Nephron-sparing treatments remain underutilized for the management of small renal masses despite a rise in incidentally detected renal cell carcinoma and a downward stage migration.
Methods
Historical publications representative of currently accepted paradigms were reviewed, and the results of a contemporary scientific literature search conducted in PubMed focusing on studies involving humans, published in English, and inclusive of clinical trials, meta-analyses, randomized controlled trials, and practice guidelines are included. Results from contemporary retrospective trials augment the data when level I or II evidence is absent.
Results
Phase III clinical trial results substantiate the long-held tenet that partial nephrectomy is equivalent to radical nephrectomy with respect to safety and oncologic efficacy. Further, minimally invasive techniques using laparoscopy and robotic assistance to achieve partial nephrectomy appear equally effective to traditional open techniques. Although no prospective randomized studies are available, large retrospective studies support the notion that active surveillance and thermal ablative techniques are viable options for carefully selected patients.
Conclusions
The management of small renal masses encompasses a host of therapeutic options, all of which must be considered and discussed with the individual patient.
References
1.
JemalA., SiegelR., XuJ.. Cancer statistics, 2010.CA Cancer J Clin.2010; 60(5): 277–300.
2.
HollingsworthJ.M., MillerD.C., DaignaultS.. Rising incidence of small renal masses: a need to reassess treatment effect.J Natl Cancer Inst.2006; 98(18): 1331–1334.
3.
KaneC.J., MallinK., RitcheyJ.. Renal cell cancer stage migration: analysis of the National Cancer Data Base.Cancer.2008; 113(1): 78–83.
4.
ChowW.H., DevesaS.S., WarrenJ.L.. Rising incidence of renal cell cancer in the United States.JAMA.1999; 281(17): 1628–1631.
5.
HockL.M., LynchJ., BalajiK.C.. Increasing incidence of all stages of kidney cancer in the last 2 decades in the United States: an analysis of surveillance, epidemiology and end results program data.J Urol.2002; 167(1): 57–60.
6.
HollenbeckB.K., TaubD.A., MillerD.C.. National utilization trends of partial nephrectomy for renal cell carcinoma: a case of underutilization?Urology.2006; 67(2): 254–259.
7.
CampbellS.C., NovickA.C., BelldegrunA.. Guideline for management of the clinical T1 renal mass.J Urol.2009; 182(4): 1271–1279.
8.
ChenD.Y., UzzoR.G.. Evaluation and management of the renal mass.Med Clin North Am.2011; 95(1): 179–189.
9.
LjungbergB., CowanN.C., HanburyD.C.. EAU guidelines on renal cell carcinoma: the 2010 update.Eur Urol.2010; 58(3): 398–406.
10.
LeveridgeM.J., FinelliA., KachuraJ.R.. Outcomes of small renal mass needle core biopsy, nondiagnostic percutaneous biopsy, and the role of repeat biopsy.Eur Urol.2011; 60(3): 578–584.
11.
VolpeA., MattarK., FinelliA.. Contemporary results of percutaneous biopsy of 100 small renal masses: a single center experience.J Urol.2008; 180(6): 2333–2337.
12.
KutikovA., FossettL.K., RamchandaniP.. Incidence of benign pathologic findings at partial nephrectomy for solitary renal mass presumed to be renal cell carcinoma on preoperative imaging.Urology.2006; 68(4): 737–740.
13.
SchmidbauerJ., RemziM., MemarsadeghiM.. Diagnostic accuracy of computed tomography-guided percutaneous biopsy of renal masses.Eur Urol.2008; 53(5): 1003–1011.
LaneB.R., BabineauD., KattanM.W.. A preoperative prognostic nomogram for solid enhancing renal tumors 7 cm or less amenable to partial nephrectomy.J Urol.2007; 178(2): 429–434.
16.
WangH.K., ZhuY., YaoX.D.. External validation of a nomogram using RENAL nephrometry score to predict high grade renal cell carcinoma.J Urol.2012; 187(5): 1555–1560.
17.
RobsonC.J.. Radical nephrectomy for renal cell carcinoma.J Urol.1969; 89: 37–42.
18.
LaneB.R., TiongH.Y., CampbellS.C.. Management of the adrenal gland during partial nephrectomy.J Urol.2009; 181(6): 2430–2437.
19.
KutikovA., PiotrowskiZ.J., CanterD.J.. Routine adrenalectomy is unnecessary during surgery for large and/or upper pole renal tumors when the adrenal gland is radiographically normal.J Urol.2011; 185(4): 1198–1203.
20.
