manejo de las lesiones renales menores de 4 centímetros ... · manejo de las lesiones renales...

59
"#$%&'() *+&,-.$&'(.& ,()) /0"-1.#+ $23425 62 *37879:;

Upload: others

Post on 30-Apr-2020

5 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

!

! !

!!!!!!!!!!!!!!!!!!

! ! ! ! ! !

"#$%&'()!*+&,-.$&'(.&!!,())!/0"-1.#+!$23425!62!*37879:;!

!

Page 2: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "!

!

!

!

!"#$%&'($')!"#$%"&'(%"#)%(!*%"#

!"#$%"&'("')!!"#$%&"$'()*+",-.#$"*

!"#$%&'()*+,)-$.&+/,0%10(%&$)

!"#$%&'(")!

!"#$#%&'()' *+,)-.*/#0*1+'2#"#'&2.#"'#' 3&-'45' 0"6(*.&-' 0&"")-2&+(*)+.)-'()3'

7"&/"#8#'()'9&0.&"#(&'()':*";/<#'()'3#'=+*,)"-*(#('>;.1+&8#'()'?#"0)3&+#@'

!

!

#$%&'(!!!!!!!!!!!!!!)'*+%*,-!.&-+%/-%*-*0*+!1/'/2!

3*'45%&'4+(!!!!!3'6!7-'*8$4!9'*::/!;4''4'/!

! ! <'&=6!3'6!>$/-!?&'&%4!@&A:4+! ! !

! !

Page 3: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! B!

!

!

!

!

!

>$/-! ?&'&%4! @&A:4+C! )/%40',%*5&! 04! D'&:&EF/! 04! :/! D-*G4'+*0/0! #$%H-&I/! 04!J/'54:&-/!2!>4=4!04!K4'G*5*&!04!D'&:&EF/!04:!;&+L*%/:!M/::!0N;4A'&-!2!7-'*8$4!9'*::/!!;4''4'/C!0&5%&'!4-!?40*5*-/!2!)*'$EF/C!O/5$:%/%*G&!7+L45*/:*+%/!4-!D'&:&EF/!2!%$%&'!04:!<'&E'/I/!?P@6!!

!

!

)7@9POP)#Q!RD7!4:!%'/A/S&!%*%$:/0&!A#+)%&'()'3#-'B)-*&+)-'C)+#3)-'A)+&")-'()'D':)+.<8)."&-'A)(*#+.)'>$3#0*1+'2&"'C#(*&E")0;)+0*#'7)"0;.F+)#!T/!+*0&!'4/:*U/0&!A/S&!+$!+$L4'G*+*H-!L&'!)'*+%*,-!.&-+%/-%*-*0*+!1/'/2!L/'/!&L%/'!/!:&+!V"!5'W0*%&+!5&''4+L&-0*4-%4+!04:!<'&E'/I/!04!3&5%&'/0&!04!)*'$EF/!04!:/!D-*G4'+*0/0!#$%H-&I/!04!J/'54:&-/6'

!

!

!

X!L/'/!8$4!5&-+%4!/!:&+!4=45%&+!&L&'%$-&+C!=*'I/-!4:!L'4+4-%4!54'%*=*5/0&!4-!J/'54:&-/!/!"Y!04!/E&+%&!04!"YV"6!

!

!

!

!

!

!

!

>$/-!?&'&%4!@&A:4+!

)/%40',%*5&!04!D'&:&EF/!04!:/!D-*G4'+*0/0!#$%H-&I/!04!J/'54:&-/!>4=4!04!K4'G*5*&!04!D'&:&EF/!04:!

;&+L*%/:!D-*G4'+*%/'*&!M/::!3Z;4A'&-!

7-'*8$4!9'*::/!;4''4'/!

O/5$:%/%*G&!7+L45*/:*+%/!4-!D'&:&EF/!9$%&'!L'&E'/I/!?P@!04!D'&:&EF/!

! !

Page 4: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! [!

!"#!$%!

P\!P-%'&0$55*H-!]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]!^!

