Editing Management of Localized and Locally Advanced Disease (section)

==== Technique ====
* '''Renal function can be optimized by (2):'''
*#'''Optimizing nephron mass preservation'''
*##'''<span style="color:#ff0000">The number of preserved nephrons is the primary factor determining renal function after PN</span>'''
*#'''Avoiding prolonged ischemia'''
*##'''<span style="color:#ff0000">Ischemic injury plays a secondary role.</span>'''
*##* '''<span style="color:#ff0000">As long as the warm ischemic interval is limited (<25 minutes) or hypothermia is applied, most preserved nephrons will recover their function</span>'''
*##** Recovery from hypothermia is more consistent and reliable with intervals up to 60-90 minutes being well tolerated. Nevertheless, even with hypothermia it is best to avoid truly prolonged durations of ischemia
*'''The extent of normal parenchyma removed should be determined by surgeon discretion taking into account the clinical situation, tumor characteristics including growth pattern, and interface with normal tissue.'''
** Traditional PN is sharp excision with intentional removal of a modest rim of normal adjacent parenchyma
**Tumor enucleation refers to blunt excision of a tumor with minimal margin during nephron-sparing surgery
*** Originated in the familial RCC population as a technique to preserve renal parenchyma in patients with multiple tumors requiring multiple surgeries over a lifetime.
***'''<span style="color:#ff0000">To optimize parenchymal mass preservation, tumor enucleation should be considered in patients with:[https://pubmed.ncbi.nlm.nih.gov/28479239/]</span>'''
***# '''<span style="color:#ff0000">Familial RCC syndromes</span>'''
***#* '''Aggressive RCC syndromes, such as HLRCC, should be best managed with wide margin PN or RN.'''
***# '''<span style="color:#ff0000">Multifocal disease</span>'''
***# '''<span style="color:#ff0000">Severe CKD</span>'''
** '''<span style="color:#ff0000">Margin</span>'''
***'''<span style="color:#ff0000">Negative margin should be prioritized</span>'''
****While positive surgical margin during PN has not definitively been shown to adversely affect survival outcomes (recurrence-free, metastasis-free, cancer-specific, or overall survival), a negative surgical margin is always the goal
*****Cohort study of 1,344 PN patients from MSK found that compared to negative margins, positive margins was not associated with worse recurrence-free or metastasis-free survival. J Urol 2008.
***** Multi-centre cohort study of 775 patients from Europe found that compared to negative margins, positive margins was not associated with worse recurrence-free, cancer-specific, or overall-survival. Eur Urol 2010.
****'''<span style="color:#ff0000">Margin width is not important as long as final margins are negative.</span>'''
*** '''Management of positive surgical margins after PN or tumor enucleation'''
**** A variety of factors should be taken into account during counseling including the extent of the margin (microscopic versus extensive), tumor histology and grade, and other indicators of tumor biology such as locally invasive phenotype.
****'''In general, close surveillance is recommended in patients with a positive surgical margin'''
*** PN in patients with absolute indications should focus on preservation of renal parenchymal volume and functional nephrons with margin width being a less relevant consideration