Objectives. To document the feasibility of nephron-sparing surgery (NSS) for the surgical treatment of renal masses measuring larger than 7？cm (cT2) on preoperative imaging. Methods. A total of 139 patients have undergone NSS between 2001 and 2012 by a single surgeon in our clinic. Of these, we identified 17 patients whose tumors were measuring greater than 7？cm on preoperative imaging studies and were limited to the kidney. Their charts were retrospectively reviewed. Results. Mean age of the study population was years. Thirteen patients were managed by open NSS, while 4 patients have undergone robot-assisted NSS. Mean diameter and mean R.E.N.A.L. score of the tumors that were enucleoresected were 8.2？cm and 8.5, respectively. A total of 5 Clavien grade 2 and higher complications were recorded within 30 days of surgery. Histopathologic examination revealed benign histology in almost 1/4 of the cases. After a median followup of 33 months, all of our patients were alive. Only one patient (5.8%) experienced local recurrence. Conclusions. NSS is a feasible and safe option for large (>7？cm) renal masses. It may be considered not only for imperative conditions but also for highly selected cases with a normal contralateral kidney. 1. Introduction Nephron-sparing surgery (NSS) offers equivalent oncologic control, as does radical nephrectomy in patients with appropriately selected stage T1 renal tumors [1, 2]. Additionally, NSS has been associated with decreased risks for renal impairment [3–5] and cardiovascular events [6, 7], which may explain the improved overall survival, documented in partial nephrectomy series [8]. Current guidelines emphasize NSS for all anatomically amenable T1 renal tumors [9]. As the benefits of NSS become apparent, the indications may continue to expand [10]. In order to establish standards for future comparisons, we must fully appreciate the efficacy, safety, and limitations of NSS for renal masses larger than 7？cm. Therefore, we reviewed our experience and reported the results in 17 patients with renal masses, which had a maximum diameter of more than 7？cm on preoperative imaging studies, treated with either open or robot-assisted laparoscopic NSS during 13 years. 2. Methods Between 2001 and 2012, a single surgeon (TE) performed 139 NSSs (97 open, 35 robot-assisted, and 7 laparoscopic NSSs) in one center. We retrospectively reviewed the charts of the patients, whose renal tumors measured more than 7？cm in diameter on preoperative imaging . Preoperative evaluation consisted of laboratory tests and cross-sectional imaging studies
References
[1]
C. T. Lee, J. Katz, W. Shi, H. T. Thaler, V. E. Reuter, and P. Russo, “Surgical management of renal tumors 4？cm. Or less in a contemporary cohort,” Journal of Urology, vol. 163, no. 3, pp. 730–736, 2000.
[2]
B. C. Leibovich, M. L. Blute, J. C. Cheville, C. M. Lohse, A. L. Weaver, and H. Zincke, “Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7？cm results in outcome similar to radical nephrectomy,” Journal of Urology, vol. 171, no. 3, pp. 1066–1070, 2004.
[3]
W. K. O. Lau, M. L. Blute, A. L. Weaver, V. E. Torres, and H. Zincke, “Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney,” Mayo Clinic Proceedings, vol. 75, no. 12, pp. 1236–1242, 2000.
[4]
W. C. Huang, A. S. Levey, A. M. Serio et al., “Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study,” The Lancet Oncology, vol. 7, no. 9, pp. 735–740, 2006.
[5]
A. T. D. Clark, R. H. Breau, C. Morash, D. Fergusson, S. Doucette, and I. Cagiannos, “Preservation of renal function following partial or radical nephrectomy using 24-hour creatinine clearance,” European Urology, vol. 54, no. 1, pp. 143–152, 2008.
[6]
W. C. Huang, E. B. Elkin, A. S. Levey, T. L. Jang, and P. Russo, “Partial nephrectomy versus radical nephrectomy in patients with small renal tumors-is there a difference in mortality and cardiovascular outcomes?” Journal of Urology, vol. 181, no. 1, pp. 55–62, 2009.
[7]
L. Zini, J. J. Patard, U. Capitanio et al., “Cancer-specific and non-cancer-related mortality rates in European patients with T1a and T1b renal cell carcinoma,” British Journal of Urology International, vol. 103, no. 7, pp. 894–898, 2009.
[8]
R. H. Thompson, S. A. Boorjian, C. M. Lohse et al., “Radical nephrectomy for pT1a renal masses may be associated with decreased overall survival compared with partial nephrectomy,” Journal of Urology, vol. 179, no. 2, pp. 468–471, 2008.
[9]
S. C. Campbell, A. C. Novick, A. Belldegrun et al., “Guideline for management of the clinical T1 renal mass,” Journal of Urology, vol. 182, no. 4, pp. 1271–1279, 2009.
[10]
S. Sengupta, H. Zincke, B. C. Leibovich, and M. L. Blute, “Surgical treatment of stage pT3b renal cell carcinoma in solitary kidneys: a case series,” British Journal of Urology International, vol. 96, no. 1, pp. 54–57, 2005.
