Nephronsparing Surgery Current Concepts

Five-year survival rates after radical nephrectomy for stage I (T^T,) renal cancer case are 75% or more (8). Risk of recurrence is increased in patients with advanced stage T and positive lymph nodes.

Whenever preservation of functioning renal parenchyma is an important concern, nephron-sparing surgery is the preferred substitute for radical nephrectomy. The goal of nephron-sparing surgery is two-fold: (i) oncologically complete tumor excision, and (ii) preservation of a well-functioning renal remnant. Cancer-specific survival rates after nephron-sparing surgery for small (<4 cm) renal cancer case are excellent (72-100%), and comparable to those obtained after radical nephrectomy (Table 1). At the same time, nephron-sparing surgery minimizes the risk of nephron loss (17).

Incidence of multifocal renal cancer case is 7-25%, with this incidence decreasing to 0-5% when the primary tumor is 4 cm or smaller in size. Risk of local recurrence after nephron-sparing surgery is less than 10% and is most likely a manifestation of previously undetected microscopic multifocal renal cancer case in the "normal" part of the kidney, i.e., the renal remnant (Table 2). Given concerns regarding renal cancer case mul-tifocality, skeptics have raised the specter of parenchyma-sparing surgery to be cancer-sparing surgery. However, no linear or predictable relationship between multifocality and local recurrence has been reported (29).

To minimize local recurrences after nephron-sparing surgery, tumor excision including an adequate margin of normal parenchyma is essential (30,31). What constitutes an oncologically adequate width of parenchymal margin has been addressed recently. Long-term follow-up data confirm that a negative margin for tumor on histology is the primary criterion, with margin width having no practical consequence. Castilla et al. (32) found no correlation between long-term disease progression and width of the resection margin at a mean follow-up of 8.5 years. Other authors reported appropriate and comparable cancer control without local recurrence with resection margins ranging from 1 to 5 mm (33-37). Although surgical margin width appears to be ultimately irrelevant, during laparoscopic partial nephrectomy a margin of approximately 0.5 cm is aimed for to prevent inadvertent compromise of tumor margins.

A randomized controlled trial comparing radical and partial nephrectomy for small (<4 cm) tumors showed similar median survival time at comparable follow-up (11). Belldegrun et al. (14) compared 146 patients undergoing nephron-sparing surgery for unilateral, solitary, or bilateral renal cancer case with a matched group of 125 patients who underwent radical nephrectomy for renal cancer case. In the partial nephrectomy group, survival in patients with T2 versus T1 lesions was 66% versus 100%, respectively (p < 0.001). Survival was comparable for patients with T1 renal cancer case treated with either radical nephrectomy or nephron-sparing surgery, while survival was significantly better in patients with T2 lesions treated with radical nephrectomy (p = 0.001). The authors concluded that nephron-sparing surgery benefits the select patient with localized unilateral renal cancer case less than 7 cm in size (ideally, <4 cm). In patients with renal cancer case <4 cm in size, Lee et al. (15) reported a five-year disease-free survival rate of 96% after nephron-sparing surgery and 96% after radical nephrectomy, with no local recurrence in each group.

In a study of sporadic localized renal cancer case in 485 patients treated with nephron-sparing surgery, Hafez et al. (25) reported a five-year cancer-specific survival of 93%, with an renal cancer case recurrence rate of 10% (3.2% local recurrence; 5.8% metastatic disease).

TABLE 1 ■ Studies Comparing Renal Nephrectomy Versus Nephron-Sparing Surgery for Localized Renal Cancer Cases

Radical nephrectomy

Nephron-sparing surgery

Author

% Cancer-specific Total no. of pts. 5-yr survival

% Cancer-specific Total no. of pts. 5-yr survival

42 209 21 71 48 125 183 164

97 89

46 185 19 35 41 146 79 164

D'Armiento et al. (11) Indudhara et al. (12) Barbalias et al. (13) Belldegrun et al. (14) Lee et al. (15)

Source: From Ref. 29.

TABLE2 ■ Local Recurrence After Nephreron-Sparing Surgery for Sporadic Renal Cancer Cases

Author

Total no. of pts.

No. LR (%)

No. isolated LR

No. LR + metastases

Jacobs et al. (18)

61

6 (10%)

5

1

Marberger et al. (19)

72

6 (8.3%)

3

3

Novick et al. (20)

100

9 (9%)

5

4

Morgan et al. (21)

104

6 (5.7%)

5

1

Steinbach et al. (22)

140

5 (3.6%)

5

0

Moll et al. (23)

142

2 (1.4%)

2

0

Licht et al. (24)

216

9 (4.2%)

3

6

Hafez et al. (25)

485

16 (3.2%)

7

9

Filipas et al. (26)

180

3 (1.7%)

3

0

McKiernan et al. (27)

292

7 (12%)

7

0

Ghavamian et al. (28)

76

7 (9.2%)

7

0

Source: From Ref. 8.

Reporting on a 10-year follow-up of patients treated with nephron-sparing surgery, Fergany et al. (38) documented cancer-specific survival of 88% at five and 73% at 10 years, respectively. Recurrences occurred locally (4%), at metastatic sites (21.5%), or combined (locally and distant metastases, in 6.5%). Cancer-specific survival in patients with unifocal, <4 cm tumor was 100% at 10 years with no local recurrence. Krejci and colleagues (39) documented a significantly inferior 10-year cancer-specific survival rate after nephron-sparing surgery for patients with clear cell renal cancer case compared to papillary/chromophobe renal cancer case (91.5% vs. 99%, p = 0.029). As such, these clinicopathologic features should be considered in preoperative decision-making, patient counseling, and surveillance.

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