Oncology: Adrenal/Renal/Upper Tract/Bladder

Open Partial Nephrectomy for Tumor

in a Solitary Kidney: Experience With 400 Cases
Amr F. Fergany,* Ismail R. Saad, Lynn Woo and Andrew C. Novick
From the Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio

Purpose: We present a series of 400 patients with tumor in a solitary kidney who underwent open surgical partial
nephrectomy performed by a single surgeon (ACN) with a primary focus on postoperative long-term kidney function.
Materials and Methods: A total of 400 patients with sporadic nonfamilial kidney tumors in a solitary kidney underwent
open partial nephrectomy between 1980 and 2002. In 323 patients (81%) the contralateral kidney had been surgically
removed, while the remaining 77 (19%) had a congenital solitary kidney. Renal insufficiency was present preoperatively in
184 patients (46%). Adverse risk factors for partial nephrectomy were present in a large percent of patients. Intraoperative
and postoperative parameters were evaluated at a mean followup of 44 months.
Results: In the overall series 5 and 10-year cancer specific survival was 89% and 82%, respectively. Surgical complications
occurred in 52 patients (13%), most commonly urinary leakage. Early postoperative renal function was achieved in 398
patients (99.5%). Only 2 patients required permanent dialysis postoperatively. Satisfactory long-term renal function was
achieved in 382 patients (95.5%). A total of 18 patients had progressed to renal failure a mean of 3.6 years after surgery.
Patient age, the amount of renal parenchyma resected, a congenitally absent or atrophic contralateral kidney and the time
of contralateral nephrectomy were noted to be significantly associated with postoperative renal function.
Conclusions: Open surgical partial nephrectomy can be safely performed in patients with tumor in a solitary kidney.
Long-term cancer-free survival with the preservation of renal function can be reliably expected in most of these cases.

Key Words: kidney; carcinoma, renal cell; nephrectomy; abnormalities

CC accounts for approximately 85% of all solid renal phrectomy for tumor in a solitary kidney with special em-

R masses. Most patients who are diagnosed with solid,

enhancing renal masses today are treated as though
they had RCC and undergo surgery. The widespread use of
phasis on the renal function outcome.

modern imaging has resulted in the increased detection of
small, asymptomatic renal tumors, which has led to the
increasing use of nephron sparing techniques (partial ne-
phrectomy) for the surgical removal of such lesions. Partial
nephrectomy has become an accepted modality for RCC with
an oncological outcome similar to that of radical nephrec-
tomy in appropriately selected cases. Although oncological
outcomes have been extensively studied,1–3 the long-term
effect of partial nephrectomy on renal function has not been
as carefully evaluated.
Tumors in a solitary kidney represent a mandatory indi-
cation for partial nephrectomy. Patients with bilateral renal
tumors in whom radical nephrectomy is the only surgical
option on 1 side (1 kidney) will effectively become patients
with tumor in a solitary kidney. Such patients are an ideal
situation in which to study the effect of partial nephrectomy
on renal function. These patients are considered high risk
surgical candidates by most urologists and they are referred
with regularity to tertiary care centers. We present our
experience with 400 patients who underwent partial ne-
Submitted for publication July 9, 2005.
* Correspondence: Glickman Urological Institute, A100, Cleve-
land Clinic Foundation, 9500 Euclid Ave., Cleveland, Ohio 44195
(telephone: 216-444-0414; FAX: 216-445-7031; e-mail: fergana@
ccf.org).
MATERIALS AND METHODS
From January 1980 to December 2002, 400 patients with
sporadic renal tumors in a solitary kidney were treated with
open surgical partial nephrectomy and included in this
study. All operations were performed by a single surgeon
(ACN) using in situ surgical techniques. Excluded from this
review were patients with familial forms of renal tumors,
mainly von Hippel-Lindau. In all patients partial nephrec-
tomy was performed for clinically presumed RCC using sur-
gical principles that have been previously described in
detail.4,5 Surgery was performed before 1990 in 36 patients
(9%), from 1990 to 1999 in 260 (65%) and after 2000 in 104
(26%). Mean followup ⫾ SD was 43.7 ⫾ 38.3 months (range
2 to 193.5).
Of the patients 263 were men (66%) and 137 were women
(34%). Mean age at surgery was 62.1 ⫾ 11.6 years (range 17
to 85). The contralateral kidney was surgically removed in
323 patients (81%), while in 98 (25%) contralateral nephrec-
tomy was performed simultaneously or within a year of
partial nephrectomy. In the remaining 77 patients (19%) the
contralateral kidney was congenitally absent or atrophic.
Recorded variables in the patients studied were preoper-
ative and postoperative serum creatinine, whether the renal
artery was clamped, whether renal hypothermia was used,
the duration of renal ischemia and the percent of renal
parenchyma that was resected. Patients were divided into 3

