Dr. med. Dirk Manski

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Partial Nephrectomy for Renal Cell Carcinoma

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:

Elective indications for partial nephrectomy:

Current guidelines prefer partial nephrectomy over radical 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:

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 depends on the appearance of distant metastases, which most often arise without local recurrence.

Oncological results after partial nephrectomy as a function of tumor size: 5- and 10-years cancer-specific survival rates (Hafez et al, 1999).
Tumor size 5-years survival 10-years survival
T1a (<4cm) 96% 90%
T1b (>4cm) 86% 66%

Follow-up after partial nephrectomy:

After R1 resection or minimal safety margin, an abdominal CT three months after surgery is useful to document postoperative alterations. Follow-up after partial nephrectomy should be done depending on symptoms and the likelihood of metastasis. The probability of metastasis can be assessed using the Stage, Size, Grade, and Necrosis (SSIGN) score (Assessing SSIGN Score and Survival and SSIGN Score).

Experimental therapy for localized renal cell carcinoma

Cryotherapy, radiofrequency ablation or active surveillance are options for selected patients. Biopsy of the renal mass to ensure malignancy is recommended before invasive treatment with complications up to 20%. All options lack long-term results.

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 or if the tumor diameter exceeds 3–4 cm.

Renal tumor pathology in relation of tumor size: in addition, the proportion of poorly differentiated tumors of the malignant tumors is given (Frank et al, 2003).
Tumor size [cm] Benign tumors [%] Malignant tumors [%] High grade RCC [%]
0 to 0.9 46 54 9
1 to 1.9 22 78 11
2 to 2.9 22 78 7
3 to 3.9 20 80 19
4 to 4.9 10 90 22
5 to 5.9 13 87 31
6 to 6.9 5 95 39
>7 6 94 62

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