PP\!7L*04I*&:&EF/!]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]!_!

PPP\!;*+%&'*/!Q/%$'/:!04!:/+!?/+/+!@4-/:4+!<48$4`/+!]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]!a!

PM\!9W5-*5/+!04!PI/E4-!</'/!34%455*H-!2!3*/E-H+%*5&!]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]!VY!

M\!bL5*&-4+!94'/LW$%*5/+!34!c/+!?/+/+!@4-/:4+!<48$4`/+!]]]]]]]]]]]]]]]]]]]]]]]]!Vd!

MP\!@4+$:%/0&!O$-5*&-/:!2!b-5&:HE*5&!04!:/!#A:/5*H-!<4'5$%,-4/!04!:/+!?/+/+!

!!!!!!!@4-/:4+!<48$4`/+!?40*/-%4!#A:/5*H-!L&'!@/0*&='45$4-5*/!]]]]]]]]]]]]]]]]]]]]!"^!

MPP\!<'&245%&!04!P-G4+%*E/5*H-!]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]!"d!

MPPP\!@4+$:%/0&+!]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]!BY!

Pe\!3*+5$+*H-!]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]![Y!

e\!)&-5:$+*&-4+!]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]!^V!

eP\!@4=4'4-5*/+!]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]!^"!

!

! !

Page 5: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! ^!

!"#!$%&'()**!+$!c/!*-5*04-5*/!04:!5/'5*-&I/!04!5W:$:/+!'4-/:4+!f))@\!T/!L'4+4-%/0&!$-!*IL&'%/-%4!

/$I4-%&!4-!:&+!g:%*I&+!^Y!/`&+V6!7+%4!/$I4-%&!L$404!+4'!4hL:*5/0&!L/'5*/:I4-%4!

L&'!:/!E'/-!0*=$+*H-!2!04+/''&::&!04!-$4G/+!%W5-*5/+!04!*I/E4-!04!/:%/!'4+&:$5*H-!

8$4!L4'I*%4-!4:!0*/E-H+%*5&!L'45&U!04! :4+*&-4+!L48$4`/+!/+*-%&I,%*5/+!5&I&!$-!

T/::/UE&!*-5*04-%/:6!<&'!&%'/!L/'%4C!4:!4-=&8$4!%4'/LW$%*5&!04:!))@!+4!4-5$4-%'/!4-!

L:4-&!L'&54+&!04!5/IA*&!2/!8$4!:/!4G*04-5*/!5'45*4-%4!4-!5$/-%&!/!:/!'4:/5*H-!04!:/!

-4='45%&IF/! '/0*5/:! 2! :/! *-+$=*5*4-5*/! '4-/:! 5'H-*5/! fP@)\! 5&-! +$+! *IL&'%/-%4+!

4G4-%&+!5/'0*&G/+5$:/'4+!/+&5*/0&+!T/!*IL:/-%/0&!/!:/!-4='45%&IF/!L/'5*/:!5&I&!4:!

-$4G&! !"#$% &'()$(*$! 4-! 4:! %'/%/I*4-%&! 04:! ))@! 4-! 4+%/0*&! 9V"! 2! T/! 5&:&5/0&! 4:!

5&-54L%&!04! i/A&'0/S4! 5&-+4'G/0&'!04!-4='&-/+j! f)+,-*")%&,(*.)!%&/*!+*0\! 4-!4:!

*-5&-+5*4-%4!5&:45%*G&!04!:/!5&I$-*0/0!$'&:HE*5/!*-%4'-/5*&-/:6!c/!L'4+4'G/5*H-!04!

:/! =$-5*H-!'4-/:!4+!04!4+L45*/:! *-%4'W+!4-!L/5*4-%4+!04!40/0!/G/-U/0/!8$4!+$4:4-!

L/0454'! 04! *IL&'%/-%4! 5&I&'A*:*0/0! 8$4! :&+! 5&-0*5*&-/! /! -&! +4'! A$4-&+!

5/-0*0/%&+! L/'/! $-! L'&540*I*4-%&! 8$*'g'E*5&! 5&I&! $-/! -4='45%&IF/! 2/! +4/! 4+%/!

