Richard E. Link, MD, PhD

Richard E. Link, MD, PhD, Professor of Urology and the Carlton-Smith Endowed Chair in Urologic Education at the Baylor College of Medicine in Houston, Texas, discusses the evolving standard of care for renal tumors, and how to determine whether someone should have nephron-sparing surgery. He provides some history, explaining that radical nephrectomy used to be standard for all patients with renal tumors, but that due to improvements in technology and technique, partial nephrectomy is now used in a large percentage of cases. Dr. Link argues that with this great power to perform partial nephrectomies on almost all renal tumors comes a great responsibility to make sure that patients receive appropriate care for their individual cases. He observes that this can be complicated for multiple reasons, including that: decision-making about suitability for nephron sparing is not solely an oncologic decision; resecting more complex tumors may be associated with higher perioperative complication risks and likely results in more renal function loss; older or sicker patients tolerate complex or more lengthy surgery less well and may be less ideal candidates; and older patients likely have less to gain from nephron-sparing due to life expectancy. Beyond those concerns, Dr. Link lists and discusses several fundamental oncologic questions to consider in determining whether a patient is a good candidate for partial nephrectomy or not. These include assessing the risk of pathologic upstaging of “resectable appearing” tumors, the impact of tumor complexity on positive margins and how positive margins after partial nephrectomy alter outcome, the risk of de novo ipsilateral second primary tumors in the future and whether pathology and stage alter this risk in some fashion, and whether the patient would benefit more from a radical nephrectomy. Dr. Link concludes that: upstaging of cT1 tumors to pT3a at partial nephrectomy is relatively rare and portends a statistically significant if rather modest negative impact on recurrence free survival; risk of upstaging appears to be higher for larger tumors, higher RENAL scores, higher grade tumors, and those with irregular morphology; renal sinus fat invasion does not appear to be higher risk for poor oncologic outcomes than perinephric fat invasion; there is little data supporting better oncologic outcomes for radical nephrectomy as compared to partial nephrectomy for completely resected pT3 renal cell carcinoma; true positive surgical margins after partial nephrectomy have a significant negative impact on oncologic outcomes; larger tumors with higher RENAL scores raise the risk of positive margins at partial nephrectomy; and since little data exists about risk of second ipsilateral primary tumor development this should not drive decision making today outside of a genetic “diagnosis.”