Original Study| Volume 20, ISSUE 6, P501-509, December 2022

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



      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-functioncontralateral, and presuming 25% renal-functional-compensation.


      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.


      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.



      AUA (American urologic association), BMI (body mass index), CKD (chronic kidney disease), CT (computed tomography), eGFR (estimated glomerular filtration rate), IQR (interquartile range), MAG-3 (mercaptoacetyltriglycine), MRI (magnetic resonance imaging), OR (oncologic risk), PN (partial nephrectomy), RCC (renal cell carcinoma), R.E.N.A.L ((R)adius (tumor size as maximal diameter), (E)xophytic/endophytic properties of tumor, (N)earness of tumor deepest portion to collecting system or sinus, (A)nterior (a)/posterior (p) descriptor, and (L)ocation relative to polar lines), RMB (renal mass biopsy), RN (radical nephrectomy), SRF (split renal function), TC (tumor complexity)
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        • Huang WC
        • Elkin EB
        • Levey AS
        • Jang TL
        • Russo P.
        Partial nephrectomy versus radical nephrectomy in patients with small renal tumors-is there a difference in mortality and cardiovascular outcomes?.
        J Urol. 2009; 181: 55-62
        • Kates M
        • Badalato GM
        • Pitman M
        • McKiernan JM.
        Increased risk of overall and cardiovascular mortality after radical nephrectomy for renal cell carcinoma 2 cm or less.
        J Urol. 2011; 186: 1247-1253
        • Moskowitz D
        • Chang J
        • Ziogas A
        • Anton-Culver H
        • Clayman R V
        Treatment for T1a renal cancer substratified by size: “less is more.”.
        J Urol. 2016; 196: 1000-1007
        • Mir MC
        • Derweesh I
        • Porpiglia F
        • Zargar H
        • Mottrie A
        • Autorino R.
        Partial nephrectomy versus radical nephrectomy for clinical T1b and T2 renal tumors: a systematic review and meta-analysis of comparative studies.
        Eur Urol. 2017; 71: 606-617
        • Touijer K
        • Jacqmin D
        • Kavoussi LR
        • et al.
        The expanding role of partial nephrectomy: a critical analysis of indications, results, and complications.
        Eur Urol. 2010; 57: 214-222
        • Kim SP
        • Thompson RH
        • Boorjian SA
        • et al.
        Comparative effectiveness for survival and renal function of partial and radical nephrectomy for localized renal tumors: a systematic review and meta-analysis.
        J Urol. 2012; 188: 51-57
        • Pierorazio PM
        • Johnson MH
        • Patel HD
        • et al.
        Management of renal masses and localized renal cancer: systematic review and meta-analysis.
        J Urol. 2016; 196: 989-999
        • Weight CJ
        • Larson BT
        • Fergany AF
        • et al.
        Nephrectomy induced chronic renal insufficiency is associated with increased risk of cardiovascular death and death from any cause in patients with localized cT1b renal masses.
        J Urol. 2010; 183: 1317-1323
        • Campbell S
        • Uzzo RG
        • Allaf ME
        • et al.
        Renal mass and localized renal cancer: AUA guideline.
        J Urol. 2017; 198: 520-529
        • Campbell SC
        • Clark PE
        • Chang SS
        • Karam JA
        • Souter L
        • Uzzo RG.
        Renal mass and localized renal cancer: evaluation, management, and follow-up: AUA guideline: part I.
        J Urol. 2021; 206: 199-208
        • Levey AS
        • Coresh J
        • Greene T
        • et al.
        Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate.
        Ann Intern Med. 2006; 145: 247-254
        • Aguilar Palacios D
        • Caraballo ER
        • Tanaka H
        • et al.
        Compensatory changes in parenchymal mass and function after radical nephrectomy.
        J Urol. 2020; 204: 42-49
        • Takagi T
        • Mir MC
        • Sharma N
        • et al.
        Compensatory hypertrophy after partial and radical nephrectomy in adults.
        J Urol. 2014; 192: 1612-1619
        • Rathi N
        • Aguilar Palacios D
        • Tanaka H
        • et al.
        PD12-04 PD12-04 Predicting renal function after radical nephrectomy: the importance of split renal function.
        J Urol. 2021; 206(Supplement 3)
        • Rathi N
        • Yasuda Y
        • Palacios DA
        • et al.
        Split renal function is fundamentally important for predicting functional recovery after radical nephrectomy.
        Eur Urol Open Sci. 2022; 40: 112-116
        • Rathi N
        • Palacios DA
        • Abramczyk E
        • et al.
        Predicting GFR after radical nephrectomy: the importance of split renal function.
        World J Urol. 2022; 40: 1011-1018
        • Zhang Z
        • Zhao J
        • Zabell J
        • et al.
        Proteinuria in patients undergoing renal cancer surgery: impact on overall survival and stability of renal function.
        Eur Urol Focus. 2016; 2: 616-622
        • Kutikov A
        • Uzzo RG.
        The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth.
        J Urol. 2009; 182: 844-853
        • Tanaka H
        • Ding X
        • Ye Y
        • et al.
        Infiltrative renal masses: clinical significance and fidelity of documentation.
        Eur Urol Oncol. 2019; (Published online)
        • Kim SP
        • Campbell SC
        • Gill I
        • et al.
        collaborative review of risk benefit trade-offs between partial and radical nephrectomy in the management of anatomically complex renal masses.
        Eur Urol. 2017; 72: 64-75
        • Liss MA
        • Wang S
        • Palazzi K
        • et al.
        Evaluation of national trends in the utilization of partial nephrectomy in relation to the publication of the American urologic association guidelines for the management of clinical T1 renal masses.
        BMC Urol. 2014; 14
        • Bjurlin MA
        • Walter D
        • Taksler GB
        • et al.
        National trends in the utilization of partial nephrectomy before and after the establishment of AUA guidelines for the management of renal masses.
        Urology. 2013; 82: 1283-1290
        • Sorokin I
        • Feustel PJ
        • O'Malley RL
        National utilization of partial nephrectomy pre- and post- AUA guidelines: is this as good as it gets?.
        Clin Genitourin Cancer. 2017; 15: 591-597.e1
        • Vigneswaran HT
        • Lec P
        • Brito J
        • Turini G
        • Pareek G
        • Golijanin D.
        Partial nephrectomy for small renal masses: do teaching and nonteaching institutions adhere to guidelines equally?.
        J Endourol. 2016; 30: 714-721
        • Campbell SC
        • Novick AC
        • Belldegrun A
        • et al.
        Guideline for management of the clinical T1 renal mass.
        J Urol. 2009; 182: 1271-1279
      1. Motzer RJ, Jonasch E, Agarwal N, et al. NCCN guidelines version 1.2021 - kidney cancer.; 2020.