L/'5*/:! &! '/0*5/:C! /A*4'%/! &! :/L/'&+5HL*5/6! c&! I*+I&! &5$''4! 5&-! L/5*4-%4+! 8$4!

L/0454-!04!$-!))@!Ig:%*L:4C!5&-!L'40*+L&+*5*H-!E4-W%*5/!5&I&!4-!:/!4-=4'I40/0!

04!M&-!;*LL4:kc*-0/$C!L/5*4-%4+!I&-&'4-&+C! %'/+L:/-%/0&+C!&!8$4!2/!L/0454-!04!

$-/!P@)!04!A/+46!)&I&!'4+L$4+%/!/!:/!-454+*0/0!04!$-!%'/%/I*4-%&!5&-+4'G/0&'!04!

-4='&-/+!4-!L/5*4-%4+!-&!5/-0*0/%&+!/!5*'$EF/!T/!T/A*0&!$-!*-%4'W+!5'45*4-%4!4-!:/+!

%W5-*5/+! /A:/%*G/+! 04! /A&'0/S4! L4'5$%,-4&! L/'/! 4:! %'/%/I*4-%&! 04:! ))@C!

L'*-5*L/:I4-%4!:/!/A:/5*H-!L&'!'/0*&='45$4-5*/!2!:/!5'*&/A:/5*H-6!!

! !

Page 6: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! _!

!!"#$%!&$'!()(*+,!7:! 5/'5*-&I/! 04! 5W:$:/+! '4-/:4+! '4L'4+4-%/! 4:! "kBl! 04! %&0&+! :&+! 5,-54'4+! 04:!

/0$:%&! 2! 5&''4+L&-04! /:! a^l! 04! :&+! %$I&'4+! '4-/:4+B6! ! 7-! 7+%/0&+! D-*0&+! f7D\!

0$'/-%4! 4:! /`&! "YYa! +4! '4L&'%/'&-! ^[6BmY! -$4G&+! 5/+&+! '4+$:%/-0&! 4-! VB6YVY!

I$4'%4+! L&'! 4+%/! 5/$+/V! 2! 4-! 5&IL/'/5*H-! 5&-! 4:! /`&! VmdVC! 4+%/+! 5*='/+!

'4L'4+4-%/-!5*-5&!G454+!I,+!04!-$4G&+!5/+&+!2!$-/!0$L:*5/5*H-!04!:/!I&'%/:*0/0[6!

7-!:/!D-*H-!7$'&L4/!fD7\!+4!0*/E-&+%*5/'&-!_B6BYY!5/+&+!0$'/-%4!4:!/`&!"YY_!2!+4!

L'&0$S4'&-!"_6[YY!I$4'%4+^6!c/!%/+/!04!*-5*04-5*/!04:!))@!+4!4+%*I/!4-%'4![C[kVVCV!

5/+&+!L&'!5/0/!VYY6YYY!L4'+&-/+!2!/`&C!+*4-0&!:/!I/2&'!*-5*04-5*/!/!L/'%*'!04!:&+!

[Y!/`&+C!5&-!L*5&!4-%'4! :&+!^Y!2! :&+!dY!/`&+_!5&-!$-/!0*+%'*A$5*H-!L&'!E4-4'&!04!

B(V!4-!G/'&-4+!'4+L45%&!/!:/!04!I$S4'4+C!/+F!5&I&!4-!:/!'/U/!-4E'/6!M/'&-4+!2!'/U/!

-4E'/! L'4+4-%/-! %/IA*W-! $-/! I4-&'! +$L4'G*G4-5*/d6! ! 7-! :/+! g:%*I/+! B! 0W5/0/+!

T4I&+! L'4+4-5*/0&! $-! /$I4-%&! L'&E'4+*G&! 4-! :/! *-5*04-5*/! 04:! 5,-54'! '4-/:! 4-!

7+L/`/! 2! 4:! '4+%&! 04:!I$-0&!&55*04-%/:! /! '/UH-!04:! Bl!/-$/:a6! 7+%4! /$I4-%&! +4!

