Is radical nephrectomy a legitimate therapeutic option in patients with renal masses amenable to nephron‐sparing surgery?

Abstract

The decision to perform a radical nephrectomy (RN) or a partial nephrectomy (PN), not unlike most decisions in clinical practice, ultimately hinges on the balance of risk. Do the higher risks of a more complex surgery (PN) justify the theoretical benefits of kidney tissue preservation? Data suggest that for patients with an anatomically complex renal mass and a normal contralateral kidney, for whom additional surgical intensity may be risky, such as the elderly and comorbid, RN presents a robust treatment option. Nevertheless, PN, especially for small and anatomically simple renal masses in young patients without comorbidities should remain the surgical reference standard, as preservation of renal tissue can serve as an ‘insurance policy’ not only against future renal functional decline, but also against the possibility of tumour development in the contralateral kidney. In the present review, we outline the ongoing debate between the role of RN and PN in treatment of the enhancing renal mass.

Age at diagnosis and the surgical management of small renal carcinomas: findings from a cross‐sectional population‐based study

“…Survival analyses that focused on data only for RCC cases found no difference between treatment arms . Findings from observational studies and matched case–control studies have suggested greater benefits of PN both in terms of kidney function and survival ; however, concerns regarding the quality of the RCT and the non‐randomized nature of observational studies have created some controversy regarding the role of PN in the treatment of small renal tumours . Queensland clinicians’ lower endorsement of PN as the treatment of choice for all T1a tumours may reflect the lack of certainty regarding the benefits of PN, particularly for older patients.…”

“…This may reflect a lack of randomized controlled trials (RCTs) specifically examining the best treatment approach for older patients. Also, some consider that, for older patients with shorter life expectancy, the renal function benefits of PN compared with RN are unlikely to offset the potential increased risk of peri‐operative complications of PN . Increased use of laparoscopic surgery may also influence surgical decisions for older patients.…”

Retrospective Comparison of Cardiovascular Risk in Preselected Patients Undergoing Kidney Cancer Surgery: Reflection of Reality or Simply What We Want to Hear?

“…The study underscores the urologic community's strong belief that NSS benefits our patients and that unnecessary RN should be avoided, especially in patients with T1a tumors [9]. Nevertheless, the study should also serve as a catalyst for our community to rekindle interest in the proposal of Campbell and colleagues for a prospective randomized trial of RN versus PN in patients with 4-to 10-cm renal masses [10].…”

“…Despite its significant limitations, the study by Capitanio et al [1] is noteworthy because it continues to keep the debate about RN versus PN at the forefront of urologic academic discourse [9]. The study underscores the urologic community's strong belief that NSS benefits our patients and that unnecessary RN should be avoided, especially in patients with T1a tumors [9].…”

Survival benefit of partial nephrectomy: Reconciling experimental and observational data

“…As such, this study has prompted some to voice skepticism concerning instrumental variable analysis [30,31]. As alluded earlier, a key, but easily overlooked, consideration with instrumental variables arises from the type of effect measured; instrumental variable analysis estimates the marginal treatment effect, whereas randomized controlled trials measure the average treatment effect.…”