How far should partial nephrectomy be extended for renal cell carcinoma?

Conservative renal surgery for cancer has now achieved consensus for imperative, relative, and elective indications (tumor < 4 cm with healthy contralateral kidney). The results show 90%–100% 10-year survival rates and 0%–3% recurrence rates. Surgical techniques are improving and complication rates are decreasing with experience.

It is now recognized that margin thickness has no real significance provided that it is negative, even if excision is flush with the tumor capsule. Finally, the frequently cited multifocal lesions are no longer an argument against conservative surgery. The usual limitations of conservative surgery are the size and location of the tumor. Nevertheless, there is no statistically significant difference in the survival and recurrence rates between T1 a (<4 cm) and T1 b (4-7 cm) tumors, even if the risk of renal sinus fat tissue involvement increases proportionally with tumor size. Finally, resectiog tumors of the renal sinus is possible without adding to the risk of metastasis but increases the risk of surgical complications.

The risk of deteriorated renal function with radical nephrectomy is now well documented. Laparoscopy, which has become the reference treatment mode for radical nephrectomy, remains reserved for conservative surgery for exophytic tumors less than 3–4 cm because of the technical difficulties involved in resection and hemostasis.

Although conservative surgery is now recognized, extending its indications to tumors greater than 4 cm or in cases of parenchymatous location is supported by real arguments that need to be confirmed. The limit remains the surgical feasibility.