Partial Versus Radical Nephrectomy: Complexity of Decision-Making and Utility of AUA Guidelines

Abstract

Introduction: The American-Urological-Association(AUA) Guidelines for renal cancer(2017) recommend consideration for radical-nephrectomy(RN) over partial(PN) whenever there is increased oncologic-risk; and RN should be prioritized if three other criteria are all also met: 1) increased tumor-complexity; 2) no preexisting chronic-kidney-disease/ proteinuria, and 3) normal contralateral kidney that will likely provide estimated glomerular-filtration-rate (eGFR) >45ml/min/1.73m² even if RN is performed. Our objective was to assess the complexity of decision-making about RN/PN and utility of AUA Guidelines statements regarding this issue.

Patients and methods: Retrospective review of 267 consecutive RN/PN from 2019(100-RN/167-PN). High tumor-complexity was defined as R.E.N.A.L.≥9. Increased oncologic-risk was defined as tumor >7cm, locally-advanced or infiltrative-features on imaging, or high-risk pathology on biopsy, if obtained. New-baseline GFR after RN was estimated using global-GFR, split-renal-function_{contralateral}, and presuming 25% renal-functional-compensation.

Results: 163 patients(61%) fit scenarios that are well-defined in the Guidelines. Of these, 34 had strong indications for RN, and all had RN. Twelve of 129 patients(9.3%) underwent RN despite Guidelines generally favoring PN. The remaining 104 patients(39%) did not fit within situations where the Guidelines provide specific recommendations. In these patients, RN was often performed despite functional-considerations favoring PN due to overriding concerns about oncologic-risk and/or tumor-complexity.

Conclusion: Our data demonstrate complexity of decision-making about PN/RN as almost 40% of patients did not fit well-described AUA Guidelines descriptors. Compliance was generally strong although occasional overutilization of RN remains a concern in our series, and will be addressed with additional education. Further studies will be required to assess the generalizability of our findings in other institutions/settings.

Keywords: Cancer surgery; Renal cell carcinoma; Renal function; Renal mass; Tumor complexity.