0022-5347/06/1755-1630/0 1630 Vol. 175, 1630-1633, May 2006

THE JOURNAL OF UROLOGY® Printed in U.S.A.
Copyright © 2006 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/S0022-5347(05)00991-2
 OPEN PARTIAL NEPHRECTOMY FOR TUMOR IN SOLITARY KIDNEY 1631

ination excised tumors were RCC in the majority of cases

TABLE 1. Serum creatinine
(369 or 92%), oncocytoma in 17, angiomyolipoma in 5, tran-
Av creatinine ⫾ SD (mg/dl): sitional cell carcinoma in 4 and benign cysts in 5. Average
Preop 1.4 ⫾ 0.5
Postop 2.2 ⫾ 1.3 tumor size was 4.18 ⫾ 2.5 cm (range 0.5 to 18). The tumor
Creatinine (%): was 4 cm or less in 221 patients (55%) and more than 4 cm
No. preop groups:
Less than 1.4 mg/dl 216 (54)
in 171 (43%), while tumor size was not available in the
1.5 mg/dl or greater 184 (46) remaining 8.
No. postop group (%): Pathological tumor stage was T1a in 134 patients
1 (no creatinine change) 85 (21)
2 (minor creatinine increase) 164 (41) (36%), T1b in 85 (23%), T2 in 28 (8%), T3a in 56 (15%), T3b
3 (significant creatinine increase*) 151 (38) in 54 (15%), T4 in 2 and not available in 10. Tumors were
* Greater than 50% of preoperative serum creatinine. unifocal in 256 patients (64%) and multifocal in 144 (36%).
Tumors were peripheral in 180 patients (45%) and central
in 176 (44%), while the location was not identified in the
remaining 44.
groups according to the percent change in serum creatinine A total of 82 patients (22%) had tumor recurrence within
postoperatively. Group 1 had no change in postoperative the study period, including 13 (3.5%) with local recurrence in
creatinine, group 2 had a minor change in postoperative the renal remnant without metastatic disease, 44 (12%) with
creatinine (less than a 50% increase from the preoperative distant metastatic disease, and 25 (6.5%) with local and
value) and group 3 had a significant increase in postopera- distant recurrent disease. Overall patient survival was 87%
tive creatinine (a 50% or more increase from the preopera- and 77% at 5 and 10 years, respectively. Cancer specific
tive value). Pathological tumor staging was done according survival was 89% and 82% at 5 and 10 years, respectively.
to the most recent TNM classification system, in addition to Postoperatively surgical complications developed in 52
the modifications recommended by the American Joint Com- patients (13%). The most common postoperative complica-
mittee on Cancer in 2002. tion was urine leakage, which occurred in 34 patients (9%).
Other postoperative complications were hemorrhage in 5
Statistical Methods patients (1%), thromboembolic complications in 5 (1%), ileus
The regression method of general linear models was used to in 5 (1%) and ureteral injury in 3 (0.7%). None of these
investigate the relationship between the percent of creati- complications required reoperation.
nine change and other variables, including patient sex, pa- In 384 patients (96.5%) immediate postoperative renal
tient age, preoperative creatinine, ischemia time in minutes, function was achieved. Transient postoperative impairment
renal artery clamping, cold or warm ischemia, tumor size, of renal function occurred in 83 patients (21%). In 14 pa-
the percent of parenchyma resected, unifocal or multifocal tients (3.5%) renal impairment was severe enough to require
tumor and followup. The percent of creatinine change was hemodialysis postoperatively. In these 14 patients the aver-
also analyzed according to the state of the contralateral age resected renal parenchyma was 45% ⫾ 15% and average
kidney as to whether it was removed a year or more before renal ischemia time was 50 ⫾ 20 minutes. Average preop-
NSS, or within the same year, or if it was atrophic or con- erative creatinine in this subpopulation was 1.55 mg/dl. Two
genitally absent. of the 14 patients (14%) remained on long-term dialysis.

