The recently released American Urological Association guidelines for the management of renal masses1 brought together a multidisciplinary team of experts to perform a rigorous evidence-based systematic review utilizing research from the Agency for Healthcare Research and Quality (AHRQ). Significant changes in the new guidelines include perspectives on the role of renal mass biopsy, a more defined role for thermal ablation, and increased use of active surveillance in elderly or infirmed patients with small renal masses. Notably, the new guidelines call for increased attention to perioperative renal function and more clear guidance on the use of partial versus radical nephrectomy.
Functional recovery after renal cancer surgery is considered a major issue for cancer survivorship. The guidelines include more comprehensive recommendations about assigning chronic kidney disease (CKD) stage, checking for perioperative proteinuria with routine urinalysis, and counseling regarding functional outcomes related to the different treatment strategies. Pathologic evaluation of non-tumorous adjacent renal parenchyma is emphasized (statement #23), as are defined recommendations for referral for nephrology consultation (statement # 8).
To avoid CKD, the guidelines now provide detailed review of the risk/benefit profile comparing partial to radical nephrectomy. The guidelines recommend considering radical nephrectomy for localized tumors under the following conditions (guideline statement #19): when increased oncologic potential is suggested by tumor size, biopsy (if performed), and or imaging characteristics. In this setting, radical nephrectomy is generally preferred if all the following criteria are met: 1) high tumor complexity and partial nephrectomy would be challenging even in experienced hands; 2) no preexisting CKD/proteinuria; and 3) normal contralateral kidney and new post-op baseline glomerular filtration rate greater than 45 mL/min/1.73 m2. Beyond this, most cT1a/b and T2 tumors can be considered for partial nephrectomy. Radical nephrectomy may be required based on surgical discretion in patients who do not meet these criteria and in whom partial nephrectomy may not be possible or advisable even in experienced hands.
Despite efforts to increase awareness of the potential benefits of nephron-sparing approaches, partial nephrectomy remains underused. A main goal of the guidelines is to refocus the physician and care team on the evaluation and implications of CKD, on the renal functional tradeoffs of surgery, and on the need to increase nephrology involvement in the care of these patients. As such, the guidelines should provide practicing urologists a valuable resource in the evaluation and management of this patient population.
Robert G. Uzzo, MD, FACS, is a Professor and Chairman of the Department of Surgery and the G. Willing “Wing” Pepper Chair in Cancer Research at Fox Chase Cancer Center at Temple University School of Medicine in Philadelphia.
- Campbell S, Uzzo RG, Allaf ME, et al. Renal Mass and Localized Renal Cancer: AUA Guideline. J Urol. 4 May 2017. doi: 10.1016/j.juro.2017.04.100