The cornerstone of treatment of small renal masses (SRMs), which are renal cancers of less than 4 cm, is surgical removal; metastatic renal cancer is largely incurable with limited response to chemotherapy and radiotherapy. Thus, most patients with SRMs elect surgery, either partial or radical nephrectomy by open or minimally invasive techniques. Guidelines from the American Urological Association1 published in 2009 urge partial nephrectomy for SRMs if technically feasible, with radical nephrectomy, ablation, or surveillance as alternatives based on tumor or patient preference. Since the description of partial nephrectomy, the techniques of vascular control (zero ischemia), urinary reconstruction, cold ischemia, and minimally invasive approaches have evolved with the goal of saving every possible nephron. Despite widespread use of partial nephrectomy at academic and tertiary referral centers,2 how far have we come as a field? In this issue of JAMA Surgery, Huang et al3 report on their analysis of national Surveillance, Epidemiology, and End Results registry4 data in which they describe trends in management of SRMs from 2001 to 2009. The authors establish partial nephrectomy as the new standard of treatment for SRMs, with the frequency of nephron-sparing surgery eclipsing that of radical nephrectomy in 2009. Survival outcomes of partial nephrectomy appear to be at least equivalent and potentially superior in the short term (median, 63 months) compared with radical nephrectomy. Practically, the support for partial nephrectomy is bolstered both by patients hoping to preserve as much kidney as possible to prevent the burdens of hemodialysis and the urologist who has benefited from improvements in surgical experience and minimally invasive surgery. In 2015, most urologists first think, “How can I perform a partial nephrectomy for this mass?” with considerable disappointment when a radical nephrectomy is necessary owing to location of the mass or patient comorbidity.
Meeks JJ, Gonzalez CM. Standard of Care for Small Renal Masses in the 21st Century. JAMA Surg. 2015;150(7):672-673. doi:10.1001/jamasurg.2015.0440