The Indications for Partial Nephrectomy in the Treatment of Renal Cell Carcinoma

Steven Joniau; Kathy Vander Eeckt; Hein Van Poppel

Disclosures

Nat Clin Pract Urol. 2006;3(4):198-205. 

In This Article

Indications for Nephron-sparing Surgery

Standard indications for NSS fall into three categories: absolute or imperative, relative, and elective.[5,6,7,8]

Absolute Indications

Absolute indications include circumstances in which RN would render the patient anephric, with a consequent immediate need for renal replacement therapy. Patients with an anatomically or functionally solitary kidney, for example because of unilateral renal agenesis, previous contralateral nephrectomy or irreversible impairment of contralateral renal function from a benign disorder, have absolute indications for NSS.

Patients with bilateral RCC also have an absolute indication for NSS. As an attempt is made to preserve as much functional parenchyma as possible, a bilateral partial nephrectomy is indicated when feasible, usually starting with the less-involved side. When a partial nephrectomy is not possible on one side, a partial nephrectomy and an RN must be attempted, as separate procedures.

Relative Indications

Relative indications include those in which the contralateral kidney has pre-existing renal disease, or its future function is threatened. Patients that fall into this category might have conditions such as stone disease, chronic pyelonephritis, renal artery stenosis, vesicoureteral reflux (with or without renal scarring), chronic renal obstruction from congenital or acquired causes, or systemic diseases such as diabetes, hypertension and nephrosclerosis. The risks and benefits of NSS must be considered individually in such patients, because the age of the patient at the time of presentation, comorbidities and risk of disease progression might influence their remaining renal function. In patients with known tumor multifocality, such as patients with a papillary histology or hereditary forms of RCC (e.g. von Hippel-Lindau disease), partial nephrectomy is also important to preserve the renal function.

Elective Indications

Patients with elective indications include those with small, localized (often incidental) tumors, and a normal contralateral kidney. Table 1 shows the results of several studies on the outcomes of patients undergoing elective NSS for localized RCC. These reports demonstrate that partial nephrectomy can achieve survival rates comparable to that of RN for low-grade, low-stage RCC tumors of 4 cm diameter or smaller, with only few local recurrences ( Table 2 ).

As open NSS is a technically demanding procedure, most urologists consider that it is only a viable option for exophytic lesions.

Partial nephrectomy is a widely accepted treatment for RCC tumors of less than 4 cm in diameter (stage T1a), while the use of partial nephrectomy for patients with larger tumors (stage T1b) is more controversial. Several studies have demonstrated significantly better survival in patients undergoing partial nephrectomy for tumors of less than 4 cm in size, compared with patients undergoing the procedure for tumors larger than 4 cm.[9,10]

Large tumors (>4 cm), or those located centrally or in the vicinity of the renal hilus or pelvicaliceal system, can be managed by NSS in patients with absolute indications, but patients with these disease characteristics and elective indications should be selected very carefully. In those with elective indications, RN offers a definitive cure in the vast majority of patients.

The ideal indication for NSS in the presence of a normal contralateral kidney is, therefore, the presence of an easily resectable, small (4 cm diameter or less), solitary, exophytic renal tumor, in a patient who is not a candidate for surveillance, and whose medical condition is good enough to undergo surgery and to benefit from it. With increasing surgical experience, this ideal indication can be expanded to progressively more challenging cases, but NSS is not advocated to be performed for non-ideal indications in general urological practice. Instead, patients with larger or more complex tumors than those described above should be referred to surgeons or treatment centers that specialize in partial nephrectomy.

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