L$404! 04A4'! /! :/! 5/0/! G4U!I/2&'! 0*+L&-*A*:*0/0! 04! L'$4A/+! 04! *I/E4-! 5&I&! 4:!

D:%'/+&-*0&!fDK\C!:/!9&I&E'/=F/!)&IL$%/0/!f9)\!&!@4+&-/-5*/!Q$5:4/'!?/E-W%*5/!

f@Q?\C! :&! 8$4! T/! 04%4'I*-/0&! 8$4! /5%$/:I4-%4! I/+! 04:! ^Yl! 04! :&+! ))@! +4!

0*/E-&+%*8$4-! 5&I&! T/::/UE&! *-5*04-%/:_6! 7+%4! =4-HI4-&! T/! 04%4'I*-/0&! $-!

/$I4-%&!04!:/!*-5*04-5*/!04:!))@!4-!%&0&+!+$+!4+%/0*&+C!L'*-5*L/:I4-%4!4-!4+%/0*&+!

*-*5*/:4+!:&!8$4!+4Eg-!$-/!'4G*+*H-!'4/:*U/0/!4-%'4!VmmB!2!"YY[!!4-!7D!A/+/0/!4-!4:!

1/*2+.##()3+4% 5,.$+6."#"!0% ()$% 5)$% 7+&/#'&% ,*"!*(6% $('(% fK77@\! L&'! ./-4! +'% (#6!

5&''4+L&-04!/!$-/!I*E'/5*H-!04+04!4:![Bl!T/+%/!4:!^dl!04:!0*/E-H+%*5&!4-!4+%/0*&!

V!4-!0*5T&!L4'*&0&m6!7-!4+%/!+4'*4!%/IA*W-!+4!&A+4'G/!$-/!0*+I*-$5*H-!04:!%/I/`&!

%$I&'/:! /:! 0*/E-H+%*5&!04+04![CV!T/+%/!BC_! 5I6!I*4-%'/+!8$4! 4-!$-/! '4G*+*H-!04:!

8+6"*.(#%1#"()%9+''+*.)!!'4/:*U/0/!L&'!c44!+'%(#6!+4!&A+4'GH!8$4!4:!%/I/`&!I40*&!

04! :&+! %$I&'4+! '4-/:4+! 4'/! 04! dCa5I! 4-! Vmam! 2! 0*+I*-$2H! /! ^CB5I! 4-! VmmaC!

4-5&-%'/-0&!/04I,+!$-!/$I4-%&!04:![l!/:!""l!04!%$I&'4+!4-!4+%/0*&!L9VVY!6!

#!L4+/'!04!8$4!4:!0*/E-H+%*5&!+4!'4/:*U/!5/0/!G4U!4-!4%/L/+!I,+!L'45&54+!2!04!8$4!

+4! T/-! 04+5'*%&! F-0*54+! 04! +$L4'G*G4-5*/! /! :&+! ^! /`&+! 4h54:4-%4+! L/'/! :/+!I/+/+!

I,+! L48$4`/+! 2! :&5/:*U/0/+! 8$4! 5&-=&'I/-! :/! I/2&'F/! 04! :&+! %$I&'4+! '4-/:4+!

0*/E-&+%*5/0&+! 4-! :/! /5%$/:*0/0C! :/+! %/+/+! 04! I&'%/:*0/0! +*E$4-! 4-! /$I4-%&VV6!

Page 7: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! d!

Q$I4'&+&+!%'/A/S&+!I$4+%'/-!8$4!:/!+&A'4G*0/!:*A'4!04!4-=4'I40/0!fKc7\!/!^!/`&+!

4+!I/2&'!4-! :&+! %$I&'4+! *-5*04-%/:4+C!8$4!+$4:4-!+4'!I4-&'4+!2!04!I4-&'!E'/0&!

8$4!:/+!:4+*&-4+!+*-%&I,%*5/+[!5&-!0*=4'4-5*/+!04!a^CBl!G+!_"C^l!&A+4'G/0&+!L&'!

