Radical Nephrectomy: Too Radical For Small Renal Masses?

There remains several options for the management of an incidental mass in the setting of a normal contralateral kidney. These include radical nephrectomy (open/laparoscopic), partial nephrectomy (open/laparoscopic), as well as needle ablation (radiofrequency ablation/cryoablation).

In 1969, open radical nephrectomy was established as the gold standard in the management of renal cell carcinoma. This paradigm was challenged in the 1980’s, when several publications demonstrated the oncologic equipoise of partial nephrectomy with radical nephrectomy. In spite of this, currently only 20% of tumors 2-4 cm in the United States are treated with this approach, and only 4% of nephrectomies in the United Kingdom employ nephron sparing techniques.A September 2006 Lancet Oncology publication by William C. Huang out of Memorial Sloan Kettering, “Chronic kidney disease after nephrectomy in patients with renal cortical tumors: a retrospective cohort study,” demonstrated that 26% of patients with renal cell carcinoma with a normal serum creatinine and a normal appearing contralateral kidney actually had a glomerular filtration rate < 60 ml/min/1.73m2 and that performing radical nephrectomy was a significant independent risk factor for the development of renal insufficiency after treatment for renal cell carcinoma.Why is nephron sparing underutilized? First and foremost, it is a technically challenging operation that may be beyond the skill set of the practicing community urologist. Second, is the common misconception that renal insufficiency is of little concern following radical nephrectomy.Finally, laparoscopic radical nephrectomy may be technically easier to perform, associated with a decrease recovery period for the patient, and more "21st Century" when compared with traditional open surgical approaches.Whatever the reason, it remains clear that nephron sparing approaches remain underutilized on a global scale, and unnecessary loss of renal mass, with its associated morbidity, is far more prevalent than it needs to be.(Source: The Lancet Oncology : Memorial Sloan Kettering Cancer Centre : March 2007.)