Nephron sparing surgery in renal cancer - individual decision or standard procedure? (original) (raw)
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How to draw the line between partial and radical nephrectomy
International braz j urol, 2021
There has been discussion over where to draw the line between partial and radical nephrectomy ever since performing the surgery was deemed possible. In 1869 Gustav Simon made history by performing the first ever planned nephrectomy to cure a urinary fistula and later in 1870, the first partial nephrectomy to treat hydronephrosis (1). That stated two important facts that are pertinent to our discussion. The first statement was that removing a kidney or part of one was possible. The second statement affirmed that it was possible to live with only one functioning organ. With that in mind, we persist year after year, trying to figure out where to put a line. Beyond oncological control, the risk of chronic kidney disease, cardiovascular events, hospitalization and death are problems that we as urologists must keep in mind when discussing long term repercussions of kidney cancer treatment, to find a way to push it as far as possible from our patients waiting for a partial or radical nephrectomy (2). Many studies have shown (3-6) that locally invasive tumors such as T3a can be resected in a nephron sparing surgery (NSS) with oncological safety in long enough follow-up. Although positive surgical margins do increase with NSS of more complex and advanced tumors, their consequences are still negligible and a two year follow up, although reduced, is probably enough time to evaluate properly a recurrence rate based on previous studies (7). Still, the literature is teeming with retrospective, non-randomized, biased filled works that try to give us some direction but are yet to give us any definitive answer. With that in mind, one other aspect to discuss would be the benefit of NSS and renal function preservation in this scenario. The follow up becomes central when dealing with this subject, once it has been reported that average time to recover original kidney function rate could take up to 25 months for 49% of patients to regain their previous eGFR (8, 9). Tumor size is also significantly different between most partial and radical nephrectomy studied groups, and that may also impact in the final renal function recovery (10). Many studies have shown even in the same T stage, that size may interfere in terms of benefit when performing NSS. According to de Andrade et al. (11) who analyzed patients submitted to radical nephrectomy, it was found that patients with kidneys with larger tumors suffered lower eGFR decreases when compared to kidneys with smaller ones and even lower than kidney donor patients, once the amount of lost functioning nephrons at surgery increases respectively. So eGFR changes after radical and partial nephrectomy depends on the quality and extension of the remaining normal tissue, mainly in the affected kidney, and the biggest EDITORIAL COMMENT
Urologic oncology, 2014
To analyze to what extent partial nephrectomy (PN) is superior to radical nephrectomy (RN) in preserving renal function outcome in relation to tumor size indication. Clinical data from 973 patients operated at 9 academic institutions were retrospectively analyzed. Glomerular filtration rate (GFR) before and after surgery was calculated with the abbreviated Modification of the Diet in Renal Disease equation. For a fair comparison between the 2 techniques, all imperative indications for PN were excluded. A shift to a less favorable GFR group following surgery was considered clinically significant. Median age at diagnosis was 60 years (19-91). Tumor size was smaller than 4 cm in 665 (68.3%) cases and larger than 4 cm in 308 (31.7%) cases. PN and RN were performed in 663 (68.1%) and 310 (31.9%) patients, respectively. In univariate analysis, patients undergoing PN had a smaller risk for developing significant GFR change following surgery than those undergoing RN did. This was true for t...
European Urology Supplements, 2006
a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w . e u r o p e a n u r o l o g y . c o m Article info Abstract Objective: Radical nephrectomy remains the gold standard for surgically resectable kidney neoplasms >4 cm and, in selected cases, also in presence of metastatic disease. We reviewed the records of the patients having surgery at the University of Genoa in the last 35 yr. Methods: We have retrospectively assessed all the radical nephrectomies performed between 1970 and 2005. Among tumours of the kidney subjected to surgical treatment during this period, we found 1105 cases of histologically proven renal cell carcinoma (RCC), 965 of which had records available for the study. The number of cases per year, symptoms at diagnosis, surgical strategy, staging of the tumour, and survival were reviewed. Results: Among 965 patients, radical nephrectomy was performed in 825 (85.5%) with a mean age of 61.26 yr (range, 20-88 yr) and partial nephrectomy in 140 (14.5%) with a mean age of 59.4 yr (range, 20-86 yr). Metastases at diagnosis were present in 81 patients (9.8%). The surgical approach was transperitoneal in 484 (58.6%) and extraperitoneal in 341 (41.4%) of the 825 patients. A transperitoneal approach was preferred for all tumours 10 cm in diameter. No postoperative deaths occurred due to technical complications but 15 patients (1.8%) died in the 30 d following the operation due to myocardial infarction, pulmonary embolus, or sepsis. At the last followup, the 5-yr overall survival rate was 56% and the 5-yr cancer-specific survival and disease-free survival rates were 70% and 65%, respectively. Conclusions: The incidence of RCC has slowly increased in recent years in our department. Surgical extirpation remains the most widely accepted and potentially curative treatment option for renal neoplasms with a good efficacy and low mortality and morbidity rates.