RESULTS

Mean preoperative serum creatinine was 1.4 ⫾ 0.5 mg/dl TABLE 2. Pathological findings
(range 0.6 to 4.2). Preoperatively creatinine was less than
No. Pts (%)
1.4 mg/dl in 216 patients (54%), while 184 (46%) had renal
insufficiency preoperatively with serum creatinine 1.5 mg/dl Tumor type:
RCC 369 (92)
or greater. Oncocytoma 17 (4)
Mean postoperative serum creatinine was 2.2 ⫾ 1.3 mg/dl Angiomyolipoma 5 (1)
(range 0.7 to 8). A total of 85 patients (21%) had no change Transitional cell Ca 4 (1)
Benign 5 (1)
in creatinine postoperatively (group 1), while the remaining Tumor size (cm):
315 showed an increase in creatinine postoperatively. Of Less than 4 221 (55)
patients with a postoperative increase 164 (41%) showed a Greater than 4* 171 (43)
Unknown 8 (2)
minor (less than 50%) increase in serum creatinine (group 2) Focality:
and 151 (38%) had a significant (50% or more) increase in Unifocal 256 (64)
Multifocal* 144 (36)
serum creatinine (group 3). Table 1 lists renal function re- Tumor location:
sults. Peripheral 180 (45)
Renal pedicle clamping was done in 383 patients (96%), Central* 176 (44)
Unknown 44 (11)
while in 17 (4%) no clamping was done. Surface hypothermia RCC stage:
with ice slush during renal ischemia was used in 232 pa- T1a 134 (36)
tients (61%). No hypothermia was used in the remaining T1b 85 (23)
T2 28 (8)
151 patients (39%), of whom 142 (94%) underwent surgery T3a* 56 (15)
after 1997 (1998 to 2002). Mean renal ischemia time was T3b* 54 (15)
T4* 2
38.1 ⫾ 20.9 minutes (range 5 to 110). The mean percent of Unknown 10
parenchyma resected was 30% ⫾ 20% (range 2% to 80%).
* Risk factor for partial nephrectomy.
Table 2 lists pathological findings. On pathological exam-
1632 OPEN PARTIAL NEPHRECTOMY FOR TUMOR IN SOLITARY KIDNEY
Therefore, early or short-term renal function was achieved
in 398 patients (99.5%).
Long-term preservation of renal function was achieved in
382 patients (95.5%), while 18 (5%) eventually progressed to
end stage renal disease, requiring renal replacement ther-
apy. Average parenchymal resection in these patients was
30% and average ischemia time was 37 minutes. Average
preoperative creatinine was 2.1 mg/dl. Only 2 of these pa-
tients required immediate hemodialysis postoperatively.
Mean time to progression to renal failure was 3.6 ⫾ 2.4 years
(range 1 to 8).
The status of the contralateral kidney was found to have
a significant effect on solitary kidney function after partial
nephrectomy in regard to short-term as well as long-term
function (p ⫽ 0.002 and 0.03, respectively). Patients with a
congenitally solitary kidney had the least increase in serum
creatinine postoperatively, followed by patients who under-
went contralateral nephrectomy 1 year or more before par-
tial nephrectomy. Patients who underwent contralateral
nephrectomy within a year of NSS had the most significant
increase in serum creatinine postoperatively.
Several factors were found to have a statistically signifi-
cant effect on postoperative creatinine in the first 2 months
after surgery, including renal ischemia time (p ⫽ 0.001),
surface hypothermia (p ⫽ 0.002), the percent of renal paren-
chyma resected (p ⫽ 0.001), patient age (p ⫽ 0.001), a
congenital solitary kidney and the timing of contralateral
nephrectomy (p ⫽ 0.002). When the same analysis was done
for renal function more than 4 months postoperatively, renal
ischemia time and surface hypothermia were found to have
no statistically significant impact. The percent of paren-
chyma resected (p ⫽ 0.01), patient age (p ⫽ 0.001), a con-
genital solitary kidney and the timing of contralateral
nephrectomy (p ⫽ 0.03) were the only statistically signifi-
cant factors affecting long-term renal function.
DISCUSSION
Partial nephrectomy is an established method of surgical
management for localized RCC. A solitary kidney or bilat-
eral renal tumors are a mandatory indication for partial
nephrectomy. Small series of patients with tumor in a soli-
tary kidney have been published to date.6,7 To our knowl-
edge we present the largest reported series of partial
nephrectomy performed in patients with a solitary kidney,
emphasizing the results of the procedure on long-term renal
function.