        • Ljungberg B
        • Albiges L
        • Abu-Ghanem Y
        • et al.
        European association of urology guidelines on renal cell carcinoma: the 2019 update.
        Eur Urol. 2019; 75: 799-810
        • Rathi N
        • Palacios D
        • Tanaka H
        • et al.
        PD12-04 predicting renal function after radical nephrectomy: the importance of split renal function.
        J Urol. 2021; 206
        • Beksac AT
        • Okhawere KE
        • Elbakry AA
        • et al.
        Management of high complexity renal masses in partial nephrectomy: a multicenter analysis.
        Urol Oncol Semin Orig Investig. 2019; 37: 437-444
        • Buffi NM
        • Saita A
        • Lughezzani G
        • et al.
        Robot-assisted partial nephrectomy for complex (PADUA score ≥10) tumors: techniques and results from a multicenter experience at four high-volume centers.
        Eur Urol. 2020; 77: 95-100
        • Shvero A
        • Nativ O
        • Abu-Ghanem Y
        • et al.
        Oncologic outcomes of partial nephrectomy for stage T3a renal cell cancer.
        Clin Genitourin Cancer. 2018; 16: e613-e617
        • Yim K
        • Aron M
        • Rha KH
        • et al.
        Outcomes of robot-assisted partial nephrectomy for clinical T3a renal masses: a multicenter analysis.
        Eur Urol Focus. 2020; (Published online)
        • Maurice MJ
        • Zhu H
        • Kim SP
        • Abouassaly R.
        Increased use of partial nephrectomy to treat high-risk disease.
        BJU Int. 2016; 117: E75-E86
        • Hollenbeck BK
        • Taub DA
        • Miller DC
        • Dunn RL
        • Wei JT.
        National utilization trends of partial nephrectomy for renal cell carcinoma: a case of underutilization?.
        Urology. 2006; 67: 254-259