N EPHRON -S PARING S URGERY FOR R ENAL C ELL C ARCINOMA

British Journal of Urology (1998), 82, 321–324

REVIEW

Nephron-sparing surgery for renal cell carcinoma A.C. NOVI CK Department of Urology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Introduction Nephron-sparing surgery (NSS) has become a successful form of treatment for patients with localized RCC when there is a need to preserve functioning renal parenchyma [1]. This need is present in patients with bilateral RCC, RCC involving a solitary functioning kidney, chronic renal failure, or unilateral RCC and a functioning opposite kidney that is at risk of future impairment from an intercurrent disorder. The technical success rate with NSS is excellent and long-term patient survival free of cancer is comparable with that obtained after radical nephrectomy, particularly for low-stage RCC (Table 1). The major disadvantage of NSS for RCC is the risk of postoperative local tumour recurrence in the operated kidney, which has occurred in 4–6% of patients [2–4]. These local recurrences are most probably a manifestation of undetected microscopic multifocal RCC in the remnant kidney. The risk of local tumour recurrence after radical nephrectomy has not been studied, but it is presumably very low. We recently reviewed the results of NSS for treatment of RCC in 500 patients managed at The Cleveland Clinic before December 1996. A technically successful operation, with preservation of function in the treated kidney, was achieved in 489 patients (98%). The mean postoperative serum creatinine level in these patients was 18 mg/L. The overall and cancer-specific 5-year patient survival rates in the series were 81% and 93%, respectively. Recurrent RCC developed postoperatively in 39 of 473 patients (8.2%) with sporadic RCC; 13 of these patients (2.7%) developed local recurrence in the remTable 1 Results of nephron-sparing surgery for renal cell carcinoma

Study

No. of patients

Local tumour recurrence, n (%)

5-year cancerspecific survival (%)

[2] [3] [4]

104 121 216

6 (5.8) 5 (4.1) 9 (4.2)

89 90 87

Accepted for publication 6 May 1998 © 1998 British Journal of Urology

nant kidney, while 26 developed metastatic disease. These data confirm that NSS provides eCective therapy for patients with localized RCC when preservation of renal function is a relevant clinical consideration.

Criteria for NSS in patients with a normal contralateral kidney Although radical nephrectomy remains the standard treatment for localized RCC in patients with an anatomically and functionally normal opposite kidney, a growing number of authors are reporting excellent results with NSS in this setting. A recent article detailed the outcome of NSS in 315 reported patients with unilateral localized RCC and a normal opposite kidney [5]. The mean cancer-specific survival rate was 95% at #3 years years of follow-up and there were only two cases of postoperative tumour recurrence. Significantly, the mean tumour size in most of these reports was