Nephron-sparing surgery has emerged while the medical procedures of preference for

Nephron-sparing surgery has emerged while the medical procedures of preference for little renal masses in the last 2 decades, replacing the original teaching of radical nephrectomy for renal cellular carcinoma. localized tumours. Consequently, Robsons traditional radical nephrectomy (RN), which involved full excision of the contents of Gerotas fascia like the kidney and adrenal gland, with early vascular control and lymphadenectomy from the crus of the diaphragm to the aortic bifurcation, remained the mainstay of treatment for nearly 50?years [1, 2]. Robson could demonstrate a standard 5-season survival of 52% in the huge symptomatic masses that predominated in those days, and radical nephrectomy remained the typical LGK-974 biological activity to which all remedies for RCC had been compared [2]. Development of Nephron-Sparing Surgical treatment Partial nephrectomy (PN) was initially described by Wells in 1884, for a perirenal fibrolipoma [1]. Subsequently in 1887, Czerny described its use for a malignant renal angiosarcoma [4]. In the 1950s, Vermooten strengthened the rationale for PN when he showed that a 1-cm margin was adequate for local tumour control LGK-974 biological activity [4]. However, the high morbidity associated with the procedure in the form of bleeding and urinary fistula, coupled with the success of Robsons RN, led to a poor adoption of PN by the urological community [4]. At this time, PN was relegated to absolute indications wherein radical nephrectomy would render the patient anephric or dialysis dependent, for example, tumours in a solitary kidney or bilateral renal tumours. Evolution in surgical techniques for open LGK-974 biological activity stone surgery and renal trauma in the 1960s and 1970s, with the development of renal cooling, reno-protective techniques and renorrhaphy, coupled with greater knowledge of the renal vascular and collecting system anatomy, led to resurgence in interest in PN for renal masses [4]. Simultaneously, the development of modern imaging techniques including ultrasound (US) and computed tomography (CT) led to the detection of a new class of small, incidentally detected renal lesions (small renal massesSRM) for whom traditional RN seemed an overkill [5]. Further understanding of the biology of cancer in general, and a move away from the Halstedian concept of wider excisions, also strengthened interest in PN. In 1993, Licht and Novick reported their experience of 241 cases with a normal contralateral kidney that underwent renal tumour resection alone [6]. The median tumour size was 3.5?cm, and they demonstrated only two local recurrences with a 95% survival at 3?years [6]. The term nephron-sparing surgery (NSS) was coined, and a new era in the management of RCC dawned. Rationale for NSS Renal Tumour Biology While the traditional large symptomatic renal masses were often lethal, 70% of tumours diagnosed today are small and incidentally detected on imaging for other indications. Despite improvements in imaging modalities, they remain non-specific for the diagnosis of malignancy and nearly 20% of SRMs are found to be benign on histopathology with diagnoses including oncocytoma, angiomyolipoma, metanephric adenoma or hemorrhagic cyst [7]. The Rabbit polyclonal to DDX20 incidence of benign tumours increases from 7% for tumours 7?cm to 38% for tumours 1?cm [8]. However, Nguyen and Gill have shown that up to 5% of tumours 2?cm can metastasize, thereby underscoring the importance of NSS as a perfect means of achieving tumour control with maximum organ preservation [9]. Oncological Efficacy of NSS A number of studies in the late 1990s and early 2000s demonstrated that NSS provided equivalent oncological outcomes to RN for tumours 4?cm [1]. Long-term results published by Fergany et al. revealed cancer-specific survival of 98% at 5?years and 92% at 10?years for patients who also underwent PN for tumours 4?cm, regardless of the indication for surgery (i.e. absolute or elective) [10]. Numerous other investigators found no difference in disease-specific survival, progression-free survival or recurrence-free survival between RN and NSS, especially in tumours 5?cm [1]. A disease-specific survival of 90C100% was found in several series for elective NSS for SRMs [1]. Initial objections to NSS for elective indications included the possibility of multifocal RCC and the risk of positive surgical margins and subsequent tumour recurrence. Many studies have since demonstrated that gross resection of all tumour, as assessed intraoperatively by the surgeon, with microscopically unfavorable margins, allows excellent local control without increased risk.