European Urology Supplements, 2006
To assess the incidence of complications of conservative renal surgery for renal cell carcinoma in both elective and imperative indications, and its evolution over a 15 year period. From 1988 to 2003, 127 patients underwent partial nephrectomy or tumorectomy for renal cell carcinoma in our department. INDICATIONs were imperative in 42% (n = 53) and elective in 58% (n=74) of cases. Morbidity was retrospectively assessed according to four parameters: 1- Period of surgery: A, from 1988 to 1999 and B, from 2000 to 2003. 2- INDICATION: elective vs. imperative. 3- experience of surgeon: senior vs. junior. 4- Nature of complications: minor or major. Comparative analysis was conducted using Chi-square and Fischer exact tests. Global incidence of complications was 30.7% (n = 39) corresponding to 18.1% minor (n = 23) and 12.6% (n = 16) major complications. Results show a moderate decrease of complication rate during Period B: 28.1% versus 32.9% during period A (p = 0.69). Complications occurred more frequently in imperative indications (49.1%) than in elective indications (17.6%) (p = 0.002), mostly regarding major complications (respectively 28.3% and 1.4%. (p < 0.001)). Overall re-intervention rate was 15.7%: 22.6% in imperative and 10.8% in elective indications (p = 0.008). Mean length of hospital stay was 14.1 days and significantly longer during period A (p = 0.003) and in imperative indications (p = 0.009). In our study, conservative renal surgery has a significant rate of complications which is extremely variable regarding to different parameters. Most discriminating factor was indication: in imperative indications, we observed a high rate of major complications (28.3%) that we consider acceptable to prevent anephria in clearly informed patients. Major complications are exceptional in elective indications. Decreased incidence of complications during the later period (B) is modest, and the role played by systematic pedicular clampage is discussed. As results published in medical literature are difficult to compare, we agree with authors who recently proposed to standardize complications data analysis, using a gravity scale, in order to provide relevant information to patients about statistical risks before surgery.
Comparison of nephron-sparing surgery in central versus peripheral renal tumors
Urology, 2005
To determine the feasibility of nephron-sparing surgery (NSS) in patients with centrally located tumors. Methods. A retrospective cohort study of 118 patients who underwent NSS between 1993 and 2002 (35 patients with centrally located tumors and 83 with peripherally located tumors) was performed. Kaplan-Meier curves were constructed to evaluate freedom from local recurrence and disease-specific survival in patients with conventional histologic subtype tumors. The Wilcoxon test was used to compare the curves (two-tailed P Յ0.05 was considered to be statistically significant). Results. Intraoperatively, in patients with centrally located tumors, the need to close the collecting system (P ϭ 0.035) and for blood transfusions (P ϭ 0.033) was greater. Two perioperative deaths occurred in patients with peripherally located tumors. Two patients with centrally located tumors subsequently underwent nephrectomy. Of the patients with centrally located tumors, 1 patient had a positive margin, 2 patients had local recurrence, and 1 patient developed metastasis. No positive surgical margins or local recurrence was found in patients with peripherally located tumors, although 4 patients developed distant metastasis. Kaplan-Meier curves for patients with conventional histologic subtype tumors demonstrated a statistically significant difference for local recurrence (P ϭ 0.04), but not for survival (P ϭ 0.71). The mean follow-up time was 38.8 and 43.8 months for patients with centrally located and peripherally located tumors, respectively. Conclusions. NSS can be used to postpone, or eliminate the need for, nephrectomy in 94.3% of patients with centrally located tumors and can achieve oncologic disease control similar to that for exophytic lesions.