Volume 10 Issue 5, May 2013

Despite the increased use of active surveillance as primary management for small renal tumours, there is a paucity of data regarding its effect on quality of life. A recent study suggests that uncertainty of illness could predict decreased quality of life in patients undergoing active surveillance.

The incidence and consequences of positive surgical margins after partial nephrectomy are important issues in the management of localized renal cell carcinoma. A recent population-based study demonstrates a slightly higher rate of positive margins than previously reported in monocentric studies. However, margin status had no impact on overall or disease-specific survival.

Currently, there is no consensus on the optimal follow-up protocol for localized renal cancer after surgery. A new study reveals that existing protocols vary widely, leading to differences in diagnostic radiation exposure and cost. Cumulative ionizing radiation exposure has been suggested to cause second malignancy, but further research is required.

Maximal renal preservation, particularly in patients with pre-existing renal dysfunction, is imperative to minimize the risk of significant renal insufficiency for patients undergoing partial nephrectomy. Improvements in surgical technology, including modalities such as off-clamp laser enucleation, might move us closer to this goal.

Partial nephrectomy has become the standard of care for small renal masses, with minimally-invasive techniques such as laparoscopic, robotic-assisted and laparoendoscopic single-site surgery (LESS) becoming increasingly popular. However, the complexity of the procedure generates uncertainty as to whether successful outcomes of LESS partial nephrectomy from large-volume centres can be translated into smaller urology practices.

The lack of standardized nomenclature and level 1 evidence has led to controversy regarding pelvic lymph node dissection during radical prostatectomy. However, the knowledge of metastases presence and location can be valuable to guide therapy. Including internal iliac nodes in standard dissection can improve metastasis detection, with minimal added risk of complications.

Analysis of long-term outcomes from the Prostate Cancer Outcomes Study has demonstrated that the differences in functional outcomes among men undergoing prostatectomy or radiotherapy for localized prostate cancer are slight. Regardless of treatment type, men experienced deteriorated urinary and erectile function in the long term. Is now the time to reconsider our aggressive treatment approaches?

Smaldone and colleagues discuss the efforts that have been made to delineate the malignant potential of small renal masses (SRMs) in the preoperative setting and describe the existing data on the natural history of SRMs under observation. They also discuss the rationale for current active surveillance protocols.

Partial nephrectomy remains the cornerstone of treatment for the otherwise healthy patient with a small renal mass and good life expectancy. Herein, the authors present an update on the contemporary status of partial nephrectomy, focusing on the evolving indications, technical advancements and current outcomes data.

Ablative modalities, which use energy–tissue interactions to ablate tumours, have emerged as an intermediate treatment option between active surveillance and surgical resection. In this Review, the authors discuss the four main ablative modalities that have been used to treat small renal masses—cryoablation, radiofrequency ablation, microwave ablation and irreversible electroporation.

Despite accumulating evidence that partial nephrectomy provides equivalent oncological outcomes to radical surgery while also preserving renal function and preventing the adverse cardiovascular effects of chronic kidney disease, the technique remains underused. In this Review, Russo discusses the evolution of the partial nephrectomy technique and the importance of kidney-sparing surgery for small renal masses.

Increasing evidence has shown that a solid tumour can 'hijack' pre-existing blood vessels and integrate them into the tumour vasculature during expansion. In this Perspectives article, Chao-Nan Qian argues that this process—vessel co-option—likely occurs in clear cell renal cell carcinoma, along with the complementary processes of vessel remodelling and extratumoural angiogenesis.