Photo: Urology, P.C. clinic
Due in part to the increased detection of small renal masses on abdominal imaging, the incidence of renal cell carcinoma has risen significantly in recent years. Accompanying this trend is a clear stage migration favoring stage I tumors and a significant decrease in tumor size even within the stage I group.
The gold standard treatment of renal tumors was previously radical nephrectomy (RN). However, investigation during the last decade has demonstrated the surgical feasibility and equivalent oncologic efficacy of partial nephrectomy (PN) for small renal masses. Furthermore, mounting evidence suggests that overtreatment of renal masses with RN is associated with increased risk of chronic renal insufficiency, cardiovascular events and premature deaths. Accordingly, the AUA guidelines now explicitly place PN as the standard of care for small renal tumors.
Photo: Dr. Wiebusch, Urology, P.C.
With the rapid uptake of minimally invasive technology by the urological community, laparoscopic partial nephrectomy (LPN) and, more recently, robot-assisted partial nephrectomy (RAPN) have emerged as viable alternatives to open partial nephrectomy (OPN) for the management of suspected renal malignancy. The long-term oncologic and functional outcomes of LPN are comparable to those of OPN, with the potential benefits of decreased blood loss, shorter hospital stay, improved cosmesis and more rapid convalescence. However, LPN remains technically challenging, requiring considerable technical expertise to achieve adequate tumor resection and renorrhaphy while minimizing ischemia times.
Among its potential advantages, robotic technology offers high definition 3-dimensional visualization, a wide range of wristed instrument motion and scaling of surgeon movements. RAPN appears to have a shorter learning curve than LPN and, as such, may facilitate and promote the use of minimally invasive nephron sparing surgery. The technique of RAPN continues to evolve.
Despite increasing acceptance of elective PN by urologists as a feasible, oncologically sound and less morbid treatment option for small renal masses, PN remains underutilized. Indeed, as expertise in robotic surgery has increased, RAPN has been offered to more patients, including those with larger, endophytic and central masses. Studies have demonstrated that RAPN can, in fact, be performed safely and with acceptable outcomes for increasingly more complex renal tumors.