9+$*!+'%(#CV"!&!04!mBl!G+!^ml!+4Eg-!</%/'0!+'%(:VB6!7:!/$I4-%&!04! :/!I&'%/:*0/0C!

4+%*I/0/!4-!_C^nVYY6YYY!T/A6!L&'!;&::*-E+o&'%T!+'%(#V[!/!L4+/'!04:!0*/E-H+%*5&!2!

%'/%/I*4-%&! L'45&54+! 2! 04! :/! I4S&'F/! 4-! :/! Kc7! T/! E4-4'/0&! $-! 0*:4I/! /g-! -&!

'4+$4:%&6!p4:5T!+'%(#V^!&A+4'G/'&-!$-!/$I4-%&!04!:/!Kc7!4-!"Y!%*L&+!04!-4&L:/+*/+C!

+*-! 4IA/'E&! &A+4'G/'&-! $-/! 0*+I*-$5*H-! 04! :/! I&'%/:*0/0! +&:&! 4-! V"! 04! 4::/+!

5&-5:$24-0&! 8$4! :/! I4S&'F/! 04! :/! Kc7! L&0'F/! 5&''4+L&-04'! /! 5/IA*&+! 4-! :&+!

L/%'&-4+!0*/E-H+%*5&+6!<&'!&%'/!L/'%4!$-!I4%/k/-,:*+*+!'4/:*U/0&!L&'!)T/o:/!+'%(#6!

4-! "YY_V_! 4-! 4:! 8$4! +&I4%*H! /! G*E*:/-5*/! /5%*G/! fM#\! /! "B[! %$I&'4+! '4-/:4+! 5&-!

0*,I4%'&! I40*&! 04! "C_5I! 4-! VY! 54-%'&+! 0$'/-%4! B[! I4+4+! 04+5'*A*H! $-!

5'45*I*4-%&!04!YC"a5I!/:!/`&!fYC[5In/`&!4-!4:!5/+&!04!)@@\!2!Vl!04!04+/''&::&!04!

I4%,+%/+*+6! 7-! A/+4! /! 4+%&+! '4+$:%/0&+! +4! T/! L&+%$:/0&! 8$4! I$5T/+! 04! 4+%/+!

:4+*&-4+!L'4+4-%/-!$-/!A/S/!L'&A/A*:*0/0!04!L'&E'4+*H-!/!4+%/0*&+!/G/-U/0&+C!&!04!

+4'!5/$+/:4+!04!=/::45*I*4-%&!L&'!:&!8$4!+$!0*/E-H+%*5&!2!%'/%/I*4-%&!L'45&U!-&!T/!

:&E'/0&!'40$5*'!+*E-*=*5/%*G/I4-%4!+$!I&'%/:*0/0[6!! !

Page 8: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! a!

!!!"#$!%&'(!)#*)&+(),#-.#,)%#/)%)%#!"#$%"&'(")*"+$&!

7:!/$I4-%&!&A+4'G/0&!4-!:/!*-5*04-5*/!04:!%$I&'!'4-/:!4-!%&0&+!+$+!4+%/0*&+!L4'&!

L'*-5*L/:I4-%4! 4-! 4+%/0*&+! L'45&54+C! 4-! L/'%4! 4hL:*5/0&! L&'! :&+! /G/-54+! 4-! :/+!

%W5-*5/+! 04! 0*/E-H+%*5&! L&'! *I/E4-! 2! +$! I/2&'! 0*+L&-*A*:*0/0! T/! E4-4'/0&! $-!

-$4G&!4+54-/'*&!L/'/!4:!I/-4S&! 5:F-*5&6!3/0&!8$4! :/!I/2&'F/!04! :&+!0*/E-H+%*5&+!

*-5*04-%/:4+! +&-! 04! I/+/+! '4-/:4+! L48$4`/+! f?@<+\! 04=*-*0/+! 5&I&! :4+*&-4+!

