Richard E. Link, MD, PhD, presented “Nephron-Sparing Renal Surgery: A Deeper Dive Into How Local Recurrence Issues Alter Preoperative and Postoperative Decision-Making” during the 25th Annual Innovations in Urologic Practice on September 26th, 2021, in Santa Fe, New Mexico.
How to cite: Link, Richard E. “Nephron-Sparing Renal Surgery: A Deeper Dive Into How Local Recurrence Issues Alter Preoperative and Postoperative Decision-Making.” September 26th, 2021. Accessed Jul 2024. https://grandroundsinurology.com/nephron-sparing-renal-surgery-a-deeper-dive-into-how-local-recurrence-issues-alter-preoperative-and-postoperative-decision-making/
Nephron-Sparing Renal Surgery: A Deeper Dive Into How Local Recurrence Issues Alter Preoperative and Postoperative Decision-Making
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.”
About The 25th Annual Innovations in Urologic Practice:
Presented by co-chairs Mohit Khera, MD, MBA, MPH, and Michael Coburn, MD, FACS, the Innovations in Urologic Practice conference provides a detailed review and commentary on multiple genitourinary and urologic diseases. Among the featured oncological topics are bladder cancer and immunotherapies, as well as upper tract cancer management, prostate cancer, including state-of-the-art imaging, focal therapy, and MRI. Experts also discuss new tools and techniques for nephrectomy and treating advanced renal cell carcinoma. In terms of general urological approaches, the conference also includes pelvic reconstruction and trauma, men’s health topics like male infertility and sexual dysfunction, and ways to diagnose and treat infections in the urology patient. Dr. Link presented this talk at the 2021 conference.
For further educational activities from this conference, visit our collection page.
ABOUT THE AUTHOR
Richard E. Link, MD, PhD, is a professor and board-certified and fellowship-trained urologist specializing in the treatment of urologic disease affecting the kidney, ureter, adrenal gland and prostate. Dr. Link holds the Carlton-Smith Endowed Chair in urologic education at the Baylor College of Medicine (BCM) in Houston, Texas and directs the BCM division of endourology and minimally invasive surgery. He serves as director of living donor procurement for several major kidney transplant programs in Houston, including Baylor St. Luke’s Medical Center, Texas Children’s Hospital, and the Houston Methodist Hospital. Dr. Link focuses on the use of laparoscopic, robotic-assisted, percutaneous, and endoscopic techniques to treat kidney and prostate tumors, benign prostatic hypertrophy, renal and ureteral obstruction, and urinary tract stones and has been an early pioneer in the development of laparoendoscopic single-site donor nephrectomy.
Dr. Link earned both his MD and PhD in molecular and cellular physiology at Stanford University in California and completed an internship and residency at BCM before completing a fellowship at The Johns Hopkins University School of Medicine in Baltimore, Maryland. Dr. Link also has a strong interest in applying single site robotic technology using the da Vinci SP platform to retroperitoneal and transvesical urologic surgery. He has published numerous papers and earned many awards, including the Fulbright and Jaworski LLP Faculty Excellence Award for Teaching and Evaluation at BCM.
