SMALL RENAL MASS SURVEY414

whether this is an entirely bad thing. There is nodebate that there are real advantages to nephronsparing surgery and that PN is now a standard ofcare for the treatment of small renal tumors. How-ever, AUA guidelines mention other possible ap-proaches as well, including active surveillance andradical nephrectomy (reference 8 in article). From aquality of care perspective PN in the hands of asurgeon who rarely performs the procedure may re-sult in significantly worse outcomes than the sim-pler radical nephrectomy in the same provider’shands. While this certainly makes the case for re-

REFERENCE

1. Miller DC, Saigal CS, Banerjee M et al: Diffusion of surgical innovation among patien

REPLY BY AUTHORS

contemporary practice. It is our hope that the survey

in nephron sparing surgery, we must remember thatthese centers ultimately only have so much band-width and there is a real risk they could exceed theircapacity quite quickly, resulting in delays in treat-ment and ultimately worse outcomes. To this end,radical nephrectomy (or, for that matter, active sur-veillance) may still be a reasonable approach in themanagement of SRMs and perhaps should not bedismissed so quickly.

David F. Penson

Vanderbilt University

gionalization of care to selected centers of excellence Nashville, Tennessee

ts with kidney cancer. Cancer 2008; 112: 1708.

We agree that there likely is a respondent bias inour survey. While we have no way of determiningwhich direction the bias occurred, we suspect therewas an overrepresentation from urologists who fa-vor nephron sparing procedures. This suspicion isbased on the observations that a disproportionatenumber of respondents were from academic centersand completed fellowships in oncology or MIS, andthe preference for partial nephrectomy seemed to behigher than what we have noted in population basedregistries. However, most population based regis-tries do not include recently treated patients, and itis not clear if practice patterns in 2002 apply tothose in 2010. There have been a plethora of studiesin the last 5 years highlighting favorable outcomesassociated with partial nephrectomy, and we expectthe impact of these findings will only be evident in

responses represent a change of opinion in the uro-logical community but only time will tell.

In regard to radical nephrectomy for T1a renaltumors, we believe that indications for this proce-dure are becoming few. Partial nephrectomy for fa-vorably located tumors should be part of the arma-mentarium of all urologists, and referral of “difficult”cases to high volume practices is appropriate. Weagree that access to timely and quality care is impor-tant, which highlights the need for efficient referralpathways and continuing education programs to en-sure that urologists are trained to safely perform renalsurgery. However, in prior series delayed surgery for 6months or longer in patients with T1a renal tumorswas not associated with significant pathological upstaging or change in treatment approach. We agreethat ongoing population based assessment of benefit

and harm is warranted.