'4-/:4+! I4-&'4+! 04! [5I! 5/L%/-%4+! 04! 5&-%'/+%4! 4-! :/! 9)C! 5$2/! *-5*04-5*/! T/!

/$I4-%/0&!04!V!/!BCB!L&'!VYY6YYYV[C!+4!T/!L:/-%4/0&! :/!-454+*0/0!04!'4/:*U/'!$-!

5/IA*&!4-!4:!L/'/0*EI/! %4'/LW$%*5&! %'/0*5*&-/:I4-%4!$%*:*U/0&!4:! 5$/:!L:/-%4/! :/!

-4='45%&IF/! '/0*5/:! 5HI&! L'*I4'/! &L5*H-! %4'/LW$%*5/6! ! 34! 4+%/! =&'I/! 0*G4'+&+!

/$%&'4+!+4`/:/-!:/!L&+*A*:*0/0!04!'4/:*U/'!G*E*:/-5*/!/5%*G/!&!%W5-*5/+!IF-*I/I4-%4!

*-G/+*G/+! 4-! 4:! I/-4S&! 04! 4+%/+! :4+*&-4+VdC! +&A'4! %&0&! 5&-+*04'/-0&! 8$4! 4:!

0*/E-&+%*5&! *-5*04-%/:! +$4:4! +4'! 4-! L/5*4-%4+! 04! 40/0! /G/-U/0/! 4-! 8$*4-4+! +$+!

5&I&'A*:*0/04+!:&+!T/54-!L&5&!5/-0*0/%&+!/!5*'$EF/!5&-G4-5*&-/:V_6!#!L4+/'!04!$-/!

*-5*04-5*/!4-!/$I4-%&C! :/!4G&:$5*H-!-/%$'/:!04! :&+! %$I&'4+!'4-/:4+!-&!T/!L&0*0&!

+4'! 4+%$0*/0/! 4hT/$+%*G/I4-%4! 2/! 8$4! 4:! %'/%/I*4-%&! 8$*'g'E*5&C! 2/! +4/!

-4='45%&IF/! %&%/:! &! L/'5*/:C! T/A*%$/:I4-%4! 4+! '4/:*U/0&! L&5&! 04+L$W+! 04:!

0*/E-H+%*5&! Va6!J&+-*/q!L$A:*5H!4-!Vmm^!$-/! '4G*+*H-!04![Y! %$I&'4+!I4-&'4+!04!

BC^!5I!0*/E-&+%*5/0&+!5&I&!T/::/UE&!*-5*04-%/:!+4E$*0&+!L&'!BC"^!/`&+!4+%*I/-0&!

4:!5'45*I*4-%&!:/!G4:&5*0/0!I40*/!04!5'45*I*4-%&!4-!YCB_!5I!/:!/`&!2!L:/-%4/-!4-!

+$+!5&-5:$+*&-4+!:/!&L5*H-!04!G*E*:/-5*/!/5%*G/!4-!4:!I/-4S&!04!:/+!?@<Vm6!!)&I&!2/!

+4! T/! 0*5T&C! )T/o:/! +'%(#! '4G*+/'&-! 4-! "YY_! "B[!?@<6! ! 7:! %/I/`&! *-*5*/:! 04! :/+!

:4+*&-4+!4'/!04!"C_5I!+*4-0&!4:!a_l!I4-&'4+!04![!5I!/:!0*/E-H+%*5&6!3$'/-%4!$-/!

I40*/!04!+4E$*I*4-%&!04!B[!I4+4+!+4!&A+4'GH!$-/!%/+/!04!5'45*I*4-%&!04!YC"a5I!

/:!/`&6!7:!["l!04!:/+!:4+*&-4+!=$4!+&I4%*0/!/!4+%$0*&!/-/%&I&L/%&:HE*5&C!04!4::/+C!

4:!m"l!5&''4+L&-0*H!/!5/'5*-&I/+6!K4!&A+4'GH!8$4!:/!G4:&5*0/0!04!5'45*I*4-%&!4-!