[11]
A. Kutikov and R. G. Uzzo, “The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth,” Journal of Urology, vol. 182, no. 3, pp. 844–853, 2009.
[12]
S. C. Campbell and A. C. Novick, “Surgical technique and morbidity of elective partial nephrectomy,” Seminars in Urologic Oncology, vol. 13, no. 4, pp. 281–287, 1995.
[13]
Z. Kirkali and A. E. Canda, “Open partial nephrectomy in the management of small renal masses,” Advances in Urology, vol. 2008, Article ID 309760, 7 pages, 2008.
[14]
D. Dindo, N. Demartines, and P. A. Clavien, “Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey,” Annals of Surgery, vol. 240, no. 2, pp. 205–213, 2004.
[15]
A. S. Levey, J. P. Bosch, J. B. Lewis, T. Greene, N. Rogers, and D. Roth, “A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation,” Annals of Internal Medicine, vol. 130, no. 6, pp. 461–470, 1999.
[16]
A. S. Levey, K. U. Eckardt, Y. Tsukamoto et al., “Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO),” Kidney International, vol. 67, no. 6, pp. 2089–2100, 2005.
[17]
C. J. Long, D. J. Canter, A. Kutikov et al., “Partial nephrectomy for renal masses ≥7？cm: technical, oncological and functional outcomes,” British Journal of Urology International, vol. 109, no. 10, pp. 1450–1456, 2012.
[18]
F. Becker, F. C. Roos, M. Janssen et al., “Short-term functional and oncologic outcomes of nephron-sparing surgery for renal tumours ≥7？cm,” European Urology, vol. 59, no. 6, pp. 931–937, 2011.
[19]
M. E. Karellas, M. F. O'brien, T. L. Jang, M. Bernstein, and P. Russo, “Partial nephrectomy for selected renal cortical tumours of ≥7？cm,” British Journal of Urology International, vol. 106, no. 10, pp. 1484–1487, 2010.
[20]
R. H. Breau, P. L. Crispen, R. E. Jimenez, C. M. Lohse, M. L. Blute, and B. C. Leibovich, “Outcome of stage T2 or greater renal cell cancer treated with partial nephrectomy,” Journal of Urology, vol. 183, no. 3, pp. 903–908, 2010.
[21]
C. Jeldres, J. J. Patard, U. Capitanio et al., “Partial versus radical nephrectomy in patients with adverse clinical or pathologic characteristics,” Urology, vol. 73, no. 6, pp. 1300–1305, 2009.
[22]
M. Peycelon, V. Hupertan, E. Comperat et al., “Long-term outcomes after nephron sparing surgery for renal cell carcinoma larger than 4？cm,” Journal of Urology, vol. 181, no. 1, pp. 35–41, 2009.
[23]
K. S. Hafez, A. F. Fergany, and A. C. Novick, “Nephron sparing surgery for localized renal cell carcinoma: impact of tumor size on patient survival, tumor recurrence and TNM staging,” Journal of Urology, vol. 162, no. 6, pp. 1930–1933, 1999.
[24]
F. Becker, S. Siemer, M. Hack, U. Humke, M. Ziegler, and M. St？ckle, “Excellent long-term cancer control with elective nephron-sparing surgery for selected renal cell carcinomas measuring more than 4？cm,” European Urology, vol. 49, no. 6, pp. 1058–1064, 2006.
[25]
A. Dash, A. J. Vickers, L. R. Schachter, A. M. Bach, M. E. Snyder, and P. Russo, “Comparison of outcomes in elective partial versus radical nephrectomy for clear cell renal cell carcinoma of 4–7？cm,” British Journal of Urology International, vol. 97, no. 5, pp. 939–945, 2006.
[26]
S. Pahernik, F. Roos, B. R？hrig, C. Wiesner, and J. W. Thüroff, “Elective nephron sparing surgery for renal cell carcinoma larger than 4？cm,” Journal of Urology, vol. 179, no. 1, pp. 71–74, 2008.
[27]
P. L. Crispen, S. A. Boorjian, C. M. Lohse et al., “Outcomes following partial nephrectomy by tumor size,” Journal of Urology, vol. 180, no. 5, pp. 1912–1917, 2008.
[28]
J. Rothman, B. Egleston, Y. N. Wong, K. Iffrig, S. Lebovitch, and R. G. Uzzo, “Histopathological characteristics of localized renal cell carcinoma correlate with tumor size: a SEER analysis,” Journal of Urology, vol. 181, no. 1, pp. 29–34, 2009.
[29]
US Renal Data System, USRDS 2011 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md, USA, 2011.
[30]
D. Canter, A. Kutikov, M. Sirohi et al., “Prevalence of baseline chronic kidney disease in patients presenting with solid renal tumors,” Urology, vol. 77, no. 4, pp. 781–785, 2011.
