Imperative partial nephrectomy versus radical nephrectomy in patients with renal cell carcinoma and venous thrombus

Introduction: Standard treatment for renal cell carcinoma (RCC) with renal (T3a) or caval (T3b-c) vein thrombosis is Radical nephrectomy (RN) plus thrombectomy. Partial nephrectomy (PN) plus thrombectomy may be used in these cases, however little evidence exists about this procedure. Materials and Methods: From 2,552 patients with RCC T3a-c of a multicentre series, 22 had an imperative PN plus thrombectomy and were compared, through an individual matched analysis, with 22 controls who underwent RN plus thrombus excision. Primary outcomes were long term renal function, evaluated through serum creatinine levels (sCr), and cancer specific survival (CSS). Kaplan-Meier curves were plotted and log-rank test were used for group comparisons. Results: The 2 groups had no differences in median age (PN 59, IQ range (IQR) 48-66 years; RN 61, IQR 59-67 years; p=0.3), mean pre-operative sCr (PN 1.24±0.57 mg/dL; RN 1.17±0.35 mg/dL; p=0.76), mean maximum tumour diameter (PN 4.86±2.1 cm; RN 5.03±1.9 cm; p=0.79), mean BMI (PN 27.9±7.68 and RN 28.59±4.7 Kg/m2; p=0.37), mean blood loss (PN 1670±2535 mL; RN 2162±3257 mL; p=0.74), median Fuhrman grade (3 in both groups) and metastasis (4 PN and 3 RN patients; p=1). Para-aortic lymphadenectomy was performed in 6 cases per group (p=1) and postoperative complications were experienced by 10 PN and 14 RN patients (p=0.36). Mean follow up was 45±47 months (p=0.78), in this time 9 PN and 13 RN patients died because of disease progression with a CSS of 59.09% and 40.91% respectively (Figure 1, p=0.428). At last follow up sCr levels were 1.53±0.63 in PN group and 1.99±2.27 mg/dl in RN group (p=0.62). At univariate analysis deceased patients, compared to alive patients at last follow up, had an increased surgical blood loss (2794.12±3633 vs. 750±630 mL; p=0.018), an increased operation time (343.86±148 vs. 218.47±97 min; p<0.01) and longer hospital stay (14.43±7.5 vs. 8.19±5.18; p=0.0049). Discussion and Conclusion: In patients with high-risk RCC plus renal or caval thrombi PN, compared (Figure presented) to RN, may have a non-inferior CSS; maintaining comparable long-term sCr levels and postoperative complication rates. Further studies are needed to evaluate the potential role of PN in T3a-c RCC.