Our complication rates with open partial nephrectomy
have been previously published.8 Surgical complications in
our patients with a solitary kidney are similar in type and
number to those in patients with 2 renal units with urine
leakage the most common complication in 9%. These leaks
usually cease spontaneously or an indwelling ureteral stent
is placed to promote urinary drainage and assist healing. No
patient in this high risk group required reoperation.
A number of adverse risk factors were present in our
patients. All patients underwent surgery for an imperative
indication and preoperative renal insufficiency was present
in 46%, while 43% of the tumors were more than 4 cm, 36%
were multifocal, at least 44% were in a central location and
30% were pathological stage T3. All of these factors contrib-
uted to increase the degree of technical difficulty as well as
the surgical and renal functional risk associated with these
cases.
We recognize that patients with a solitary kidney may
experience some transient renal function deterioration in
the immediate postoperative period after NSS. Attempts to
minimize this ischemic insult include administering intra-
venous mannitol before and after ischemia, limiting warm
ischemia time to 30 minutes and using renal hypothermia
with ice slush when longer ischemic time is expected. Intra-
venous dopamine did not prove to have a renal protective
effect in these patients.9 Renal replacement therapy may be
required if this deterioration is severe but this does not
preclude the eventual return of enough function for discon-
tinuing dialysis.
In the immediate postoperative period three-quarters of
the patients maintained the same preoperative serum cre-
atinine, while about a quarter had some increase in serum
creatinine immediately postoperatively. In 4% of the pa-
tients this was severe enough to necessitate renal replace-
ment therapy. All except 2 of these patients eventually
recovered adequate renal function and were discharged from
the hospital without requiring long-term dialysis. The fac-
tors that significantly affected this short-term renal function
were renal ischemia time, renal hypothermia, the percent of
kidney remaining and patient age as well as the timing of
contralateral nephrectomy. In this small group of patients
with severe immediate renal dysfunction requiring dialysis
the amount of renal parenchyma resected as well as renal
ischemia time were more than the overall study average
(45% vs 30% and 50 vs 38 minutes, respectively). These 2
factors may have contributed to a more profound deteriora-
tion of renal function immediately postoperatively.
Our study conclusively establishes the safety of open
partial nephrectomy regarding renal function in a large
number of patients. About a fifth of the patients (21%) in our
study had no change in serum creatinine postoperatively,
while 41% showed an insignificant change and 38% showed
a significant increase postoperatively. We estimated that an
increase in preoperative serum creatinine of 50% or more
would be significant. As mentioned, only 2 patients (0.5%) in
this study required permanent renal replacement therapy
immediately after surgery. It is well recognized that pa-
tients with small kidney remnants and usually accompany-
ing renal insufficiency have proteinuria and a gradual
decrease in renal function due to hyperfiltration and glomer-
ulosclerosis.10 For this reason we screen our patients with
small (less than 50%) kidney remnants for proteinuria and
begin therapy with angiotensin-converting enzyme inhibi-
tors and protein restriction in those who have progressive
proteinuria.11 This progressive decrease was noted in 5% of
our patients with an average time to renal failure of 3.6
years.
Statistical analysis of factors affecting long-term renal
function differed from factors affecting short-term renal
function. In the short term renal function was affected by
the duration of renal ischemia, surface hypothermia, the
percent of parenchyma resected, patient age and the timing
of contralateral nephrectomy. In the long term the only
significant factors were the percent of the renal parenchyma
remaining, which increases susceptibility to hyperperfusion,
patient age, which is related to a baseline effect by glomer-
