What are the alternatives to radical nephrectomy in the treatment of renal cell carcinoma (RCC)?

Updated: Feb 05, 2019
  • Author: Richard A Santucci, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Nephron-sparing surgery (NSS) has become a successful alternative treatment to radical nephrectomy for RCC when a functioning renal parenchyma must be preserved, such as in patients with (1) bilateral RCC; (2) RCC involving a solitary functioning kidney; (3) chronic renal insufficiency; or (4) unilateral RCC with a functioning opposite kidney at risk for future impairment from an intercurrent disease, such as calculus disease, renal artery stenosis, diabetes, hypertension, or nephrosclerosis. Novick played an important role in establishing NSS, proving its efficacy and safety, and describing the ideal technique. [4]

Several studies have confirmed that NSS provides curative treatment that is as equally effective as radical nephrectomy in patients who have a single, small (< 4 cm in diameter), unilateral, localized RCC. NSS is also becoming increasingly recognized as effective treatment for small, select, incidentally discovered tumors, even when the contralateral kidney is normal. Recent reports suggest using NSS for tumors up to 7 cm in diameter, particularly for polar tumors that do not extend into the renal hilum.

The major disadvantage of NSS is the small risk (1-6%) of local tumor recurrence due to undetected microscopic multifocal RCC in the remnant of the operated kidney. Partial nephrectomy is also associated with a higher risk of bleeding and urine leak. Despite this higher complication rate, saving the normal nephrons in the kidney reduces the risk of impaired kidney function and its associated complications.

A study by Huang et al that described trends and outcomes in the management of small kidney cancers reported that the use of nephron-sparing surgery exceeds radical nephrectomy in patients who receive surgery. [5]

Laparoscopic partial nephrectomy is a new modality that is increasingly used. It offers faster convalescence than open partial nephrectomy. However, it is associated with a higher rates of positive margins, major intraoperative complications, and urologic complication rates. Laparoscopic partial nephrectomy should be reserved for patients with small exophytic tumors and should be performed by a well-trained laparoscopic urologist.


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