:&+!5/'5*-&I/+!5&-=*'I/0&+!4'/!I/2&'!fYC[5I!G4'+$+!YC"V5I!/:!/`&\!+*-!4-5&-%'/'!

0*=4'4-5*/+!4-!4:!%/I/`&!04!L'4+4-%/5*H-!*-*5*/:6!!<&+%4'*&'I4-%4!4-!"YYd!.&$A/!+'%

(#! 4+%$0*/-! 4-! [B! L/5*4-%4+C! [_! I/+/+! '4-/:4+! 5/L%/-%4+! 04! 5&-%'/+%4! +H:*0/+! &!

8$F+%*5/+!fJ&+-*/q!PM\!5&-!$-/!I40*/!04!+4E$*I*4-%&!04!B_!I4+4+C! :/!5&''4:/5*H-!

Page 9: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! m!

4-%'4! :/! 40/0! 2! :/! G4:&5*0/0! 04! 5'45*I*4-%&! 04! :/+! ?@<! &A+4'G/-0&! 8$4! :&+!

L/5*4-%4+! I4-&'4+! 04! _Y! /`&+! I$4+%'/-! G4:&5*0/04+! 04! 5'45*I*4-%&! I/2&'4+!

fYCdd5I! ='4-%4! /! YC"_5I! /:! /`&\6! 7-! +$! +4'*4! "_l! 04! :&+! L/5*4-%4+! -&! L'4+4-%H!

5'45*I*4-%&! %$I&'/:! 2! VB! L/5*4-%4+! fV[! %$I&'4+\! =$4'&-! +&I4%*0&+! /! 5*'$EF/! 2/!

8$4! L'4+4-%/A/-! %/+/+! 04! 5'45*I*4-%&! I/2&'4+6! c/! /-/%&IF/! L/%&:HE*5/! f#<\!

5&-=*'IH!))@!4-!V"!04! :&+! V[! %$I&'4+C! +*4-0&! %&0&+! 4+%/0*&!L9V!2!0$'/-%4!$-/!

I40*/!04![V!I4+4+!04!+4E$*I*4-%&!-&!T$A&!I&'%/:*0/0!L&'!5,-54'6!)&-!4+%&+!0/%&+!

:&+! /$%&'4+! L'&L&-4-! :/! G*E*:/-5*/! /5%*G/! 5&I&! $-/! /:%4'-/%*G/! '/U&-/A:4! 4-!

L/5*4-%4+!+4:455*&-/0&+!2!+$E*4'4-!8$4!4:!!'4%'/+&!4-!4:!%'/%/I*4-%&!8$*'g'E*5&!4-!

=$-5*H-!04:!+4E$*I*4-%&!-&!*IL:*5/!$-!4IL4&'/I*4-%&!04:!L'&-H+%*5&"Y!2!/L&2/'F/!

:/!*-%4'G4-5*H-!I,+!%4IL'/-/!4-!L/5*4-%4+!SHG4-4+"V6!<&'!&%'/!L/'%4C!:/!/$+4-5*/!04!

5'45*I*4-%&!0$'/-%4!4:!+4E$*I*4-%&!-&!L/'454!*-0*5/'!T*+%&:&EF/!A4-*E-/6!.$-q:4!+'%

(#""!L$A:*5/-!4-!"YYd!$-/!+4'*4!04!VY_!I/+/+!'4-/:4+!5/L%/-%4+!04!5&-%'/+%4!5&-!

$-!+4E$*I*4-%&!IF-*I&!04!V"!I4+4+!'4/:*U/-0&!/04I,+!$-/!'4G*+*H-!A*A:*&E',=*5/!

/54'5/!04! :/!T*+%&:&EF/!04! :/+!I/+/+! '4-/:4+! 5&-! 5'45*I*4-%&! 54'&6! 7+%/A:454-!$-!

E'$L&!04!B^!fBBl\!%$I&'4+!5&-!5'45*I*4-%&!54'&!2!:&!5&IL/'/-!5&-!$-!+4E$-0&!

E'$L&! 04! dV! %$I&'4+! 8$4! L'4+4-%/'&-! 5'45*I*4-%&6! K4! +&I4%*4'&-! /! 5*'$EF/! _!

