**4. Discussion**

The mean tumour size was 48.1 mm. (range: 41-70 mm.). The mean tumor size in the patients who underwent NSS for elective indications was 44.7 mm. and in the patients who underwent NSS for absolute and relative indications was 65.8 mm (p<0.04). The difference between the lat‐ er two groups was not significant. Fifty three out of 57 tumors were pT1b (92.9 %) and 4 (7.1%) were pT3a. Pathological T3a stage was confirmed by tumor microinvasion into the perirenal fat. The final pathological evaluation did not reveal any case of tumor extension out of the inked area of the surgical specimens. Grade I tumor was diagnosed in 22 (38.6%), Grade 2 in 27 (47,4%) and Grade 3 in 8 (14%) cases. Morphological evaluation revealed 49 (85.9%) clear cell, 5

The mean duration of renal ischemia was 22 minutes (range: 18-35 mm.). No perioperative mortality and/or serious general complications (myocardial infarction, deep venous throm‐ bosis etc.) have been observed. Postoperative complications occurred in 5 (8.8%) patients in‐ cluding: one (1.7%) postoperative bleeding and 4 (7%) urinary fistulas. The bleeding was observed in peripherally located, large (6 cm. in size) tumor operated for absolute indica‐ tion. Urinary leakage occurred in two patients operated for centrally located (18.1%) and in two (4.2%) peripherially located tumors. This difference was statistically significant in favor of peripherially located tumors (p<0.0001). All patients required a double "J" stenting. Peri‐ renal hematoma was observed in 2 (3.5%) cases but did not need any intervention and re‐ solved spontaneously. Renal functions were stable in all patients during the follow-up period with a median postoperative creatinine level of 0.9 mg/dl (range: 0.7–1.4 mg/dl). The

The tumor has recurred in 6 (10.5%) patients. Of them, local recurrence was detected in 2 (3.5%) and systemic recurrence in 4 (7%) patients. At the end of the follow-up overall surviv‐ al was 85.8%, the disease-free survivals was 88.2 %. Both disease-free and overall survival were significantly better in groups of relative and elective indications as compared with ab‐

> 20 40 60 80 100 120 140 160 Followup

**Figure 1.** Cancer-specific survival in the patients with elective, relative and absolute indications for NSS.

Elective; Relative; Absolute

papillary (8.7%), 2 chromophobe (3.7%) and 1 cystic (1.75%) RCCs.

90 Renal Tumor

median hospital stay was 6 days (range: 4-15 days).

0.0

0.2

0.4

0.6

Surviving

0.8

1.0

solute indication (p=0.014 and p=0.023, respectively) (Figure 1).

The widespread use of modern radiological modalities substantially changed clinical pre‐ sentation of renal tumors in recent decades. Currently, there is a trend towards the diagnosis of asymptomatic, incidental, smaller lesions at lower stages [1, 3, 10]. The local disease re‐ currence is the major drawback of NSS mostly due to the incomplete resection of the pri‐ mary tumor. In this due radical nephrectomy still remains the gold standard for the treatment of RCC [4, 10].

Improved diagnostic and surgical techniques have led to wider use of NSS. Uzzo RG. and Novick AC. in their review of the results of more than 1800 cases of NSS have showed that the true biological significance of multicentric renal tumors and its implications for NSS re‐ mains to be elucidated [3]. In a prospective, randomized EORTC (European Organisation for Research and Treatment of Cancer) phase 3 study comparing open partial nephrectomy (OPN) with open radical nephrectomy (ORN) in small renal tumors (< 5 cm.) found compa‐ rable oncological results in the both arms [8, 9]. Moreover, excellent 5 and 10 year diseasefree survival rates of 98.5% and 96.7% have been reported after NSS in non-randomized studies [5-7]. These data are now widely accepted. Finally, the recent evidence favoring the NSS over radical nephrectomy in the prevention of chronic kidney disease and possibly linking it to a better overall survival will constitute a strong argument for wider use of NSS. On the other hand, NSS is technically more demanding than RN even for small renal tumors [13]. The previous report of the EORTC 30904 trial revealed that complication rate in NSS was slightly higher than in radical nephrectomy [8].

Based on the success of NSS in the tumors of ≤ 4 cm, it has been increasingly used for the treatment of 4-7 cm. tumors in case of a normal contralateral kidney. Leibovich BC. *Et al.* retrospectively compared the results of NSS and radical nephrectomy in the tumors of 4 to 7 cm in size. There were no statistically significant differences in cancer-specific survival and distant metastases-free survival after adjusting for important pathological features. Thus, the authors concluded that the NSS has excellent results for the treatment of 4 to 7 cm renal tumors in appropriately selected patients [14].

Dash A. *et al.* compared the outcomes of the patients who had an elective partial or radi‐ cal nephrectomy for clear cell renal cell carcinoma of 4–7 cm. in size. With the median follow-up of 21 months the authors failed to show that radical nephrectomy was associ‐ ated with a better cancer control than the NSS. In terms of functional results the authors found that the serum creatinine level 3 months after surgery was significantly lower in the patients who had NSS [15].

