Skip to main content

Trends in Renal Tumor Surgery in the United States and Germany Between 2006 and 2014: Organ Preservation Rate Is Improving



Nephron-sparing surgery (NSS) is the treatment of choice for T1 renal tumors. This study compared the implementation of NSS in the United States and Germany.


Data were derived from the National Inpatient Sample and from the Nationwide German Hospital Billing Database. All cases of NSS and radical nephrectomy from 2006 to 2014 were analyzed. To assess tumor stage distribution, data from the Surveillance, Epidemiology, and End Results database (United States) and from German cancer registries were used.


The study identified 74,663 cases in the United States and 130,051 cases in Germany. The proportion of NSS for T1 tumors increased from 30.6 to 57% in the United States compared with 38.5 to 72.9% (estimation) in Germany (p < 0.001). The proportion of robotic NSS increased from 0 to 54.5% in the United States (p < 0.001) and from 0.2 to 8.6% in Germany (p < 0.001). In a multivariate model, hospitals with higher annual caseloads and a surgical robot favored NSS.


Patients with renal tumors might receive inhomogeneous care based on the resources of the treating institution. The robotic approach is a key driver for better implementation of NSS in the United States, and relevant potential still may exist for more organ preservation.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4


  1. Fergany AF, Hafez K, Novick AC. Long-term results of nephron-sparing surgery for localized renal cell carcinoma: 10-year follow-up. J Urol. 1999;163:442–5.

    Article  Google Scholar 

  2. Lee CT, Katz J, Shi W, et al. Surgical managment of renal tumors 4 cm or less in a contemporary cohort. J Urol. 2000;163:730–6.

    CAS  Article  Google Scholar 

  3. Campbell SC, Novick AC, Belldegrun A, et al. Guideline for management of the clinical T1 renal mass. J Urol. 2009;182:1271–9.

    Article  Google Scholar 

  4. Ljungberg B, Bensalah K, Canfield S, et al. EAU guidelines on renal cell carcinoma: 2014 update. Eur Urol.2015;67:913–24.

    Article  Google Scholar 

  5. Breau RH, Crispen PL, Jimenez RE, et al. Outcome of stage T2 or greater renal cell cancer treated with partial nephrectomy. J Urol. 2010;183:903–8.

    Article  Google Scholar 

  6. Daugherty M, Bratslavsky G. Compared with radical nephrectomy, nephron-sparing surgery offers a long-term survival advantage in patients between the ages of 20 and 44 years with renal cell carcinomas (< 4 cm): an analysis of the SEER database. Semin Urol Oncol. 2014;32:549–54.

    Article  Google Scholar 

  7. Kim SP, Campbell SC, Gill I, et al. Collaborative review of risk benefit trade-offs between partial and radical nephrectomy in the management of anatomically complex renal masses. Eur Urol. 2017;72:64–75.

    Article  Google Scholar 

  8. Ghani KR, Sukumar S, Sammon JD, et al. Practice patterns and outcomes of open and minimally invasive partial nephrectomy since the introduction of robotic partial nephrectomy: results from the nationwide inpatient sample. J Urol. 2014;191:907–13.

    Article  Google Scholar 

  9. Bjurlin MA, Walter D, Taksler GB, et al. National trends in the utilization of partial nephrectomy before and after the establishment of AUA guidelines for the management of renal masses. Urology. 2013;82:1283–90.

    Article  Google Scholar 

  10. Hollenbeck BK, Taub DA, Miller DC, Dunn RL, Wei JT. National utilization trends of partial nephrectomy for renal cell carcinoma: a case of underutilization? Urology. 2006;67:254–9.

    Article  Google Scholar 

  11. HCUP Nationwide Inpatient Sample (NIS). Healthcare cost and utilization project (HCUP), Rockville, MD. Agency for Health-Care Research and Quality, 2012. Retrieved April 1, 2019, at

  12. Groeben C, Koch R, Baunacke M, et al. Urinary diversion after radical cystectomy for bladder cancer: comparing trends in the US and Germany from 2006 to 2014. Ann Surg Oncol. 2018;25:3502–9.

    Article  Google Scholar 

  13. Hager B, Kraywinkel K, Keck B, et al. Integrated prostate cancer centers might cause an overutilization of radiotherapy for low-risk prostate cancer: a comparison of treatment trends in the United States and Germany from 2004 to 2011. Radiother Oncol. 2015;115:90–5.

    Article  Google Scholar 

  14. Gettman MT, Blute ML, Chow GK, et al. Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with daVinci robotic system. Urology. 2004;64:914–8.

