How do you decide between partial and radical nephrectomy?

Urology Times reached out to three urologists (selected randomly) and asked them each the following question: How do you decide between partial and radical nephrectomy?

"Indications for partial versus radical depend on tumor size or location, and on a desire for

Jeffrey Ferguson, MD

nephron sparing. The goal is always to remove the tumor but save any viable kidney tissue. The first priority is cancer control, and the second is nephron sparing.

The possibility of perioperative complications, risk of recurrence, and procedure difficulty are considerations. With robotic technology and experience, we try to do a partial if we can. Cancer control is an issue, but if surgeons are experienced, the positive margin rate should be low.

I don’t think there’s much controversy now between performing radical versus partial procedures. The state-of-the-art surgery, the gold standard, is nephron-sparing surgery, preserving renal function.

If someone has a relatively small kidney cancer and the entire kidney is removed, there’s a chance of developing cancer on the other side, or renal insufficiency for other reasons. Then they’d only have 1 kidney because the other one was removed when it wasn’t necessary.

If a person has a car accident after a kidney is removed and they lose their other kidney, they’re on the transplant list and need dialysis, which is pretty horrible. If you can do partial nephrectomy and spare the noncancerous part of the kidney, you should try to do that.

The controversy has been thoroughly debated and I believe the gold standard is partial nephrectomy.”

Jeffrey Ferguson, MD/ Colorado Springs, Colorado

“Our goal is to do partial nephrectomies robotically. With urological guidelines, a partial is

Joseph DeOrio, MD

indicated for tumors that are 4 cm or smaller. For amenable tumors—good location, good anatomy—we may attempt a partial if we can get nice margins. Anything larger, or more technically complicated, like involvement of the renal hilum, we would probably lean toward a radical nephrectomy.

The only caveat would be someone with a solitary kidney, so you try to spare as much function as possible. We would lean toward a partial, even with soft indications.

In older patients, 75 to 80 years old, with a second normal kidney, I lean toward a radical for expediency of surgery, because blood loss may be riskier than potential recurrence or loss of another kidney. Even with an amenable tumor, at 80, I probably just remove the kidney, because the remaining kidney will probably last the rest of their life just fine.

Most problems occur when there is massive involvement of the collecting system or extensive dissection off the renal hilum. I wouldn’t consider a partial for anything with venous involvement. But with well-chosen candidates, complication rates with partials are relatively low.

We don’t do hundreds of nephrectomies, so I haven’t seen a higher risk of end-stage disease or shorter survival rates with partials. When a tumor is more technically challenging, I lean toward the radical, because risks increase.

With patients in whom a partial nephrectomy is possible but could be difficult, I refer them to the university, because I wouldn’t want to do them a disservice. Given my patient volume and technical skills, I would be more comfortable with the radical, and that might not be right for that particular patient.”

Joseph DeOrio, MD/ Long Beach, California

“It’s case dependent. For appropriately selected patients, partial nephrectomy is preferred.

Justin Isariyawongse, MD

Patients tend to do equally well with either procedure. More than anything, it’s tumor characteristics that really define which we elect to do: mostly size, tumor location, and whether the tumor is primarily endophytic or exophytic.

Although we don’t have a strict size criteria, if the tumor is large enough, it’s likely to be higher-stage disease. Then I would perhaps opt for radical nephrectomy rather than a partial nephrectomy.

The potential for complications or recurrence is always in the discussion when we’re offering options to patients. It’s in the discussion, but whether I’m actually concerned about it? In our experience, recurrence rates have been low so if patients are appropriately selected, we expect recurrence rates are acceptable, if not negligible.

There’s always the potential for bleeding, and when a patient is borderline for a partial and they might be an appropriate radical nephrectomy patient, I’ve found that consideration of risks may guide the patient’s decision-making to some extent.

It’s basically a shared decision-making model for most cases. Often, when we discuss the partial nephrectomy option, we talk about other options, including cryoablation, for example, which we would have to refer out. Cryoablation may be an option for some people when otherwise they would be a candidate for partial nephrectomy.

We discuss multiple treatment modalities and all their attendant risks and benefits. To a large extent, discussing risks and benefits is just what practicing 21st-century medicine really means.”

Justin Isariyawongse, MD/ Monroeville, Pennsylvania