The management of older adults with small renal masses presents unique challenges, as the degree of aggressive management must be balanced with expected life expectancy, patient willingness, and urgency of the intervention. Because the renal functional benefit of PN is realized over many years and is the procedure is associated with a higher complication rate than RN, some suspect that elderly patients may not receive the benefit of PN at the cost of higher risk. We sought to characterize perioperative, renal functional and oncologic outcomes of elderly patients undergoing PN vs. RN to help determine management in this unique population.
Our institutional renal mass registry was queried for patients 65 and older with solitary cT1-T2 renal mass resected by PN ofgdxc r RN. Clinicopathologic features and perioperative outcomes were compared between groups. Renal function outcomes measured by change in eGFR and freedom from eGFR < 45 ml/minute/1.73m2 were analyzed. Multvariate Cox proportional hazards models for overall survival (OS) and cancer-specific survival (CSS) were analyzed.
Overall, 787 patients met inclusion criteria. Of these, 437 (55.5%) underwent PN and 350 (44.5%) underwent RN. Median follow-up was 36 months. Patients in the PN cohort were younger (median age 70.3 vs. 71.9 years, p<0.001), had lower ASA scores (2.6 vs. 2.8, p=0.001), smaller tumors (tumor diameter 2.8 vs. 5.0cm, p<0.001), and lower proportion of RCC (76.7 vs. 87.4%, p<0.001). Perioperative outcomes were similar between PN and RN groups as were complications (37.8 vs. 38.9%). Estimated change in eGFR was less in PN vs. RN (6.4 vs. 19.7, p<0.001) at last follow-up. OS and CSS were equivalent between modalities.
Selection of patients for PN vs. RN remains a challenge for clinicians- especially in older patients with concomitant clinical factors to consider. Well-intended considerations for an individual’s overall health status can sometimes lead to selection bias for patients with the most to gain. In our analysis, renal functional outcomes were found to be superior in the PN cohort in terms of both change in eGFR and freedom from eGFR <45 ml/minute/1.73 m2. Nephron preservation should not be weighted lightly, as it has vast systemic implications. While the previous literature fails to demonstrate a causal relationship between renal surgery and adverse cardiovascular outcomes, a fair amount of circumstantial and retrospective data exists to the merits of PN. In this series, PN was associated with no additional morbidity, and similar OS and CSS compared to RN. This report adds to the growing body of contemporary evidence supporting the safety of PN in appropriately selected elderly patients.
Written by: Julie Y. An, Mark W. Ball, and Phillip M. Pierorazio
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