Analysis Suggests Partial Nephrectomy Is New Gold Standard for Small Renal Masses

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Although partial nephrectomy may be more technically challenging, it should now be considered the gold-standard technique in the treatment of small renal masses.
Although partial nephrectomy may be more technically challenging, it should now be considered the gold-standard technique in the treatment of small renal masses.

While partial nephrectomy (PN) may be more technically challenging, it should now be considered the gold-standard surgical technique in the treatment of small renal masses, according to Italian researchers.1

A recent review article suggested that in the current era it is time for open partial nephrectomy (OPN) to be considered as a possible treatment only at medium-volume centers with less experience in laparoscopic and robotic procedures or at locations where cost issues prevent it.

Otherwise, they report that it is “not ethical” for patients to undergo radical surgery simply because the urologists do not have adequate experience with PN or have concerns about their ability to manage potential complications associated with PN.

The researchers conducted a review of 94 studies that were published between January 1980 and December 2014. The studies were found using PubMed/MEDLINE and EBASE databases and studies were excluded if they were single case reported or meeting abstracts and conference proceedings.

The investigators reported that this is the first comprehensive study to review the various surgical techniques of PN and it should serve as guidance in this new era of surgical treatment of renal masses.

“At present time, nephron-sparing surgery represents undoubtedly the gold standard for treatment of limited dimension renal tumors. Renal function preservation as well as optimal oncological control are the cornerstones of this minimally invasive surgical approach” said lead study author Mauro Seveso, MD, of Humanitas Research Hospital Mater Domini Castellanza in Italy.

“Laparoscopic partial nephrectomy (LPN) and robotic assisted partial nephrectomy (RPN), and OPN still play a role in perihilar renal tumors as well as in the presence of contraindications (severe cardiovascular diseases or pneumological disorders). However, in my opinion every effort should be made by the urology community to enter into the new era of minimally invasive surgery for renal cancers.”

Dr. Seveso said PN in the past was reserved for only the essential indications of a renal tumor in terms of an anatomical or functional solitary kidney.

The researchers reported that has changed and LPN and RPN now represent the combined benefits of minimally invasive surgery with a quicker recovery and nephron-sparing surgery. For these reasons, the authors believe PN should now be appointed the gold-standard procedure.

Over the past decade, there has been a paradigm shift in how most renal masses are detected and treated. Dr. Seveso said that the current data suggest that up to 40% of small tumors are incidentally detected due to routine use of ultrasound, computed tomography, and magnetic resonance imaging.

The management of small localized renal tumors has evolved as this trend has continued and studies have shown oncological equivalence of PN compared with robotic nephrectomy for stage 1 lesions.

This new review has found that studies overall demonstrated that PN confers better survival, oncologic equivalence, and lower risk of severe chronic kidney disease compared to radical nephrectomy for the treatment of T1a tumors.

However, there is still considerable controversy surrounding the treatment of stage T1b tumors (4 to 7 cm) secondary to the small risk of local recurrence (4% to 6%) and multifocality (5% to 6%), according to the researchers. For this reason, they believe that careful selection of patients with T1b stage patients is mandatory.

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“The future of conservative renal surgery will be characterized by progressive diffusions of these techniques even in non- tertiary hospitals, due to a surgeon's expertise improvement despite a complex learning curve in laparoscopic and robotic approaches as well as cost reductions,” Dr. Seveso told Cancer Therapy Advisor

“Parallel imaging techniques improvement will facilitate this choice. At that point, OPN will be comparable to open cholecystectomy.”

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