Partial nephrectomy (PN) versus ablative therapies (AT) for T1a clear cell renal cell carcinoma (ccRCC): Analysis of 2,161 patients.

459 Background: PN is considered the standard treatment for T1a ccRCC, whereas AT have been increasingly utilized as minimally invasive alternatives, particularly in patients with high surgical risk or impaired kidney function. However, comparative data on oncologic and kidney outcomes between these two strategies are limited. Methods: This retrospective study included 2,161 patients with clinical T1a ccRCC who underwent either PN (N = 2,045) or AT (N = 116) between January 2006 and December 2024. Baseline characteristics, survival outcomes, and renal functional preservation were evaluated in both the overall cohort and the propensity score–matched cohort to adjust for confounders. Kidney outcome events were defined as declines of ≥30%, ≥40%, or ≥50% in estimated glomerular filtration rate (eGFR) from baseline, respectively. Results: Before matching, patients in the PN group were younger (mean age 55.1 vs. 63.9 years, P < 0.001) and had higher body mass index (BMI) (mean BMI 25.3 vs. 24.4 kg/m², P = 0.004), whereas the AT group had a lower baseline eGFR level (84.7 vs. 90.6 mL/min/1.73 m², P = 0.014) and were more likely to have underlying hypertension (57.8% vs. 42.0%, P < 0.001) and diabetes (33.6% vs. 24.2%, P = 0.022). During the median follow–up duration of 66.3 months (95% confidence interval [CI] 64.0–68.5), locoregional recurrence (hazard ratio [HR] and 95% CI: not estimable, P < 0.001), distant recurrence (HR: 0.189, 95% CI: 0.072–0.500, P < 0.001), death (HR: 0.141, 95% CI: 0.085–0.235, P < 0.001) and kidney function decline (≥30% [HR: 0.220, 95% CI: 0.111–0.433, P < 0.001], ≥40% [HR: 0.124, 95% CI: 0.058–0.264, P < 0.001], or ≥50% [HR: 0.141, 95% CI: 0.052–0.383, P < 0.001] decline in eGFR from baseline) were significantly superior in the PN group compared to AT group. The superior oncologic outcomes and kidney function preservation of PN were consistently observed in the propensity score–matched cohort (n = 605; 489 treated with PN and 116 with AT): locoregional recurrence (HR and 95% CI: not estimable, P < 0.001), distant recurrence (HR: 0.186, 95% CI: 0.059–0.584, P = 0.004), death (HR: 0.275, 95% CI: 0.162–0.468, P < 0.001), and kidney function decline (≥30% [HR: 0.383, 95% CI: 0.196–0.748, P = 0.005], ≥40% [HR: 0.230, 95% CI: 0.101–0.525, P < 0.001], or ≥50% [HR: 0.164, 95% CI: 0.049–0.548, P = 0.003]). Conclusions: PN demonstrated superior oncologic control and kidney function preservation compared with AT in patients with T1a ccRCC. These findings strongly support that PN should be prioritized as the curative treatment approach whenever clinically feasible.