    Article  Google Scholar 

  15. Aboumarzouk OM, Tietze S, Eyraud R, et al. Robotic versus laparoscopic partial nephrectomy: a systematic review and meta-analysis. Eur Urol. 2012;62:1023–33.

    Article  Google Scholar 

  16. Sun M, Abdollah F, Shariat SF, et al. Propensity-score matched comparison of complications, blood transfusions, length of stay, and in-hospital mortality between open and laparoscopic partial nephrectomy: a national series. Eur J Surg Oncol. 2012;38:80–7.

    CAS  Article  Google Scholar 

  17. Groeben C, Koch R, Baunacke M, Wirth MP, Huber J. Robots drive the German radical prostatectomy market: a total population analysis from 2006 to 2013. Prostate Cancer Prostatic Dis. 2016;23:1–5.

    Google Scholar 

  18. Patel HD, Mullins JK, Pierorazio PM, et al. Trends in renal surgery: robotic technology is associated with increased use of partial nephrectomy. J Urol. 2013;189:1229–35.

    Article  Google Scholar 

  19. Sivarajan G, Taksler GB, Walter D, et al. The effect of the diffusion of the surgical robot on the hospital-level utilization of partial nephrectomy. Med Care. 2015;53:71–8.

    Article  Google Scholar 

  20. Ljungberg B, Hanbury DC, Kuczyk MA, et al. Renal cell carcinoma guideline. Eur Urol. 2007;51:1502–10.

    Article  Google Scholar 

  21. Ridic G, Gleason S, Ridic O. Comparisons of health care systems in the United States, Germany, and Canada. Mater Sociomed. 2012;24:112–20.

    Article  Google Scholar 

  22. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-income countries. JAMA. 2018;319:1024–39.

    Article  Google Scholar 

  23. Uzzo RG, Wei JT, Hafez K, Kay R, Novick AC. Comparison of direct hospital costs and length of stay for radical nephrectomy versus nephron-sparing surgery in the managment of localized renal cell carcinoma. Urology. 1999;54:994–8.

    CAS  Article  Google Scholar 

  24. Tanagho YS, Figenshau RS, Sandhu GS, Bhayani SB. Is there a financial disincentive to perform partial nephrectomy? J Urol. 2012;187:1995–9.

    Article  Google Scholar 

  25. Dickman SL, Himmelstein DU, Woolhandler S. Inequality and the health-care system in the USA. Lancet. 2017;389:1431–41.

    Article  Google Scholar 

  26. Diaz A, Schoenbrunner A, Pawlik TM. Trends in the geospatial distribution of inpatient adult surgical services across the United States. Ann Surg. 2019.

    Article  PubMed  Google Scholar 

  27. Weight CJ, Crispen PL, Breau RH, et al. Practice-setting and surgeon characteristics heavily influence the decision to perform partial nephrectomy among American Urologic Association surgeons. BJU Int. 2012;111:731–8.

    Article  Google Scholar 

  28. Woldrich J, Palazzi K, Stroup SP, et al. Trends in the surgical management of localized renal masses: thermal ablation, partial, and radical nephrectomy in the USA, 1998–2008. BJU Int. 2013;111:1261–8.

    Article  Google Scholar 

  29. Campbell S, Uzzo RG, Allaf ME, et al. Renal mass and localized renal cancer: AUA guideline. J Urol. 2017;198:520–9.

    Article  Google Scholar 

  30. Vigneswaran HT, Lec P, Brito J, et al. Partial nephrectomy for small renal masses: do teaching and nonteaching institutions adhere to guidelines equally? J Endourol. 2016;30:714–21.

    Article  Google Scholar 

Download references


The sources of data for this study were the SEER database, the U.S. Nationwide Inpatient Sample, German research data centers of the federal and state statistical offices (DRG statistics 2006–2014), and own calculations. The study was supported by a Med-Drive Grant of the Medical Faculty Carl Gustav Carus TU Dresden (Grant No. 60.356).

Author information

Authors and Affiliations


Corresponding author

Correspondence to Johannes Huber.

Ethics declarations


Dr. Huber received personal fees from Amgen and Janssen and grants and nonfinancial support from Intuitive Surgical and Takeda, outside the submitted work. The other authors have no conflicts of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 85 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Flegar, L., Groeben, C., Koch, R. et al. Trends in Renal Tumor Surgery in the United States and Germany Between 2006 and 2014: Organ Preservation Rate Is Improving. Ann Surg Oncol 27, 1920–1928 (2020).

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: