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Renal Cell Carcinoma
Surgical Therapy for Renal Cell Carcinoma
Vincenzo Ficarra, Simonetta Fracalanza and Giacomo Novara
Department of Oncological and Surgical Sciences, Urological Unit, University of Padua
Abstract
Surgical therapy is the only curative approach for the treatment of non-metastatic renal cell carcinoma. Elective open nephron-sparing
surgery (NSS) is the gold standard treatment of small renal tumours ≤4cm in size. However, compelling data highlighted the possibility of
expanding the indication of open NSS to patients with tumours between 4.1 and 7cm in size. Laparoscopic partial nephrectomy is a
challenging procedure and it should be considered as a potential alternative to open surgery only in patients with T1a tumours and if
performed by expert laparoscopists. Laparoscopic radical nephrectomy should be preferred to open surgery in all T1b–3a patients.
Lymphadenectomy should be reserved for patients with clinically positive lymph nodes. In the era of multitargeted therapies, cytoreductive
nephrectomy retains an important role in the complementary treatment of patients with good performance status and metastatic disease.
Keywords
Renal cell carcinoma, nephron-sparing surgery, radical nephrectomy, laparoscopy, lymphadenectomy, cytoreductive nephrectomy,
multitargeted therapies
Disclosure: The authors have no conflicts of interest to declare.
Received: 2 June 2009 Accepted: 10 July 2009
Correspondence: Vincenzo Ficarra, Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Monoblocco Ospedaliero – IV Floor,
Via Giustiniani 2, 35128 Padua, Italy. E: vincenzo.ficarra@unipd.it
Although the use of elective nephron-sparing surgery (NSS) was recommended only for large upper pole tumours or positive
postulated for the first time by Vermooten in 1950,
1
for many decades pre-operative imaging, and extended lymph-node dissection is
the gold standard of treatment for renal cell carcinoma (RCC) remained recommended only for patients with computed tomography
open radical nephrectomy. Specifically, early ligation of the renal (CT)-detected or intra-operatively palpable enlarged nodes.
8
vessels and ‘en bloc’ kidney removal including Gerota fascia, peri-renal
fat, ispilateral adrenal gland and regional lymph nodes represented the Concerning the role of surgical therapy in patients with metastatic
accepted surgical techniques to obtain better cancer control.
2
RCC (mRCC), the European Organisation for Research and
Treatment of Cancer (EORTC) and Southwest Oncology Group
Historically, the early use of NSS was restricted to patients with RCC in (SWOG) trials supported the use of cytoreductive nephrectomy
anatomical solitary kidney, in patients with inadequate contralateral before immunotherapy with inteferon (IFN)-α.
9
The role of
renal function or patients with bilateral synchronous RCC, with the aim cytoreductive nephrectomy is still supported by major guidelines in
of avoiding fatal uraemia. Moreover, the good results observed in the era of targeted therapy.
8,10
patients who underwent imperative NSS stimulated the progressive
application of NSS for patients with relative indications such as This article focuses on some of the most relevant issues concerning
conditions that could potentially impair renal function (e.g. stones, the surgical therapy of localised and metastatic RCC, including the
hypertension, diabetes, pyelonephritis) and with normal controlateral extension of safety surgical margins after NSS, the comparison
kidney (elective NSS).
3
between open, laparoscopic and robotic partial nephrectomy (RPN)
in T1a cases, the potential extension of indications to elective NSS,
NSS is currently considered to be the gold standard for tumours ≤4cm the role of lymphadenectomy in patients without clinical lymph-
(T1a) in patients with a contralateral normal kidney. In this category node involvement and the role of cytoreductive nephrectomy in the
of patients, open NSS provokes a non-significant increase in era of targeted therapies.
peri-operative complications
4
compared with radical nephrectomy,
while it gives overlapping results in terms of cause-specific Nephron-sparing Surgery and Safety Margins
survival.
3,5,6
Currently, more than 60% of tumours ≤4cm are treated The objective of NSS is the complete removal of the tumour while
with partial nephrectomy in European tertiary centres.
7
preserving the largest possible amount of the healthy renal
parenchyma. With the objective of reducing the risk of local
Radical nephrectomy remains the gold standard treatment for all other recurrences due to incomplete resections, for several years the
kidney cancer (T1b–T4). However, adrenalectomy is currently standard surgical technique of NSS for RCC involved excising an
© TOUCH BRIEFINGS 2009 43
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