Becker F. *et al.* reported the excellent results of NSS performed for elective indications. 69 patients with the tumor size of more than 4 cm. underwent NSS. After a mean follow-up of 6.2 years seven patients (10.1%) have died, none of them due to the tumor-related causes. Tumor recurrence was detected in four patients (5.8%). The 5-year overall survival was 94.9%. The 10-year and 15-year overall survival was 86.7%. Cancer-specific survival was 100% at 5, 10, and 15 years. The authors concluded that the selected patients with localized RCC of > 4 cm. can be treated with elective NSS providing optimal long-term outcome. The surgeon's decision for organ-preserving surgery should depend on the tumor location and technical feasibility rather than on the tumor size [16].

The weak points of our study are retrospective nature and absence of control group consist‐ ing of RN patients. However, the prospective randomized study is very difficult to conduct

Nephron-Sparing Surgery for the Treatment of Renal Cell Carcinoma 4 to 7 cm in Size

http://dx.doi.org/10.5772/53830

93

In conclusion, the NSS is a feasible procedure for RCCs of 4-7 cm in size. The local cancer control can be achieved in most patients. Oncological outcome of the treatment is negatively related with the tumor size. Long-term prospective studies on the higher number of patients are required to prove the similar oncological efficacy of NSS and radical nephrectomy in the

[1] Hollingsworth JM, Miller DC, Daignault S, Hollenbeck BK. Rising incidence of small renal masses: a need to reassess treatment effect. J Natl Cancer Inst 2006; 98: 1331–

[2] Siegel R, Ward E, Brawley O, Jemal, A. Cancer Statistics, 2011. CA Cancer J Clin 2011;

[3] Uzzo RG, Novick AC. Nephron sparing surgery for renal tumors: indications, techni‐

[4] Herr HW. A history of partial nephrectomy for renal tumors. J Urol. 2005; 173:

[5] Lerner SE, Hawkins CA, Blute ML. Disease outcome in patients with low stage renal cell carcinoma treated with nephron sparing or radical surgery J Urol. 1996; 155:

[6] Herr HW. Partial nephrectomy for unilateral renal carcinoma and a normal contrala‐

[7] Fergany AF, Hafez KS, Novick AC. Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year followup. J Urol. 2000; 163: 442–445.

especially in the era of minimally invasive approaches for the treatment of RCC.

Ambrosi Pertia, Laurent Managadze and Archil Chkhotua

ques and outcomes. J Urol. 2001; 166(1): 6-18.

teral kidney: 10-year follow-up J Urol. 1999; 161: 33-34.

National Centre of Urology, Tbilisi, Georgia

**5. Conclusion**

RCCs of 4-7 cm. in size.

**Author details**

**References**

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Pahernick S. *et al.* compared the results of NSS for the tumors of less and more than 4 cm. in size. Out of 474 treated patients 102 had the tumor of more than 4 cm. The mean follow-up was 4.7 years. The 5 and 10-year cancer-specific survival for small and large tumors were: 97.9% and 95.8%, 94.9% and 95.8%, respectively. In contrast to the tumor size, stage pT3a was associated with a significantly higher risk of tumor related death. The authors advocat‐ ed that the surgeon's decision with regard to the organ preservation should consider the tu‐ mor location and safe surgical resectability, rather than the tumor size [17]. This conclusion has been later supported by Antonelli A. *et al.* [18].

Joniau S. *et al.* presented their results of NSS for the patients with bigger than 4 cm renal tumors. The following data have been collected and analyzed: surgical indication, tumor characteristics, complications, serum creatinine level, time to recurrence and time to the pa‐ tient death. Local cancer control has been achieved in the vast majority of patients. The renal function was preserved in the patients with elective indications. NSS for absolute indica‐ tions was significantly correlated with the loss of renal function but not with a cancer-specif‐ ic survival [19].

In our study the local disease recurrence was detected in 2 (3.5%) and the systemic recur‐ rence in 4 (7%) patients. We could not reveal any changes in the serum creatinine level preand postoperatively in the both groups, despite cold ischemia which was used in all patients. Both, the cancer-specific and overall survival was significantly better in the groups of relative and elective indications as compared with the absolute indication (p<0.014 and p<0.023, respectively). These data are similar to the results of the eight-institution multicen‐ tre review of 1048 NSS procedures [13].

It has been shown by Badalato GM. *et al*. in their recent publication that the oncological effi‐ cacy of NSS for pT1b renal tumors was comparable to that of radical nephrectomy [20]. The authors compared the NSS with radical nephrectomy in the patients with T1b RCC using a propensity scoring approach. 11 256 cases of 4-7 cm. tumors that underwent partial or radi‐ cal nephrectomy have been evaluated. The propensity score analysis was used to adjust for the potential differences in the baseline characteristics of the patients between the two groups. Overall and disease-free survival of the patients was compared in stratified and ad‐ justed analysis, controlling for propensity scores. For the entire patient cohort, no difference in the survivals was found in the NSS and radical nephrectomy groups. The survival differ‐ ence between the groups in a propensity-adjusted cohort of patients could not be confirmed even when stratified by the tumor size and patient age.

We've observed that the NSS for centrally located tumors was associated with a higher com‐ plication rate. This goes in accordance with the data of Ficarra V. *et al.* who recently pro‐ posed a new tumor scoring system [21]. According to the authors this system can better predict the complications after NSS than linear tumor size.

The weak points of our study are retrospective nature and absence of control group consist‐ ing of RN patients. However, the prospective randomized study is very difficult to conduct especially in the era of minimally invasive approaches for the treatment of RCC.
