EAU 2020: Controversies in Renal Cancer Surgery: Do the Benefits Outweigh Additional Risks? — Pro: Partial Nephrectomy

(UroToday.com) The controversies in renal cancer surgery session at the 2020 European Association of Urology (EAU) Virtual Annual Meeting featured a debate on organ preservation and the appropriate surgical approach to take. Alberto Breda, MD, discussed the pros of partial nephrectomy for this debate.

Dr. Breda started by highlighting that several studies have demonstrated the risk of chronic kidney disease associated with metabolic syndrome.

Furthermore, renal cancer surgery also puts patients at risk of chronic kidney disease. Results from the EORTC 30904 randomized trial showed that with a median follow-up of 6.7 years, eGFR <60 was reached by 85.7% with radical nephrectomy as compared to 64.7% for patients undergoing nephron-sparing surgery, with a difference of 21.0% (95% CI, 13.8-28.3).1 Additionally, eGFR <30 was reached by 10.0% for those undergoing radical nephrectomy, compared to 6.3% for those undergoing nephron-sparing surgery, with a difference of 3.7% (95% CI, -1.0 to 8.5). Finally, an eGFR <15 was reached by 1.5% undergoing radical nephrectomy and 1.6% undergoing nephron-sparing surgery, with a difference of -0.1% (95% CI, -2.2 to 2.1).

Dr. Breda notes that the EAU guidelines also support the use of partial nephrectomy when feasible. There is grade 1b evidence that the oncological outcome in terms of overall survival following partial nephrectomy equals that of radical nephrectomy in patients with T1 RCC. There is also a strong recommendation from the guidelines that patients should be offered a partial nephrectomy in the setting of a T1 tumor.

Dr. Breda advocates for a partial nephrectomy even in patients with cT2 tumors if technically feasible, which has been assessed in several studies as summarized below:

PNvRN_cT2_EAU2020.png

Generally, this approach has non-inferior oncological outcomes, lower change in eGFR, possibly better overall survival, but more complications and positive surgical margins.

Recent data from the ROSULA Collaborative Group suggests that a robotic partial nephrectomy for cT2a tumors is both safe and feasible with similar oncologic outcomes [2]. Among 648 patients matched, there were no differences in intraoperative complications (p = 0.478), Clavien-Dindo Grade ≥III complications (p = 0.063), and re-admissions (p = 0.238). Additionally, there was no significant differences for 5-year OS (76.3% vs 88.0%, p = 0.221) and 5-year DFS (78.6% vs 85.3%, p = 0.630) for pT2 RCC, and no differences for 3-year OS (p = 0.351) and 3-year DFS (p = 0.117) for pT3a upstaged RCC. Furthermore, in multivariable analysis, partial vs radical nephrectomy was not associated with all-cause mortality or recurrence.

However, radical nephrectomy was a risk factor for stage III chronic kidney disease (HR 2.51, p<0.001).

Indeed, there is a risk-benefit ratio with regards to complications associated with a difficult partial nephrectomy versus eGFR preservation. A paper published this year from Vilaseca and colleagues3 showed that for tumors with diameters between 7 and 12cm, the risk of eGFR downgrade associated with radical nephrectomy was higher than the risk of complications associated with partial nephrectomy. To summarize this point, the eGFR loss risk in radical nephrectomy is ~40% higher than the complication risk in partial nephrectomy.

Dr. Breda concluded with the following closing remarks:
  • The role of partial nephrectomy in cT2 tumors is still debatable but is probably has similar oncological outcomes with better functional outcomes compared to radical nephrectomy
  • cT2c partial nephrectomy has worse complication rates and positive margin rates, especially in very complex cases, thus patient selection is key
  • cT2 to pT3a upgrading does not seem to affect CSS or OS, thus we should attempt a partial nephrectomy whenever feasible
Presented by: Alberto Breda, University Autonoma of Barcelona, Barcelona, Spain

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md, at the Virtual 2020 EAU Annual Meeting #EAU20, July 17-19, 2020

References:
  1. Scosyrev E, Messing EM, Sylvester R, et al. Renal function after nephron-sparing surgery versus radical nephrectomy: Results from EORTC randomized trial 30904. Eur Urol 2014 Feb;65(2):372-277.
  2. Bradshaw AW, Autorino R, Simone G, et al. Robotic partial nephrectomy vs minimally invasive radical nephrectomy for clinical T2a renal mass: A propensity score-matched comparison from the ROSULA (Robotic Surgery for Large Renal Mass) Collaborative Group. BJU Int 2020 Jul;126(1):114-123.
  3. Vilaseca A, Guglielmetti G, Vertosick EA, et al. Value of partial nephrectomy for renal cortical tumors of cT2 or greater stage: A risk-benefit analysis of renal function preservation versus increased postoperative morbidity. Eur Urol Oncol 2020 Jun;3(3):365-371.

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EAU 2020: Controversies in Renal Cancer Surgery: Organ Preservation: Do the Benefits Outweigh Additional Risks? – Pro: Minimally Invasive Nephrectomy 
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