Dear Editor:
I read with interest the recent article by Maurice et al. Multiple Tumor Excisions in Ipsilateral Kidney Increase Complications after Partial Nephrectomy published in your journal.
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As the kidney surgeon in a practice with a large hereditary kidney cancer patient population, I am well aware of the litany of complications that are more common with these operations.
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The authors are to be commended for corroborating the fact that the presence of multiple tumors in an ipsilateral kidney leads to different perioperative outcomes relative to traditional partial nephrectomy. In fact, we previously coined the term “multiplex partial nephrectomy” to emphasize the fact that this is a distinct surgical entity.
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This was done because a review of our data demonstrated a marked increase in operative times, blood loss, and complications compared to similar procedures for solitary renal tumors (unpublished data), which is similar to the findings in Table 3 of this article. Clearly, the presence of multiple tumors and the resulting surgical modifications necessary to successfully perform these operations not only affect the intraoperative measurable outcomes such as blood loss and conversion rates (both from minimally invasive to open but also from partial to radical nephrectomy) but also impact the likelihood and severity of postoperative measurable outcomes like urine leak, delayed bleeding, ileus, and prolonged lengths of stay.
While it may seem unnecessary to rename variations of a standard operation, in this era of global payments and compensation being linked to perioperative outcomes, as well as the ongoing emphasis on minimizing complications, it is critical that appropriate metrics are applied when assessing result of these procedures. It is incumbent upon our field to carefully define the expected outcomes of these cases so that our individual and institutional outcomes are evaluated appropriately. As it is, the current climate of diminishing compensation and increasing liability has already created less incentive for urologic surgeons to take on complex cases. Perhaps the architects of our healthcare system view this climate of disincentivization as the first step toward a longer term strategy of regionalization of care.
In conclusion, the authors are to be commended for their valuable contribution to the growing literature defining the true complexity of multifocal kidney cancer. Please note that these comments are my own personal views and do not reflect any official position or opinion of my employer.