O'MalleyR.L., GodoyG., KanofskyJ.A.. The necessity of adrenalectomy at the time of radical nephrectomy: a systematic review.J Urol.2009; 181(5): 2009–2017.
21.
BlomJ.H., van PoppelH., MarechalJ.M.. Radical nephrectomy with and without lymph-node dissection: final results of European Organization for Research and Treatment of Cancer (EORTC) randomized phase 3 trial 30881.Eur Urol.2009; 55(1): 28–34.
22.
HarmonM., ed. TNM Classification of Malignant Tumours.Geneva, Switzerland: UICC, International Union Against Cancer; 1978.
23.
WhitsonJ.M., HarrisC.R., ReeseA.C.. Lymphadenectomy improves survival of patients with renal cell carcinoma and nodal metastases.J Urol.2011; 185(5): 1615–1620.
24.
PantuckA.J., ZismanA., DoreyF.. Renal cell carcinoma with retroperitoneal lymph nodes: role of lymph node dissection.J Urol.2003; 169(6): 2076–2083.
PareekG., HedicanS.P., GeeJ.R.. Meta-analysis of the complications of laparoscopic renal surgery: comparison of procedures and techniques.J Urol.2006; 175(4): 1208–1213.
27.
LuoJ.H., ZhouF.J., XieD.. Analysis of long-term survival in patients with localized renal cell carcinoma: laparoscopic versus open radical nephrectomy.World J Urol.2010; 28(3): 289–293.
LichtM.R., NovickA.C.. Nephron sparing surgery for renal cell carcinoma.J Urol.1993; 149(1): 1–7.
30.
WinfieldH.N., DonovanJ.F., GodetA.S.. Laparoscopic partial nephrectomy: initial case report for benign disease.J Endourol.1993; 7(6): 521–526.
31.
GoA.S., ChertowG.M., FanD.. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.N Engl J Med.2004; 351(13): 1296–1305.
32.
HuangW.C., ElkinE.B., LeveyA.S.. Partial nephrectomy versus radical nephrectomy in patients with small renal tumors: is there a difference in mortality and cardiovascular outcomes?J Urol.2009; 181(1): 55–62.
33.
ThompsonR.H., BoorjianS.A., LohseC.M.. Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared with partial nephrectomy.J Urol.2008; 179(2): 468–473.
34.
PatardJ.J., PantuckA.J., CrepelM.. Morbidity and clinical outcome of nephron-sparing surgery in relation to tumour size and indication.Eur Urol.2007; 52(1): 148–154.
35.
GillI.S., KavoussiL.R., LaneB.R.. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors.J Urol.2007; 178(1): 41–46.
36.
PierorazioP.M., PatelH.D., FengT.. Robotic-assisted versus traditional laparoscopic partial nephrectomy: comparison of outcomes and evaluation of learning curve.Urology.2011; 78(4): 813–819.
37.
MarszalekM., ChromeckiT., Al-AliB.M.. Laparoscopic partial nephrectomy: a matched-pair comparison of the transperitoneal versus the retroperitoneal approach.Urology.2011; 77(1): 109–113.
38.
BenwayB.M., BhayaniS.B., RogersC.G.. Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes.J Urol.2009; 182(3): 866–872.
39.
SpanaG., HaberG.P., DulabonL.M.. Complications after robotic partial nephrectomy at centers of excellence: multi-institutional analysis of 450 cases.J Urol.2011; 186(2): 417–421.
40.
DulabonL.M., KaoukJ.H., HaberG.P.. Multi-institutional analysis of robotic partial nephrectomy for hilar versus nonhilar lesions in 446 consecutive cases.Eur Urol.2011; 59(3): 325–330.
41.
HerrH.W.. Partial nephrectomy for unilateral renal carcinoma and a normal contralateral kidney: 10-year followup.J Urol.1999; 161(1): 33–35.
42.
FerganyA.F., HafezK.S., NovickA.C.. Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year followup.J Urol.2000; 163(2): 442–445.
43.
Van PoppelH., Da PozzoL., AlbrechtW.. A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma.Eur Urol.2007; 51(6): 1606–1615.
44.
Van PoppelH., Da PozzoL., AlbrechtW.. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma.Eur Urol.2011; 59(4): 543–552.
45.
GettmanM.T., BluteM.L., ChowG.K.. Robotic-assisted laparoscopic partial nephrectomy: technique and initial clinical experience with DaVinci robotic system.Urology.2004; 64(5): 914–918.
RodriguezA.R., HakkyT., SpiessP.E.. Laparo-endoscopic single site retroperitoneal partial nephrectomy: a novel concept.Int Braz J Urol.2011; 37(1): 136–137.
