Table 2.
Comparison of treatment modalities for RCC in solitary kidneys
| Characteristic | Open Partial Nephrectomy (OPN) | Robot-Assisted Partial Nephrectomy (RAPN) | Ablative Therapies (Cryo/RFA/MWA) | Stereotactic Ablative Radiotherapy (SABR) | Active Surveillance (AS) | Neoadjuvant Therapy |
|---|---|---|---|---|---|---|
| Mechanism/Approach | Open surgical resection | Minimally invasive, robotic-assisted resection | In situ thermal destruction (percutaneous/laparoscopic) | Targeted high-dose radiation delivered in a few sessions | Non-invasive imaging-based monitoring; biopsy if needed | Systemic administration of drugs (TKIs/ICIs) preoperatively to shrink tumor and downstage disease |
| Tumor suitability | Complex, centrally located tumors | T1 tumors (≤7 cm) with variable complexity | Small tumors (<3–4 cm); preferably peripheral | Small tumors; patients deemed non-surgical | Small tumors (<3 cm), slow growth; selected patients | Locally advanced or borderline resectable tumors; cases where downstaging may increase the feasibility of PN |
| Invasiveness/Morbidity | High (significant blood loss, longer hospital stay, prolonged recovery) | Moderate (minimally invasive with reduced morbidity) | Minimal (percutaneous/laparoscopic approach) | Minimal (percutaneous/laparoscopic approach) | Non-invasive | Non-invasive (biopsy possible) |
| Impact on ischemia | Frequent global warm ischemia (variable warm ischemia time) | Minimal ischemia (selective/off-clamp techniques; reduced warm ischemia time) | No ischemia | No ischemia | Not applicable | Improves feasibility of PN by reducing tumor size, thereby indirectly preserving renal parenchyma |
| Renal function preservation | Moderate to good (dependent on warm ischemia time and residual parenchyma) | Very good (due to reduced ischemia and high precision) | Excellent (no clamping required) | Excellent (highly precise targeting) | Maximal preservation (no surgical intervention) | Improves feasibility of PN by reducing tumor size, thereby indirectly preserving renal parenchyma |
| Oncologic control | Excellent | Excellent (potential for improved negative margins) | Good to excellent (risk increases with tumors >3 cm) | Good to excellent (local control achieved) | Acceptable risk of progression | Potentially improves resectability and long-term oncologic outcomes when combined with surgery; variable responses |
| Key advantages | Standard approach for handling extreme complexity | Minimally invasive, high precision, reduced ischemia, rapid recovery | Minimally invasive; no ischemia; repeatable | Non-invasive; avoids general anesthesia | Avoids treatment-related morbidity | May render unresectable tumors resectable; reduces tumor size and warm ischemia time; may treat micrometastatic disease |
| Key limitations | High morbidity, slower recovery, and greater blood loss | Requires specialized expertise and technology; higher cost | Limited efficacy for larger tumors; requires careful follow-up | Limited long-term data; no pathological confirmation; cost considerations | Risk of tumor progression/metastasis; potential patient anxiety | Systemic toxicities; variable response; requires careful patient selection and standardization of protocols |
| Follow-up requirements | Standard imaging protocols | Standard imaging protocols | Frequent and meticulous imaging | Regular imaging assessments to evaluate treatment response | Regular imaging and clinical monitoring | Regular imaging to assess tumor response and routine monitoring of systemic therapy side effects |