Which factors can influence post-operative renal function preservation after nephron-sparing surgery for kidney cancer: a critical review

Abstract

Introduction: The aim of this article was to compare different surgical approaches to perform nephron-sparing surgery (NSS) in terms of preservation of renal function.

Material and methods: We critically reviewed the literature from January 2000 to December 2020 including studies comparing different surgical techniques.

Results: A total of 51 studies met the inclusion criteria. Functional outcomes were evalutated in terms of percentual change of estimated glomerular filtration rate (eGFR) and impaired renal function (IRF) on scintigraphy. In cases with a mean age <60 years, the mean decrease in eGFR after NSS was 11.7% and that of IRF 10.0%, whereas higher changes were found in cases with a mean age ≥60 years. For open NSS, the mean eGFR and IRF changes were 15.3% and 21.1%, respectively; using the laparoscopic approach, the mean percentual eGFR and IRF changes were 13.9% and 11.1%, respectively; in robotic cases, the mean eGFR and IRF changes were 10.8% and 13.1%, respectively. In cases performed with global ischemia, the mean eGFR and IRF changes were 12.7% and 15.1%, respectively. Similar results were found distinguishing ischemia time ≤20 and >20 minutes, whereas using the off-clamp technique the mean decreases in eGFR and IRF were only 4.2% and 6%, respectively.

Conclusions: Patients' age, tumor size, off-clamp technique, and robot-assisted approach were significant independent predictive factors able to influence renal function changes after NSS. A lower reduction of eGFR and IRF after NSS was reported in patients aged <60 years, submitted to a robot-assisted procedure, and using selective and cold ischemia <20 minutes or an off-clamp technique.

Keywords: kidney cancer; nephron-sparing surgery; partial nephrectomy; renal function.

Figure 1

PRISMA flow diagram. From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed1000097 For more information, visit www.prisma-statement.org

Figure 2

Surgical approach (open, laparoscopic or robot-assisted) (A) and ischemia technique (global, selective, warm or cold ischemia) (B) used in the whole population of the 51 included studies.

Figure 3

eGFR and IRF percentual change stratified by patient’s age (≥60 or <60 years) (A), tumor size (≤4 or >4 cm) (B), and surgical approach (open, laparoscopic or robot-assisted) (C) in the whole population of the 51 included studies. eGFR – estimated glomerular filtration rate; IRF – impaired renal function

Figure 4

eGFR and IRF percentual change stratified by ischemia type (global, selective, warm or cold ischemia) (A), and ischemia time (≤20 or >20 minutes) (B) in the whole population of the 51 included studies. eGFR – estimated glomerular filtration rate; IRF – impaired renal function