48.
MirS.A., CadedduJ.A., SleeperJ.P.. Cost comparison of robotic, laparoscopic, and open partial nephrectomy.J Endourol.2011; 25(3): 447–453.
49.
OrvietoM.A., ZornK.C., MendiolaF.. Recovery of renal function after complete renal hilar versus artery alone clamping during open and laparoscopic surgery.J Urol.2007; 177(6): 2371–2374.
50.
GongE.M., ZornK.C., OrvietoM.A.. Artery-only occlusion may provide superior renal preservation during laparoscopic partial nephrectomy.Urology.2008; 72(4): 843–846.
51.
NguyenM.M., GillI.S.. Halving ischemia time during laparoscopic partial nephrectomy.J Urol.2008; 179(2): 627–632.
52.
EisenbergM.S., PatilM.B., ThangathuraiD.. Innovations in laparoscopic and robotic partial nephrectomy: a novel “zero ischemia” technique.Curr Opin Urol.2011; 21(2): 93–98.
WardJ.P.. Determination of the optimum temperature for regional renal hypothermia during temporary renal ischaemia.Br J Urol.1975; 47(1): 17–24.
55.
NovickA.C.. Renal hypothermia: in vivo and ex vivo.Urol Clin North Am.1983; 10(4): 637–644.
56.
GillI.S., AbreuS.C., DesaiM.M.. Laparoscopic ice slush renal hypothermia for partial nephrectomy: the initial experience.J Urol.2003; 170(1): 52–56.
57.
WeldK.J., KoziolS., MontiglioC., SorensonP., CespedesR.D., BishoffJ.T.. Feasibility of laparoscopic renal cooling with near-freezing saline irrigation delivered with a standard irrigator aspirator.Urology.2007; 69(3): 465–468.
CrainD.S., SpencerC.R., FavataM.A.. Transureteral saline perfusion to obtain renal hypothermia: potential application in laparoscopic partial nephrectomy.JSLS.2004; 8(3): 217–222.
62.
La RochelleJ., ShuchB., RiggsS.. Functional and oncological outcomes of partial nephrectomy of solitary kidneys.J Urol.2009; 181(5): 2037–2043.
63.
BeckerF., Van PoppelH., HakenbergO.W.. Assessing the impact of ischaemia time during partial nephrectomy.Eur Urol.2009; 56(4): 625–634.
64.
RussoP.. Partial nephrectomy for renal cancer: part I.BJU Int.2010; 105(9): 1206–1220.
65.
LaneB.R., RussoP., UzzoR.G.. Comparison of cold and warm ischemia during partial nephrectomy in 660 solitary kidneys reveals predominant role of nonmodifiable factors in determining ultimate renal function.J Urol.2011; 185(2): 421–427.
66.
FicarraV., NovaraG., SeccoS.. Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery.Eur Urol.2009; 56(5): 786–793.
67.
SimmonsM.N., ChingC.B., SamplaskiM.K., ParkC.H., GillI.S.. Kidney tumor location measurement using the C index method.J Urol.2010; 183(5): 1708–1713.
68.
KutikovA., UzzoR.G.. The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth.J Urol.2009; 182(3): 844–853.
69.
KollaS.B., SpiessP.E., SextonW.J.. Interobserver reliability of the RENAL nephrometry scoring system.Urology.2011; 78(3): 592–594.
70.
OkhunovZ., Rais-BahramiS., GeorgeA.K.. The comparison of three renal tumor scoring systems: C-index, p.a.d.u.a., and R.e.N.a.L. nephrometry scores.J Endourol.2011; 25(12): 1921–1924.
71.
CanterD., KutikovA., ManleyB.. Utility of the R.E.N.A.L. nephrometry scoring system in objectifying treatment decision-making of the enhancing renal mass.Urology.2011; 78(5): 1089–1094.
72.
ChaE.K., NgC.K., JeunB.. Preoperative radiographic parameters predict long-term renal impairment following partial nephrectomy.World J Urol.2011. [Epub ahead of print].
73.
BuetheD., MousslyS., LinH.. Is the R.E.N.A.L. nephrometry scoring system predictive of the functional efficacy of nephron-sparing surgery in the solitary kidney?J Urol.2012; 188(3): 729–735.
74.
BensalahK., PantuckA.J., Rioux-LeclercqN.. Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery.Eur Urol.2010; 57(3): 466–471.
BernhardJ.C., PantuckA.J., WallerandH.. Predictive factors for ipsilateral recurrence after nephron-sparing surgery in renal cell carcinoma.Eur Urol.2010; 57(6): 1080–1086.
