ORLANDO, FL USA (UroToday.com) - The treatment of small renal masses (SRM’s) and localized kidney cancer has undergone significant changes over the last 2 decades. Renal cell carcinoma (RCC) continues to present clinicians with a unique opportunity to model competing risk outcomes. Partial nephrectomy (PN) was initially pioneered for patients who would require renal replacement after PN. The American Urological Association published guidelines in 2009 establishing PN, when technically feasible, as a recommended treatment option. Since then, studies have reported a continued increase in utilization of PN. This rise in the application of PN is due to the sudden rise in the incidence of SRMs due to increased utilization of cross-sectional imaging and the rapid uptake of robotic-assisted laparoscopic surgery. In this debate, moderated by Dr. Michael Jewett, Drs. Robert Uzzo and Inderbir Gill debated that minimal invasive PN is the new gold standard, while Drs. Michael Blute and John Libertino argued against it.
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The pro side of minimal invasive PN (MIPN) presented data showing that the postoperative recovery from MIS, across the board, has been shown to be generally quicker and associated with shorter hospital stays and less blood loss. Data was presented that compared to the technically demanding laparoscopic PN (LPN), robotic PN (RPN) overcomes a number of the technical hurdles of LPN with a shorter learning curve, and now has emerged as an attractive minimally-invasive treatment option for amenable tumors. Although experience with RPN is still relatively limited , series from high-volume centers have demonstrated oncologic outcomes comparable to OPN and equivalent perioperative outcomes to LPN and OPN. Although presented data are encouraging, cons of MIPN argued whether RPN or LPN are equally efficacious to OPN with regard to cancer control in more complex and locally advanced renal tumors.
In my opinion, use of standardized reporting methods is necessary because the reporting of clinical outcomes often focuses on operative site-specific complications (such as urine leak or postoperative bleeding) and underestimates overall complication rates. Having said that, to-date, data showing superiority of OPN to MIPN for localized and masses with low to medium complexity is lacking. An objective measure of renal tumor complexity, such as the renal nephrometry score, is essential to examine certain questions, including surgical treatment approach in RCC patients. Dr. Uzzo presented data that, with growing surgeon experience with the robotic platform, RPN can be done for larger tumors with increasingly challenging features, such as collecting system involvement, a centrally located mass, and close proximity to the hilar vessels. However, as the experience with RPN for increasingly complex tumors grows, rigorous comparative efforts are needed against the reference standard of OPN.
Although both sides argued which surgical approaches (MIS or Open) should be the “gold standard” for management of renal cancer, presented data were all limited to either their retrospective designs, institutional experience, or lack of validation. Even with high-volume surgeons, most patients with highly complex tumors or a renal mass in a solitary kidney undergo OPN, which implies selection bias that limits the generalizability of RPN or LPN. As contemporary experience with robotic surgery grows, one can anticipate that a larger proportion of highly complex lesions will be approached via a MIS approach in the future. Although prospective evidence would be ideal, clinical trials comparing LPN/RPN to OPN will be fraught with accrual challenges and are not expected in the near future. Until more definitive, prospective evidence is available, decisions regarding the optimal surgical approach for the small renal mass will be determined by individual patient and surgeon preference, experience and comfort level.
Moderated by Michael A.S. Jewett, MD at the American Urological Association (AUA) Annual Meeting - May 16 - 21, 2014 - Orlando, Florida USA
Debater - Pro: Inderbir S. Gill, MD, MCh
Debater - Pro: Robert G. Uzzo, MD
Debater - Con: Michael L. Blute, MD
Debater - Con: John A. Libertino , MD
Written by Reza Mehrazin, MD, medical writer for UroToday.com