Expanding indication for elective nephron-sparing surgery in renal cell carcinoma

Nephron-sparing surgery is the reference standard for the management of a small renal masses, especially in patients with a solitary kidney or bilateral renal tumors. The rationale for elective partial nephrectomy is based on the risk of developing kidney failure and the significant percentage of benign lesions on final histopathologic examination. Recent studies have demonstrated comparable survival and recurrence rates with partial and radical nephrectomy for renal tumors of 4 cm or less, and it is well demonstrated that radical nephrectomy is a significant risk factor for the development of chronic kidney disease. The latest evidences indicate that the outcomes are similar after partial nephrectomy for selected tumors 4 to 7 cm in size. The laparoscopic partial nephrectomy showed functional and oncologic outcomes comparable to those after open partial nephrectomy. Nevertheless, laparoscopic partial nephrectomy is a technically demanding procedure. With increasing experience and technical refinements, the complications rates have decreased substantially. Simultaneously, the indications of laparoscopic partial nephrectomy are being carefully extended to include more complex tumors. The purpose of this paper was to underline the evolution of, and expanding indications for, a nephron-sparing approach also for renal masses between 4 and 7 centimeters and a normal contralateral kidney, presuming a careful and sensible patient selection. This option should be reserved only to experienced centers.