Kidney-sparing treatments are salvage options for renal cell carcinoma (RCC) after local recurrence. However, there is no level 1 evidence in the literature examining the efficacy of focal therapies (FTs) and partial nephrectomy (PN) in a head-to-head, randomised comparison.
A systematic search (PROSPERO CRD420251033642) was performed. The present analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement.
Overall, 30 studies involving 873 patients were included in the final analysis. Patients with RCC were treated primarily with FTs (n = 376, 43%) and PN (n = 462, 53%). Of FTs, cryoablation was received by 198 (57%) RCC patients. The rates of recurrence for FTs ranged from 4% to 20%, while those for PN ranged from 3% to 19%. The intraoperative complication rates ranged from 2% to 6% for FTs and from 3% to 9% for PN. The postoperative complications rates ranged from 2% to 40% for FTs and from 8% to 40% for PN, while the major postoperative complications rates, defined as Clavien-Dindo ≥3, ranged from 2% to 9% for FTs and from 1% to 18% for PN. The rates of overall survival ranged from 82% to 100% for FTs, and from 96% to 100% for PNs. Limitations included the bias in patients’ selection and the absence of time-to-event data.
PN achieved acceptable overall survival, recurrence, and complication profiles, demonstrating its feasibility in a salvage setting. Patient selection is mandatory to identify those best candidates for PN and FT, thereby prioritising oncological outcomes.
Local recurrence after surgery for renal cell carcinoma (RCC) is a relatively rare occurrence, whose true incidence is unknown mainly due to the use of broad definitions. In the literature, data on natural history, oncological outcomes and prognostic factors of local recurrence are scarce. Therefore, it is difficult to make specific treatment recommendations. Available data highlight the role of kidney-sparing strategies, i.e. partial nephrectomy or focal therapy or radiotherapy, as reliable treatment options with good survival outcomes and low perioperative complication rates.
Recently, a systematic review on the role of kidney-sparing treatments for local recurrence in renal cell tumours after partial nephrectomy or focal therapy was published by Di Bello and al. on European Urology Focus. In this review, the authors analysed data from studies of patients undergoing partial nephrectomy or focal therapy as salvage treatment for local recurrence of RCC following prior nephron-sparing treatment (either partial nephrectomy or focal therapy).
The authors included 30 studies involving 873 patients overall. Primary treatment was nearly equally distributed, as 53% (n = 462) of patients underwent partial nephrectomy and 43% (n = 376) focal therapy. Among the latter, cryoablation was the most used (n = 198, 53%). The primary treatment was not specified for 35 (4%) patients.
The rates of recurrence ranged from 4% to 20% in patients treated with primary focal therapy and from 3% to 19% for those treated with partial nephrectomy. However, only a minority of papers reported on median time to local recurrence, which appeared shorter in focal therapy-treated patients (from 4 to 33 months) than in partial nephrectomy-treated ones (from 26 to 99 months).
Regarding perioperative outcomes of salvage treatment, intraoperative complications occurred in up to 6% of focal therapies and up to 9% of partial nephrectomy. The postoperative complications rates varied considerably, ranging from 2% to 40% for focal therapies and from 8% to 40% for partial nephrectomies. Nonetheless, major postoperative complications rates, defined as Clavien-Dindo ≥3 were relatively low (up to 9% for focal therapies and up to 18% for partial nephrectomies).
Regarding survival outcomes, both focal therapies and partial nephrectomies achieved excellent overall survival rates, ranging from 82% to 100% and from 96% to 100%, respectively. Similarly, recurrence rates after salvage treatment were acceptably low, ranging from 1% to 20%, depending on the clinical scenario.
The results of this article are in line with previous ones that demonstrated the feasibility and accuracy of nephron-sparing treatments in cases of local recurrence. As previous articles, the main limitation of this review is the heterogeneity of included studies, in terms of patients and tumour characteristics, definition of local recurrence, as well as reporting on treatment outcomes. For these reasons and for the lack of randomised clinical trials, evidence-based recommendations are difficult to make, and each case should be discussed within a multidisciplinary team to identify the best treatment for the ideal candidate, balancing comorbidities and life expectancy, kidney function, recurrence characteristics and expected outcomes.
Nonetheless, with the expanding indications of nephron-sparing strategies as primary treatment for RCCs, including partial nephrectomy, focal therapy and emerging radiotherapy, – slightly higher rates of local recurrence may be expected in the near future. While, although desirable, it would be difficult to have level I evidence on this topic, we should encourage the use of standard definitions of both inclusion criteria and outcomes, to guide clinicians in the decision-making process of this scenario.