Radical nephrectomy versus nephron sparing surgery: run after a chimera?
Literature data regarding oncological outcomes after radical nephrectomy and nephron sparing surgery are conflicting.
Van Poppel et al showed overlapping oncological data between radical nephrectomy (RN) and nephron sparing surgery (NSS), but NSS seems to provide lower OS results in comparison with RN  and slightly higher complication rate .
Moreover, a recent SEER database analysis conducted on a young population (20-44 yrs) showed no difference in cancer-specific survival at 5 or 10 years and in 5-year overall survival (P = 0.07), but a significative advantage in 10-year overall survival (P = 0.025) in partial nephrectomy cohort , whereas a retrospective study conducted on patients with T1 renal cancer documented that type of nephrectomy was not associated with overall survival 
The aim of our study was to compare the long-term oncological and functional outcome as well as the surgical complications of nephron sparing surgery (NSS) versus radical nephrectomy (RN) for any renal cell carcinoma (RCC) over all stages (T1-T4).
Materials and Methods
Between April 2000 and June 2016, 392 patients underwent renal surgery for RCC in two European academical centers.
129 women and 263 men with a median age of 65 years (range 23-88) underwent RN or NSS. 162/392 (41.3%) experienced a RN, whereas 239/392 (58.7%) underwent a NSS.
We compared long term overall survival (OS), cancer specific survival (CSS), disease free survival (DFS) in both groups of patients.
Moreover, functional parameters and surgical complications (according to Clavien Dindo classifications) were evaluated in the whole cohort.
Median follow-up time for these patients was 48.08 months (range 0.26-194.43).
Compared to RN, patients with NSS showed a significantly higher disease free survival (DFS) (70.2% vs 93.5%, p<0.001) and cancer specific survival (CSS) at 10 years (78.4% vs 97.8%, p<0.001), whereas the 10 years overall survival (OS) in both groups did not differ significantly (RN 65.3% vs NSS 71.3%, p= n.s.).
4% of NSS had a positive resection margin (PRM), but only 0.4% developed a recurrence within 23 months.
Within the follow up period, 7% of patients in the NSS group developed metastases VS 28.1% of the RN group.
At the last follow up, renal function preservation, moreover, was better in the NSS group, with a median glomerular filtration rate of 65 ml/min/1.72m2 (6-113) for NSS VS. 54 ml/min/1.72m2 (1.73-144) for RN (p<0.001). The new onset of chronic kidney diseases was significantly less in the NSS group.
Total complication rate was significantly lower in the RN group (5.6% vs 8.9%), but became comparable in the last years of observation.
Contrary to the literature data, our study showed an advantage in term of CSS and DFS in the NSS group, with no significative effects on OS, and with an acceptable complication rate.
NSS was performed whenever technically possible but was obtained with a higher (but acceptable) surgical complication rate. It could be shown that also for higher stages of RCC, NSS can be safely performed. Renal function preservation, CSS and DFS were better in the NSS group but surprisingly NSS did not lead to a better OS. This stands in contrast to the most published studies of the last decades.
1. Van Poppel H, Da Pozzo L, Albrecht W, et al. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol. 2011 Apr;59(4):543-52.
2. Van Poppel H, Da Pozzo L, Albrecht W, et al. A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol. 2007 Jun;51(6):1606-15.
3. Daugherty M, Bratslavsky G. Compared with radical nephrectomy, nephron-sparing surgery offers a long-term survival advantage in patients between the ages of 20 and 44 years with renal cell carcinomas (≤4 cm): an analysis of the SEER database Urol Oncol. 2014 Jul;32(5):549-54.
4. Kyung YSm You D, Kwon T et al The type of nephrectomy has little effect on overall survival or cardiac events in patients of 70 years and older with localized clinical t1 stage renal masses. Korean J Urol. 2014 Jul;55(7):446-52.