A critical analysis of the actual role of minimally invasive surgery and active surveillance for kidney cancer.
BACKGROUND
The incidence of renal cell carcinomas (RCCs) has increased steadily-most rapidly for small renal masses (SRMs). Paralleling the changing face of RCC in the past 2 decades, new, less invasive surgical options have been developed. Laparoscopic radical nephrectomy (LRN) is an established procedure for the treatment of RCC. Treatment of SRMs includes open partial nephrectomy (OPN), laparoscopic partial nephrectomy (LPN), thermal ablation, and active surveillance.


OBJECTIVE
To present an overview of minimally invasive treatment options and data on surveillance for kidney cancer.


METHODS
Literature and meeting abstracts were searched using the terms renal cell carcinoma, minimally invasive surgery, laparoscopic surgery, thermal ablation, surveillance, and robotic surgery. The articles with the highest level of evidence were identified with the consensus of all the collaborative authors and reviewed.


RESULTS
Renal insufficiency, as measured by the glomerular filtration rate, occurs more often after radical nephrectomy than partial nephrectomy (PN). OPN and LPN show comparable results in long-term oncologic outcomes. The treatment modality for SRMs should therefore be nephron-sparing surgery (NSS). In select patients, thermal ablation or active surveillance of SRMs is an alternative.


CONCLUSIONS
LRN has become the standard of care for most organ-confined tumours not amenable to NSS. Amongst NSS options, PN is the treatment of choice, yet remains underutilised in the community. Initial data during its learning curve revealed that LPN had higher urologic morbidity. However, current emerging data indicate that in experienced hands, LPN has shorter ischaemia times, a lower complication rate, and equivalent long-term oncologic and renal functional outcomes, yet with decreased patient morbidity compared to OPN. Robotic partial nephrectomy is being explored at select centres, and cryotherapy and radiofrequency ablation are options for carefully selected tumours. Active surveillance is an option for selected high-risk patients. Percutaneous needle biopsy is likely to gain increasing relevance in the management of small renal tumours.
Department of Urology, University Medical Centre, 20246 Hamburg-Eppendorf, Germany. heuer@uke.de
Roman
R
Heuer
Inderbir S
IS
Gill
Giorgio
G
Guazzoni
Ziya
Z
Kirkali
Michael
M
Marberger
Jerome P
JP
Richie
Jean J M C H
JJ
de la Rosette
D002292:Carcinoma, Renal Cell / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D017115:Catheter Ablation; D003452:Cryosurgery; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D010535:Laparoscopy; D019060:Minimally Invasive Surgical Procedures; D009392:Nephrectomy / Q000379:methods*; D011159:Population Surveillance