ulosclerosis, etc, and the timing of contralateral nephrec-
tomy. The other factors, namely renal ischemia time and
 OPEN PARTIAL NEPHRECTOMY FOR TUMOR IN SOLITARY KIDNEY
surface hypothermia, are believed to be more related to
acute ischemic injury and they lost significance on long-term
analysis. We do not routinely perform surface hypothermia
anymore because most open partial nephrectomies are per-
formed within the 30-minute window for warm renal isch-
emia. In the last 4 years of this study no hypothermia was
used in 142 consecutive patients.
The status of the contralateral kidney significantly af-
fected the renal function outcome on short-term and long-
term analyses. Patients with congenitally atrophic or absent
contralateral kidneys had the least degree of renal function
impairment after NSS. This probably resulted from a longer
period for compensatory hypertrophy to develop. In patients
with a congenitally solitary kidney this hypertrophy occurs
at the optimum time, that is during development and child-
hood. Our clinical impression is that congenital solitary kid-
neys are most resistant to renal ischemic injury. The same
mechanism would explain our finding that patients who
underwent contralateral nephrectomy more than 1 year be-
fore NSS experienced less renal function impairment than
patients who underwent contralateral nephrectomy the
same year as NSS.
The oncological outcome in this group of patients was
quite satisfactory. At 5 and 10 years cancer specific survival
was 89% and 82%, while overall patient survival was 87%
and 77%, respectively. Tumor recurrence developed in 22%
of the patients with an overall local recurrence rate of 10%,
including 6.5% with local as well as distant recurrence.
Notwithstanding the high incidence of pT3 tumors in our
patient population these results emphasize the oncological
efficacy of open partial nephrectomy at experienced centers.
CONCLUSIONS
We believe that open partial nephrectomy is a safe and
effective procedure in patients with tumor in a solitary kid-
ney. Surgical complications are acceptable and long-term
cancer-free survival with the preservation of renal function
can be expected in the majority of patients.
Abbreviations and Acronyms
NSS ⫽ nephron sparing surgery
RCC ⫽ renal cell carcinoma
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EDITORIAL COMMENT
The authors report a vast, 22-year experience with 400
patients undergoing open partial nephrectomy in the high
risk, surgical challenge of renal tumor in a solitary kidney.
This clinical scenario was secondary to prior nephrectomy in
81% of the patients and congenital renal absence or atrophy
in 19%. Using the relatively crude serum creatinine of
greater than 1.5 mg/dl as the indicator of impaired renal
function 46% of the patients had preoperative renal insuffi-
ciency. The authors used hilar clamping in 96% of the pa-
tients with or without surface hypothermia to resect tumors
with a mean size of 4.18 cm, of which 92% were renal
cancers. Of interest was the fact that 36% of these patients
had multifocal tumors resected. Only 13 of the 82 patients
(3.5%) who experienced recurrent disease had local renal
recurrence and only 2 required long-term dialysis, further
evidence of the effectiveness and skill of the involved sur-
geons with open partial nephrectomy.
This article should remind the urological community that
training in and experience with open partial nephrectomy
remain an essential part of the urological armamentarium
despite expanding experience with minimally invasive sur-
gery and the active investigation of renal tumor ablation.
Because renal cortical tumors, of which up to 45% are benign
or have an indolent malignant potential, are increasingly
diagnosed incidentally at a small (median now less than 4
cm) and highly curable size, radical nephrectomy by any
method should be discouraged unless partial nephrectomy is
technically not feasible. The liberal application of partial
nephrectomy for the index tumor will ultimately decrease
the need for these challenging operations and the high like-
lihood of renal insufficiency.
Paul Russo
Department of Urology
Memorial Sloan-Kettering Cancer Center
New York, New York