The expanding role of partial nephrectomy: a critical analysis of indications, results, and complications.
BACKGROUND
The gained expertise in the surgical technique of partial nephrectomy (PN) with excellent oncologic outcome and reduced morbidity has contributed to more frequent use of PN in many centres of reference, and the recent evidence favouring PN over radical nephrectomy (RN) in the prevention of chronic kidney disease and possibly linking it to a better overall survival (OS) will constitute a strong argument for wider use of PN.


OBJECTIVE
To objectively analyse the advantages of PN over RN and to evaluate the risk-benefit ratio of expanding the indications of PN T1b renal cortical tumours.


METHODS
Literature searches on English-language publications were performed using the National Library of Medicine database. The queries included the keywords partial nephrectomy and nephron sparing surgery. Eight hundred four references were scrutinised, and 175 publications were identified and reviewed. Sixty-nine articles were selected for this review. These references formed the basis for this analysis and were selected based on their relevance and the importance of their content.


RESULTS
The use of PN has been steadily increasing, particularly in tertiary care centres. This trend is now strengthened by evidence supporting the role of PN in reducing the risk of chronic kidney disease in patients with renal masses < or =4 cm. A wider use of PN for larger tumours, granted technical feasibility, is supported by the preliminary evidence, suggesting an OS advantage favouring PN over RN. However, the potential for selection bias and residual confounding factors may contribute to the observed difference. In the carefully selected patients with tumours >4 cm, PN obtained equivalent oncologic outcome to that achieved after RN. Although higher morbidity rates were seen after PN, the complication type and severity were not prohibitive.


CONCLUSIONS
The available evidence supports elective PN as the standard surgical treatment for renal cortical tumours < or =4 cm. For larger tumours, PN has demonstrated feasibility and oncologic safety in the carefully selected patient population studied.
Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA. touijera@mskcc.org
Karim
K
Touijer
Didier
D
Jacqmin
Louis R
LR
Kavoussi
Francesco
F
Montorsi
Jean Jacques
JJ
Patard
Craig G
CG
Rogers
Paul
P
Russo
Robert G
RG
Uzzo
Hendrik
H
Van Poppel
D002292:Carcinoma, Renal Cell / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D006801:Humans; D007680:Kidney Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D009392:Nephrectomy / Q000009:adverse effects / Q000379:methods*; D015996:Survival Rate; D016896:Treatment Outcome