Abstract
Historically, radical nephrectomy represented the gold standard for the treatment of small (≤ 4cm) as well as larger renal masses. Recently, for small renal masses, the risk of ensuing chronic kidney disease and end stage renal disease has largely favored nephron-sparing surgical techniques, mainly partial nephrectomy. In this review, we surveyed the literature on renal functional outcomes after partial nephrectomy for renal tumors. The largest randomized control trial comparing radical and partial nephrectomy failed to show a survival benefit for partial nephrectomy. With regards to overall survival, surgically induced chronic kidney disease (GFR < 60 ml/min/ 1.73m2) caused by nephrectomy might not be as deleterious as medically induced chronic kidney disease. In evaluating patients who underwent donor nephrectomy, transplant literature further validates that surgically induced reductions in GFR may not affect patient survival, unlike medically induced GFR declines. Yet, because patients who present with a renal mass tend to be elderly with multiple comorbidities, many develop a mixed picture of medically, and surgically-induced renal disease after extirpative renal surgery. In this population, we believe that nephron sparing surgery optimizes oncological control while protecting renal function.
Highlights
Renal lesions can be classified as malignant, benign, or inflammatory.Inflammatory renal lesions may mimic malignant renal lesions on imaging and include infection, inflammation, or trauma induced lesions [1].Of the noninflammatory cases, benign masses compose approximately 13% of newly diagnosed lesions such as oncocytomas and angiomyolipomas; the rest renal cell carcinoma [2]
The first documented radical nephrectomy was completed for the treatment of renal cell carcinoma in 1963 [10]
In a retrospective study of 290 patients with small renal masses (SRM) < 4 cm, McKiernan, et al showed that 5-year freedom from chronic renal insufficiency, which was defined as a creatinine of > 2 mg/mL, was 100% in the partial nephrectomy (PN) group and 84.6%% in the radical nephrectomy (RN) group [27]
Summary
Renal lesions can be classified as malignant, benign, or inflammatory. Inflammatory renal lesions may mimic malignant renal lesions on imaging and include infection, inflammation, or trauma induced lesions [1]. A retrospective study by Kaushik and colleagues evaluated patients undergoing RN or PN for a benign renal mass, which eliminates the confounder of malignancy in the survival equation They demonstrated that overall survival at ten years was 69% for RN and 80% for PN, with a decreased risk of CKD in the PN group in comparison to RN group [31]. Ibrahim and colleagues evaluated the incidence of ESRD after unilateral donor nephrectomy and found that 14.5% of their cohort developed CKD with a GFR of less than 60 ml/min/ 1.73m2 at most recent follow up They noted a higher than expected incidence of hypertension and albuminuria, but overall survival did not differ between kidney donors and matched non-donors [61]. While surgically induced CKD seems to be a separate entity with different mortality rates, the literature currently makes little or no distinction
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