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

Disadvantages of Nephron-sparing Surgery

Tumor Recurrence in the Preserved Kidney

The major disadvantage of NSS for treating RCC is the risk of recurrence in the ipsilateral kidney (ipsilateral recurrence). The incidence of local recurrence is reported to be between 0% and 10%, but is lowest in patients who undergo elective NSS for low-stage lesions of less than 4 cm in diameter.[34,35] Ipsilateral recurrence is more often associated with tumor multifocality than with incomplete resection of the tumor that leaves positive surgical margins.[28,32,36,37]

In a review on the overall incidence of multifocality in RCC tumors, Uzzo and Novick[38] estimated the overall incidence of multifocality in renal tumors to be between 6.5% and 28%. Interestingly, the risk of multifocality in small tumors (<4 cm) was only 5%. More recently, Lang et al.[39] investigated the relationship between multifocality in renal tumors and other prognostic factors in 255 patients who were treated by RN. Study parameters were patient age and sex, the side of the affected kidney, tumor stage and grade, and the presence of capsular invasion, renal vein involvement and microvascular invasion. The authors concluded that there was a significant positive correlation between multifocality and capsular invasion, while no other parameters were correlated. Although the risk of multifocality must be considered when advising patients who are considering NSS, the exact relationship between multifocality and risk of recurrence is still unknown and requires further investigation.

Resection, with excision of a margin of 1 cm of normal-appearing parenchyma around the tumor, was considered to be the standard surgical technique in NSS.[5] Broad margins such as these, however, could compromise residual renal function. Li et al.[34] investigated the distance between extra-pseudocapsule lesions and primary tumors in 82 patients, in order to find the optimal surgical margin in NSS for RCC tumors of 4 cm or less in diameter. They reported that in tumors of this size, all of the extra-pseudocapsule lesions were located within 5 mm from the primary tumor. The authors concluded that in these patients, a surgical margin of 1 cm might be too large, and might result in excessive excision of parenchyma that could compromise subsequent renal function. Sutherland et al.[40] have shown that when a negative surgical margin was achieved, recurrence at the resection site was absent. Recurrence was independent of the width of the margin around the tumor. These results indicate that only a minimal margin of normal renal parenchyma (less than 5 mm) should be removed during partial nephrectomy for localized RCC. Ensuring that the margin is clear of tumor cells is more important than the width of the surgical margin.[41]

To avoid positive surgical margins, frozen-section biopsies of the tumor bed have been performed. One study of 301 patients who underwent NSS for tumors with a mean diameter of 3.6 cm analyzed frozen-section biopsies for the presence of tumor cells.[42] The authors concluded that the accuracy of frozen-section analysis is low, and that the results of such analyses have minimal clinical significance and should, therefore, not be incorporated in routine urologic practice.

Although the disease-specific and overall survival rates of patients undergoing NSS are comparable to those of patients undergoing RN, the presumed higher risk of postoperative local recurrence after NSS mandates a more-intensive surveillance than that proposed in the European Association of Urology guidelines.[43] Regular ultrasound and/or annual CT scan of both the ipsilateral and contralateral kidney is considered appropriate.

Complications and Morbidity Associated With Nephron-sparing Surgery

Another argument that was initially used against expanding the indications for NSS was the greater risk of complications with NSS compared with RN. Partial nephrectomy is a more complicated operation than RN. Hemorrhage is the most common complication, with an incidence between 0% and 5% in NSS.[44,45] Less-frequent complications include urinary leakage or fistula formation, renal artery thrombosis and acute renal failure.[46] In some of the early series examining outcomes of NSS a significant risk of complications was reported.[47] Stephenson et al.[48] recently reviewed the early complications of RN and partial nephrectomy in 1,049 patients. They concluded that NSS is not associated with a higher rate of postoperative complications compared to open RN. Although patients undergoing NSS experience more procedure-related complications, these are generally minor and include perirenal or intrarenal hemorrhage and urinary fistula that can, almost always, be managed by minimally invasive techniques.

Complications in patients undergoing open NSS are related to the level of experience the surgeon has with the procedure. Complications in these patients are rare, therefore, in experienced hands, and when they do occur they can mostly be managed conservatively.[46,49]

Laparoscopic partial nephrectomy is an emerging minimally invasive approach for the treatment of RCC. Gill et al.[24] compared the perioperative outcomes after laparoscopic and open NSS for patients with a tumor of 7 cm or less. Laparoscopic RN seems to result in significantly less blood loss, a shorter hospital stay and less postoperative analgesic use than open NSS.[50]

The laparoscopic approach had a longer renal warm-ischemia time compared with the open approach (27.8 min versus 17.5 min), and was associated with more frequent and more severe intraoperative complications (5% versus 0%) and more postoperative urological complications (11% versus 2%) than open NSS. The authors concluded that open partial nephrectomy still remains the standard technique for NSS.[50]

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