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JU INSIGHT: Unplanned Conversion From Partial to Radical Nephrectomy: An Analysis of Incidence, Etiology, and Risk Factors

By: Matvey Tsivian, MD; Daniel D. Joyce, MD; Vignesh T. Packiam, MD; Christine M. Lohse, MD, MS; Stephen A. Boorjian, MD; Theodora A. Potretzke, MD; George K. Chow, MD; Bradley C. Leibovich, MD; Vidit Sharma, MD; R. Houston Thompson, MD | Posted on: 01 Nov 2022

Tsivian M, Joyce DD, Packiam TT, et al. Unplanned conversion from partial to radical nephrectomy: an analysis of incidence, etiology, and risk factors. J Urol. 2022;208(5):960-968.

Study Need and Importance

Current data on the incidence of, reasons for, and characteristics associated with increased risk of conversion from partial to radical nephrectomy are sparse and often conflicting. Identifying which patients are at increased risk of conversion is important for shared decision making, operative planning, and patient counseling. We comprehensively described the incidence and etiology of conversions from partial to radical nephrectomy over a 15-year period at our quaternary care referral center, and identified preoperative patient and tumor characteristics associated with conversion.

Figure. Rates and types of conversions from partial nephrectomy to radical nephrectomy between 2000 and 2015. A, Rates of conversion from partial nephrectomy to radical nephrectomy. B, Rate of conversion for planned open and minimally invasive (MI) radical nephrectomy. C, Attempted vs abandoned partial nephrectomy over time.

What We Found

In this case-control study, conversion from planned partial nephrectomy for localized solid renal masses to radical nephrectomy was rare at our institution with decreasing incidence over time (see Figure). Most conversions were due to concerns regarding tumor upstaging (44%), insufficient remaining viable renal parenchyma (27%), and positive surgical margins (11%). Furthermore, male sex (OR 2.34, 95%CI 1.07-5.13), greater comorbidity burden (OR 1.28, 95%CI 1.02-1.59), and 2 components of the RENAL (for radius, exophytic/endophytic, nearness of tumor to collecting system, anterior/posterior, location relative to polar line) Nephrometry Score, hilar (OR 5.61 95%CI 2.63-11.97) and nonanterior tumor location (OR 6.38 for middle location, 95%CI 2.39-17.03; OR 2.83 for posterior location, 95%CI 1.15-6.94), were identified as predictors of conversion.

Limitations

Missing imaging data for cases and controls may have resulted in selection bias. RENAL Nephrometry Score measurement bias may have been introduced by unblinded imaging review. Results are from a single-institutional experience, which may limit generalizability.

Interpretation for Patient Care

RENAL Nephrometry Score components that do not contribute to the overall score, such as hilar and nonanterior tumor location, should be preferentially considered when evaluating the risk of conversion from partial to radical nephrectomy. In addition, male sex may be associated with factors that increase surgical dissection difficulty resulting in a higher likelihood of conversion to radical nephrectomy.

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