A 45-year-old man presents with a 4 cm enhancing solid mass in the left kidney on CT. CT guided biopsy confirms clear cell renal cell carcinoma. Pre-operative workup shows a solitary kidney on the right. The left kidney GFR is 35 mL/min. What is the surgical preference in this scenario?
- A Radical left nephrectomy
- B Active surveillance with repeat imaging at 3 months
- C Ablative therapy (radiofrequency or cryoablation) as it preserves more renal parenchyma than partial nephrectomy
- D Partial nephrectomy (nephron-sparing surgery) ✓
Explanation
In the setting of a solitary functioning contralateral kidney, partial nephrectomy (nephron-sparing surgery) is an imperative indication — even for tumours >4 cm where it might otherwise be optional. Radical nephrectomy would leave this patient with a single kidney operating at 35 mL/min, risking progression to end-stage renal disease requiring dialysis. EAU guidelines classify imperative indications for partial nephrectomy as: solitary kidney, bilateral tumours, familial RCC, hereditary RCC syndromes, or pre-existing impaired renal function. The oncological outcomes of partial nephrectomy for T1 RCC are equivalent to radical nephrectomy.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.