Outcome of nephron-sparing surgery for T1b renal cell carcinoma

To present our experience with nephron-sparing surgery (NSS) for T1b renal cell carcinoma (RCC) in a high-volume tertiary referral centre. NSS for RCC of <4 cm (T1a) is increasingly accepted, although its role for RCC of 4-7 cm (T1b) remains controversial.

The records of 67 consecutive patients who had NSS for RCC of 4-7 cm at our institution were reviewed retrospectively. Data were collected on surgical indications, tumour characteristics, complications, changes in serum creatinine level, time to recurrence and time to death. Clinical progression-free survival (CPFS), overall survival (OS), cancer-specific survival (CSS) rates were estimated statistically.

The mean patient age was 62 years. Surgical indications were absolute in 26 (39%) patients, relative in 11 (16%) and elective in 30 (45%). Two patients (3%) required postoperative embolization, and none developed a urinary fistula. Four patients (6%) had positive resection margins; none of these developed tumour recurrence. After a median (range) follow-up of 40.1 (1-98.3) months, 10 patients (15%) had died, of whom only one death was related to NSS (postoperative hypovolaemic shock). The tumour recurred in seven patients (10%) all of whom were alive at the last follow-up. Three patients (4%) developed a local recurrence and four (6%) developed locoregional or distant disease. The projected 5-year CPFS, CSS and OS rates were 84%, 99% and 72%, respectively. Seven (10%) patients developed de novo renal insufficiency. Elective and relative indications were not associated with a significant change in serum creatinine level (P = 0.22 and 0.10, respectively); in the absolute category this difference was statistically significant (P = 0.005). The main limitation is that the study was uncontrolled and retrospective, with a medium-term follow-up.

This study showed the excellent surgical feasibility and CSS for NSS in T1b RCC. Local cancer control was achieved in the large majority of patients, with preservation of renal function in those with elective indications. Absolute indications significantly correlated with loss of renal function.