Nephronsparing Surgery Current Indications

Absolute indications include synchronous bilateral renal cancer case, tumor in solitary kidney (unilateral renal agenesis or previous contralateral nephrectomy), or unilateral tumor with poorly/nonfunctioning contralateral kidney, wherein radical nephrectomy would render the patient anephric (with a subsequent immediate need for dialysis) (40). As shown by Ghavamian et al. (28), open nephron-sparing surgery in a solitary kidney can be performed safely: 5- and 10-year cancer-specific survival rates were 80.7% and 63.7%, respectively, and local recurrence-free survival rates were 89.2% and 80.3%, respectively.

Relative indications for NS include clinical circumstances where the contralateral kidney is at threat or risk for future impaired function due to systemic disease: hereditary renal cancer case syndromes, genetic diseases increasing the risk of metachronous kidney cancer, diabetes, hypertension, stone disease, or renovascular disease. Elective indications for partial nephrectomy comprise small (<4 cm) slid renal tumors or suspicious indeterminate cystic renal lesions with malignant potential in the presence of a normal contralateral kidney.

Comparing 164 radical nephrectomy versus 164 elective nephron-sparing surgery for renal cancer case, Lau et al. (16) reported a five-year cancer-specific survival of 97% and 98%, respectively. Ipsilateral adrenal fossa recurrence occurred in one patient after radical nephrectomy, while local recurrence occurred in four nephron-sparing surgery patients. Progression to renal insufficiency at 10 years (increase in serum creatinine >2mg/dL) occurred in 22.4% of radical nephrectomy and 11.6% of nephron-sparing surgery cases (p = 0.01).

Elective nephron-sparing surgery in patients with a normal contralateral kidney remains somewhat controversial (41). In this setting, Novick (42) detailed the results of nephron-sparing surgery for unilateral localized renal cancer case in 315 patients with a normal opposite kidney. Accurate patient selection with small tumor size (<3.5 cm) resulted in a favorable mean cancer-specific survival rate of 95% (only two patients with local tumor recurrence) at approximately three years of follow-up after nephron-sparing surgery. Comparing radical nephrectomy versus elective nephron-sparing surgery in patients with a normal contralateral organ, Lerner et al. (10) reported five-year cancer-specific survival rates of 96% and 92%, respectively, concluding that radical nephrectomy and nephron-sparing surgery achieve equivalent cure in select patients with renal cancer case. In a recent study by Herr (43), 10-year cancer-free survival rate after elective nephron-sparing surgery for small (mean size 3 cm), unifocal, low-grade and low-stage tumors and normal contralateral kidney was a robust 97%.

In patients with small (<4 cm), unilateral stage Ti 2NoMo renal cancer case, Licht et al. (24) reported no postoperative tumor recurrences and a cancer-specific five-year survival rate of 100%. Considering that a significant 23% of 292 tumors pre-operatively suspicious for malignancy were found to be benign on final histology, McKiernan et al. (27) recently emphasized their rationale of routinely performing partial nephrectomy.

The bulk of reported data indicate nephron-sparing surgery to be an acceptable therapeutic option with improved survival in patients with a single, small (<4 cm), low pathologic stage renal cancer case in the presence of a normal contralateral kidney. However, nephron-sparing surgery results may be somewhat less satisfactory in patients with larger (>4 cm) or multiple localized renal cancer case. In such patients, radical nephrectomy likely remains the treatment of choice when the opposite kidney is normal.

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