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Partial Nephrectomy for Renal Cell Carcinoma
- Renal cell carcinoma (1/8): Definition and Epidemiology
- Renal cell carcinoma (2/8): Etiology
- Renal cell carcinoma (3/8): Pathology
- Renal cell carcinoma (4/8): Signs and symptoms
- Renal cell carcinoma (5/8): Diagnostic work-up
- Renal cell carcinoma (6/8): Treatment with radical nephrectomy
- Renal cell carcinoma (7/8): Treatment with partial nephrectomy
- Renal cell carcinoma (8/8): Targeted therapy of advanced disease
Imperative indications for partial nephrectomy:
Partial nephrectomy is imperative, if radical nephrectomy would result in renal insufficiency requiring dialysis. If oncologically possible, partial nephrectomy is strongly indicated for:
- RCC in a single kidney
- Chronic kidney disease
- Bilateral tumors
- Familial renal tumors
- Known diseases with imminent future renal insufficiency (e.g. diabetes mellitus or renal artery stenosis).
Elective indications for partial nephrectomy:
If technically possible, organ-preserving partial nephrectomy should be performed for any T1 tumor. Retrospective comparisons between nephrectomy and partial nephrectomy for T1 tumors showed a better survival rate of patients after partial nephrectomy. This is explained with a reduction of cardiovascular disease due to better renal function (Zini et al, 2009) (Weight et al, 2010) (Sun et al, 2012). The randomized EORTC study (nephrectomy vs. partial nephrectomy) could not demonstrate this effect (van Poppel et al, 2011).
Surgical technique of partial nephrectomy:
In principle, open partial nephrectomy is done via a lumbar or, less often, via a transperitoneal access to the kidney. Vascular control is mandatory. Tumor excision is accomplished with or without the use of temporary ischemia, depending on tumor size and location. The safety margin to the tumor should be 5–10 mm, negative surgical margins are important. For technical details please refer to section open partial nephrectomy.
Favorable cases (peripheral small renal tumor) may be treated with laparoscopic partial nephrectomy. However, previous retrospective comparisons found a prolonged intraoperative ischemia and increased complications compared with open surgery (Gill et al, 2003). Patient selection is crucial for minimizing complications and long ischemia times. Robot-assisted laparoscopy is a promising tool to simplify and optimize the laparoscopic technique leading to better clinical results and to enable complex partial nephrectomy of central tumors.
Approach to bilateral renal cell carcinoma:
In the first step, the simpler partial nephrectomy is done first. This avoids requiring dialysis due to transient ischemia of a single kidney. After full recovery from surgery, the residual renal function is determined with renal scintigraphy. With sufficient residual renal function, complex or central contralateral tumors may be treated with radical nephrectomy. In case of insufficient residual renal function, imperative partial nephrectomy should be attempted, if oncologically possible.
Oncological results after partial nephrectomy:
The randomized EORTC study (radical nephrectomy vs. partial nephrectomy, n = 541) proofed the oncological safety of partial nephrectomy (van Poppel et al, 2011): only 12 of the 117 deaths were caused by advanced renal cell carcinoma (4 vs. 8). 21 patients experienced tumor progression (9 vs. 12). The oncological results are depending (comparable to radical nephrectomy) on the tumor stage, see Table oncological results after partial nephrectomy. Local recurrence after partial nephrectomy occurs between 1.4–10%, depending on the patient population and maximum tumor size. Survival after partial nephrectomy is determined for the major part of the patients by the appearance of distant metastases, which most often arise without local recurrence.
|Tumor size||5-years survival||10-years survival|
Follow-up after partial nephrectomy:
Renal cell carcinoma T1 N0 M0:
History, physical examination, laboratory (blood count, AP, calcium, liver enzymes, creatinine, urea, sodium, potassium) and ultrasound of the kidneys and liver annually.
Renal cell carcinoma T2 N0 M0:
History, physical examination, laboratory (blood count, AP, calcium, liver enzymes, creatinine, urea, sodium, potassium), ultrasound of the kidneys and chest x-ray annually. CT abdomen every 2 years.
Renal cell carcinoma T3 N0 M0:
History, physical examination, laboratory (blood count, AP, calcium, liver enzymes, creatinine, urea, sodium, potassium), ultrasound of the kidneys and chest x-ray every 6 month. CT abdomen annually. After three years, the examination intervalls are doubled.
Patient with symptoms:
Depending on symptoms, abdominal CT, chest CT, or bone scan are necessary.
Experimental therapy for localized renal cell carcinoma
Cryotherapy or radiofrequency ablation are options for selected patients. Both techniques are well tolerated, but lack long-term results. This also applies to the active monitoring of patients with high comorbidity.
Cryotherapy of renal cell carcinoma:
Percutaneous or laparoscopic application of repetitive freezing and thawing of the tumor tissue. Reliable cell destruction requires several freeze-thaw cycles with rapid freezing and gradual thawing. The frozen tissue is replaced by granulation tissue. There are several advantages for the laparoscopic cryotherapy: the mobilized kidney can be cooled better, the risk of injury of adjacent organs is minimized and there is a visual control of the "ice ball" in respect to the tumor margins.
Radiofrequency ablation of renal cell carcinoma:
Peripher tumors up to 5 cm can be treated with radiofrequency ablation. In comparison to cryotherapy, treatment monitoring is more difficult and experience in this new technique is limited.
Active surveillance for T1a renal cell carcinoma:
In case of severe comorbidity and advanced age, active surveillance is a treatment option for small renal tumors. If the tumor diameter less than 3 cm, 22–46% of renal tumors are benign. Only 10% of renal cell carcinomas are poorly differentiated [Table tumor pathology in relation of tumor size]. Active surveillance should be reconsidered if significant growth of the tumor is detected of if the tumor diameter exceeds 3–4 cm.
|RCC nephrectomy||Index||RCC M1 treatment|
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