Both partial and radical nephrectomy offer excellent oncological outcomes for organ confined kidney cancer.
EAU guidelines:
- Offer partial nephrectomy to patients with T1 tumours
- Do not perform lap nephrectomy in patients with T1 tumours if a partial nephrectomy is feasible by any approach (including open partial).
- Offer radical nephrectomy for T2 tumours and localised masses not treatable by partial
- Offer partial to patients with T2 tumours and a solitary kidney or CKD, if technically feasible
AUA guidelines:
- Prioritise partial nephrectomy for the management of cT1a mass when intervention is indicated
- Consider radical nephrectomy in patients where increased oncological potential is suggested by tumour size, biopsy or imaging characteristics
- Radical is preferred if high tumour complexity/partial would be challenging, no pre-existing CKD, and normal contra-lateral kidney with expected post-op eGFR > 45
Partial nephrectomy is accepted as standard of care in guidelines for clinical T1 renal masses when feasible. However, this remains somewhat controversial as the only RCT comparing the two failed to show significant benefit.
- Included masses < 5 cm, normal contra-lateral kidney
- Underpowered / failed to accrue
- Median follow up 9 years
- Higher rates of complications (bleeding, urine leak) in partial nephrectomy
- Higher rates of CKD (eGFR < 60 ml/min) in radical nephrectomy
- No difference in cancer specific survival
- Radical nephrectomy associated with better overall survival partial (81 vs 76 %, p=0.03) (intention to treat analysis)
- This difference fades when looking at patients with proven RCC only
Very large retrospective meta-analyses have shown that:
- Partial nephrectomy associated with better overall survival, better cancer specific mortality, and lower rates of CKD
- CKD is an independent risk factor for mortality; hence the theory that preventing CKD is better for survival
- The retrospective nature of all studies included naturally lead to concerns about selection bias
Renal function long-term is now thought to be primarily mediated by underlying medical causes contributing rather than surgical effect.
- “Medical CKD” vs “surgical CKD”
- Medical causes (diabetes/hypertension etc) will have ongoing progressive decline in renal function -> affecting survival
- Large retrospective analysis suggests CKD due to surgery alone have nearly identical survival to patients with no CKD, especially if post-surgical eGFR is > 45 ml/min