77.
del CuraJ.L., ZabalaR., IriarteJ.I.. Treatment of renal tumors by percutaneous ultrasound-guided radiofrequency ablation using a multitined electrode: effectiveness and complications.Eur Urol.2010; 57(3): 459–465.
78.
FerakisN., BouropoulosC., GranitsasT.. Long-term results after computed-tomography-guided percutaneous radiofrequency ablation for small renal tumors.J Endourol.2010; 24(12): 1909–1913.
79.
LewinJ.S., NourS.G., ConnellC.F.. Phase II clinical trial of interactive MR imaging-guided interstitial radiofrequency thermal ablation of primary kidney tumors: initial experience.Radiology.2004; 232(3): 835–845.
80.
StromK.H., DerweeshI., StroupS.P.. Second prize: Recurrence rates after percutaneous and laparoscopic renal cryoablation of small renal masses: does the approach make a difference?J Endourol.2011; 25(3): 371–375.
CooperI.S., LeeA.S.. Cryostatic congelation: a system for producing a limited, controlled region of cooling or freezing of biologic tissues.J Nerv Ment Dis.1961; 133: 259–263.
GageA.A., BaustJ.. Mechanisms of tissue injury in cryosurgery.Cryobiology.1998; 37(3): 171–186.
86.
HwangJ.J., WaltherM.M., PautlerS.E.. Radio frequency ablation of small renal tumors:: intermediate results.J Urol.2004; 171(5): 1814–1818.
87.
SchulmanC., ZlottaA.. Transurethral needle ablation of the prostate (TUNA): pathological, radiological and clinical study of a new office procedure for treatment of benign prostatic hyperplasia using low-level radiofrequency energy.Arch Esp Urol.1994; 47(9): 895–901.
88.
ZlottaA.R., WildschutzT., RavivG.. Radiofrequency interstitial tumor ablation (RITA) is a possible new modality for treatment of renal cancer: ex vivo and in vivo experience.J Endourol.1997; 11(4): 251–258.
89.
TracyC.R., RamanJ.D., DonnallyC.. Durable oncologic outcomes after radiofrequency ablation: experience from treating 243 small renal masses over 7. 5 years.Cancer.2010; 116(13): 3135–3142.
90.
ZagoriaR.J., PettusJ.A., RogersM.. Long-term outcomes after percutaneous radiofrequency ablation for renal cell carcinoma.Urology.2011; 77(6): 1393–1397.
91.
JiC., LiX., ZhangS.. Laparoscopic radiofrequency ablation of renal tumors: 32-month mean follow-up results of 106 patients.Urology.2011; 77(4): 798–802.
92.
ChalasaniV., MartinezC.H., LimD.. Surgical cryoablation as an option for small renal masses in patients who are not ideal partial nephrectomy candidates: intermediate-term outcomes.Can Urol Assoc J.2010; 4(6): 399–402.
93.
KunkleD.A., UzzoR.G.. Cryoablation or radiofrequency ablation of the small renal mass: a meta-analysis.Cancer.2008; 113(10): 2671–2680.
94.
Abou YoussifT., KassoufW., SteinbergJ.. Active surveillance for selected patients with renal masses: updated results with long-term follow-up.Cancer.2007; 110(5): 1010–1014.
95.
AbouassalyR., LaneB.R., NovickA.C.. Active surveillance of renal masses in elderly patients.J Urol.2008; 180(2): 505–509.
96.
CrispenP.L., WongY.N., GreenbergR.E.. Predicting growth of solid renal masses under active surveillance.Urol Oncol.2008; 26(5): 555–559.
97.
HaramisG., MuesA.C., RosalesJ.C.. Natural history of renal cortical neoplasms during active surveillance with follow-up longer than 5 years.Urology.2011; 77(4): 787–791.
98.
JewettM.A., MattarK., BasiukJ.. Active surveillance of small renal masses: progression patterns of early stage kidney cancer.Eur Urol.2011; 60(1): 39–44.
99.
MasonR.J., AbdolellM., TrottierG.. Growth kinetics of renal masses: analysis of a prospective cohort of patients undergoing active surveillance.Eur Urol.2011; 59(5): 863–867.
100.
KoubaE., SmithA., McRackanD.. Watchful waiting for solid renal masses: insight into the natural history and results of delayed intervention.J Urol.2007; 177(2): 466–470.
101.
ChawlaS.N., CrispenP.L., HanlonA.L.. The natural history of observed enhancing renal masses: meta-analysis and review of the world literature.J Urol.2006; 175(2): 425–431.
