Which is the real gold standard for small-volume renal tumors? Radical nephrectomy versus nephron-sparing surgery

Until recently, the gold standard for treatment of localized renal-cell carcinoma with a normal contralateral unit was deemed to be a formal radical nephrectomy. Advocates of nephron-sparing surgery have recently challenged this concept; we wished to evaluate the evidence to determine which treatment is objectively superior for patients with renal tumors up to 4 cm.

MEDLINE, CANCERLIT, and EMBASE computer literature searches were performed to identify peer-reviewed papers pertaining to radical nephrectomy (RN), nephron-sparing surgery (NSS), or comparisons of these methods for tumors as large as 4 cm in maximum diameter. Review of the bibliographies of recovered articles and data in recent textbooks were used to supplement the computerized searches. There were a total of 797 cases in the RN group and 1211 in the NSS group. The parameters specifically evaluated were evidence of local recurrence, disease progression, and death within 33 months, this period being chosen primarily because it was the shortest follow-up in the studies evaluated. The data were then subjected to rigorous statistical analysis. Laparoscopic radical nephrectomy (LRN) and laparoscopic nephron-sparing surgery (LNSS) articles were also reviewed; however, current follow-up periods were considered too short to draw a statistically significant conclusion.

Disease-specific survival rates (P=0.001; Mann-Whitney test) as well as the incidence of metastases (P<0.05; Mann-Whitney test) were significantly better in the NSS group. The incidence of local recurrence (P=0.22; Mann-Whitney test) was not significantly different. It should be borne in mind that there are different follow-up periods for each study, and this may have had an impact on the results.

Nephron-sparing surgery seems to be as effective as RN in patients with renal cell tumours up to 4 cm, although only a large randomized controlled trial with long follow-up periods would provide a definite answer.