Nephron-Sparing Surgery: Some Considerations Regarding an Underused Standard of Care

Abstract

Radical nephrectomy (RN), which includes nephrectomy with the perinephric fat and ipsilateral adrenalectomy, had been considered the standard of care of renal tumors. The concept was challenged in the 1980 s by favorable results with partial nephrectomy (PN) in imperative situations [1]. Nephron-sparing surgery (NSS) is considered imperative when the contralateral kidney is anatomically or functionally absent or when there is overall impairment of renal function such that an RNwill drive the patient immediately or in the short term to end-stage renal disease. In the 1990 s, when the widespread use of routine body imaging led to a greater number of small renal masses being diagnosed, elective PN became the preferred treatment for such masses. It had been demonstrated extensively that PN provides excellent survival and recurrence rates comparable to those achieved with RN for tumors 4 cm. Consequently, 4 cm became the accepted cutoff for electively treating renal masses with NSS and the threshold for splitting stage 1 into T1a and T1b. The concept of a cut-off for size has been challenged subsequently, following proof that the risk of dying from stage T1b cancer is increased for both RN and PN patients [2]. Mortality would be inherent to tumor histology rather than to the surgical approach, suggesting that the indication for NSS be expanded to renal masses 4–7 cm in size. Once it was proved that cancer-specific survival (CSS) in selected cases was not worse, several reports indicated that, due to better preservation of renal function, NSS resulted in improved overall survival (OS) when compared with RN [3,4].