The Management of a Clinical T1b Renal Tumor in the Presence of a Normal Contralateral Kidney The Case for Nephron-Sparing Surgery.

Department of Urology, University of Minnesota, Minneapolis, MN. Electronic address: .
The Journal of urology (Impact Factor: 3.75). 01/2013; DOI: 10.1016/j.juro.2013.01.030
Source: PubMed
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    ABSTRACT: Purpose of review To review current status of partial nephrectomy for treatment of T1b and T2 renal mass, focusing oncological and renal functional outcomes reported in the last 18months, and to understand the emerging role of minimally invasive surgery (MIS) techniques in nephron-sparing management of T1b/T2 tumors. Recent findings With recent long-term oncological equivalence to radical nephrectomy and renal functional benefit, partial nephrectomy is becoming an alternate standard to radical nephrectomy in the management of T1b tumors. The role of partial nephrectomy in nonelective treatment of T2 tumors is more controversial; however, recent publication of two large North American series have added to other contemporary work that suggests oncologic equivalence and renal functional benefit compared to radical nephrectomy in select patients. Emerging data demonstrate feasibility of MIS for increasing the proportion of T1b/T2 tumors; however, recent trends analyses demonstrate that the majority of T1b/T2 partial nephrectomy are still carried out by open surgery, and concerns continue about prolonged ischemic times and risk of bleeding in various MIS settings. Summary Management of T1b and T2 renal masses is transforming with adoption of partial nephrectomy as a safe and feasible surgical option with comparable oncological and improved renal function outcomes compared to radical nephrectomy. MIS techniques play an expanding, though still limited, role, and more robust prospective data is requisite before drawing overarching conclusions.
    Current Opinion in Urology 06/2014; 24(5). DOI:10.1097/MOU.0000000000000081 · 2.12 Impact Factor
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    ABSTRACT: Purpose: We assessed compensatory hypertrophy in the contralateral kidney after partial and radical nephrectomy in adults. We also examined predictive factors to facilitate more accurate estimation of global renal function after surgery. Materials and Methods: We analyzed the records of 172 patients who underwent partial or radical nephrectomy with appropriate studies to determine function and parenchymal mass specifically in the operated and contralateral kidneys. All patients required renal scans to provide split renal function preoperatively and postoperatively. Parenchymal volume was measured by computerized tomography. All studies were done less than 2 months preoperatively and 4 to 12 months postoperatively. Results: A total of 113 and 59 patients underwent partial and radical nephrectomy, and median tumor size was 3.5 and 7.0 cm, respectively (p <0.0001). Of patients treated with partial nephrectomy 19% had high complexity tumor compared to 80% of those treated with radical nephrectomy (p <0.0001). Median ipsilateral parenchymal volume was reduced 18% after partial nephrectomy and the median glomerular filtration rate in this kidney decreased 24.4%. The median contralateral kidney function increase after partial nephrectomy was 2.3% vs 21.1% after radical nephrectomy (p < 0.0001). Median global function decreased 9.6% after partial nephrectomy vs 32.2% after radical nephrectomy (p <0.0001). A larger percent parenchymal volume loss (p = 0.0001) and fewer comorbidities (p = 0.0072) significantly correlated with greater compensatory hypertrophy in the contralateral kidney on multivariable analysis. Conclusions: Compensatory hypertrophy in adults was limited after partial nephrectomy and it correlated significantly with the amount of parenchymal volume excised. Healthier patients also appeared to respond better. These results may allow for more accurate estimation of global renal function after partial and radical nephrectomy.
    The Journal of Urology 06/2014; 192(6). DOI:10.1016/j.juro.2014.06.018 · 3.75 Impact Factor
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    ABSTRACT: The decision between a radical (RN) and a partial nephrectomy (PN), not unlike most decisions in clinical practice, ultimately hinges upon a balance of risk. Do the higher risks of a more complex surgery (PN) justify the theoretical benefits for kidney tissue preservation? Data suggest that for patients with an anatomically complex renal mass and a normal contralateral kidney for whom additional surgical intensity is not trivial, such as the elderly and comorbid, RN presents a robust treatment option. Nevertheless, PN, especially for small and anatomically simple renal masses in the young and non-comorbid, should remain the surgical reference standard, since preservation of renal tissue can serve as an "insurance policy" not only against future renal functional decline, but also against the possibility of tumor development in the contralateral kidney. Herein we outline the ongoing debate between the role of RN and PN in treatment of the enhancing renal mass.
    BJU International 02/2014; 115(3). DOI:10.1111/bju.12696 · 3.13 Impact Factor

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