Current Criteria for Nephron Sparing Surgery, What are the Limits?

Acapulco, GRO, Mexico (UroToday.com) Bernardo Gabilondo Pliego, MD presented a convincing talk with regards to the limits of nephron-sparing surgery (NSS). He stressed that surgeon experience; tumor size and localization are critical when deciding the surgical approach in patients with localized clinical masses. The current indications for NSS include:

Small renal masses and tumors from 4-7 cm
Solitary Kidneys
Chronic Kidney Disease and;
Bilateral Renal Tumors

Patient factors (previous abdominal surgeries, BMI, the presence of comorbidities and functional status), as well as tumor nephrometry evaluated with current scores, determine the viability of this technique. He underlines the importance of taking into account perinephric fat which is not contemplated in many scoring systems and can potentially complicate the surgical procedure transoperatively. In addition, the benefits of the transperitoneal approach were highlighted when considering minimally invasive surgery (anatomic relationships and it facilitates surgical movements by working in a larger cavity). The use of kidney cancer predictive tools and other kidney function normograms was also encouraged.

Current treatment trends have changed the paradigm in the treatment of renal masses and renal biopsy should be done when clinically indicated. In the United States, 60% of NSS are robot-assisted laparoscopic procedures but open surgery (OPN) is still considered standard of care in many centers worldwide. Limitations of the robotic approach were evaluated in a multicenter study that compared TRIFECTA outcomes between OPN and robotic partial nephrectomy (RAPN) in completely endophytic renal tumors where no differences were found in TRIFECTA achievement between these two techniques. The learning curve for this approach was assessed by a study that compared RAPN with laparoscopy where the threshold for acceptable perioperative outcomes was 30 cases. This learning curve is reasonable when considering how technically demanding it can be when teaching complex laparoscopy cases to trainees. Several cases were described and he emphasized the use of transoperative ultrasound to obtain adequate margins in endophytic tumors. (see Figure 1)

Figure 1:

He concludes that NSS should always be considered when clinically indicated and surgically feasible to preserve renal function as well as obtaining equivalent oncological outcomes. All techniques are acceptable and are subject to surgeon preference and experience.

Presented by: Bernardo Gabilondo Pliego, MD from the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico

Written by: Adrián M. Garza-Gangemi, MD, Resident of Urology, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico @aggangemi & Dr Ashish M. Kamat, Professor of Urologic Oncology, MD Anderson Cancer Center, Houston, TX at the 2018 Congreso de la Asociación Mexicana de Urología Oncológica – July 25-28, 2018, Acapulco, GRO México

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