:4+*&-4+!04:!E'$L&!V!2!B_!04:!E'$L&!"!+*-!4-5&-%'/'!0*=4'4-5*/+!4-!:/!#<!4-!5$/-%&!/!

I/:*E-*0/0! 04! 4+%/+! faBl! G4'+$+! amlC! ,rYC^_\6! K&:&! $-! L/5*4-%4! 04:! E'$L&! "!

L'4+4-%H!I4%,+%/+*+!0$'/-%4!4:! +4E$*I*4-%&6!7-!+$!'4G*+*H-!A*A:*&E'/=F/! '4g-4-!m!

L$A:*5/5*&-4+! f*-5:$24-0&! :/! L'&L*/\! /E'$L/-0&! "m^! :4+*&-4+C! 04! :/+! 5$/:4+! da!

f"_l\! L'4+4-%/'&-! 5'45*I*4-%&! 54'&C! &A%4-*4-0&! #<! 4-! VY! 5/+&+! &A+4'G/-0&!

I/:*E-*0/0!4-!a!:4+*&-4+!f))@\!5&-%'/+%/-0&!4+%&+!T/::/UE&+!5&-!:/!+4'*4!L$A:*5/0/!

4-! "YYB! L&'! O'/-q! +'% (#! 4-! :/! 8$4! +4! 4+%$0*/! :/! #<! 04! "6mB^! %$I&'4+! '4-/:4+!

f&A%4-*0&+! 04! -4='45%&IF/+! '/0*5/:4+\! &A+4'G/-0&! V"Cal! 04! T*+%&:&EF/! A4-*E-/!

fVYkBYl! +4Eg-! %/I/`&! %$I&'/:\"B6! <&04I&+! '4+$I*'! 4-%&-54+! 8$4! E'/5*/+! /! :/+!

g:%*I/+! %4-04-5*/+! 4-! 5$/-%&! /:! I/-4S&! 04! :/+! I/+/+! '4-/:4+! L48$4`/+! 8$4!

*-5:$24-!L'&%&5&:&+!04!G*E*:/-5*/!/5%*G/!+4!5&-&54-!T&2!/:E$-&+!/+L45%&+!+&A'4!:/!

T*+%&'*/! -/%$'/:! 04! 0*5T/+! :4+*&-4+C! :/+! 5$/:4+! /! L4+/'! 04! 8$4! 4-! +$! I/2&'F/!

5&''4+L&-04-!/!5/'5*-&I/+!+$4:4-!+4'!:4+*&-4+!04!5'45*I*4-%&!:4-%&!2!8$4!'/'/!G4U!

+4!/+&5*/-!/!I4%,+%/+*+6!

! !

Page 10: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! VY!

!"#$%&'(!')*$+,$!-).,($/)0)$!"#"$$%&'()(!%*+'&,#%$-!c&+!E'/-04+!/G/-54+!4-!:/!%W5-*5/+!04!0*/E-H+%*5&!L&'!*I/E4-!/+&5*/0&!/!+$!I/2&'!

0*+L&-*A*:*0/0! T/-! L4'I*%*0&! 8$4! 4:! 0*/E-H+%*5&! 04:! %$I&'! '4-/:! +4! '4/:*54! 4-!

4+%/0*&+! 5/0/! G4U! I,+! L'45&54+! 5&-! 4:! 5&-+45$4-%4! /$I4-%&! 04! *-%4'G4-5*&-4+!

8$*'g'E*5/+C!2/!+4/!-4='45%&IF/+!%&%/:4+!&!L/'5*/:4+6!):,+*5/I4-%4!4+%/+!%W5-*5/+!04!

*I/E4-!+4!T/-!$%*:*U/0&!L/'/!4:!0*/E-H+%*5&!2!+4E$*I*4-%&!04! :/+! :4+*&-4+!'4-/:4+!

+*-! 4IA/'E&! /5%$/:I4-%4! 4:! '&:! 04! :/! '/0*&:&EF/! *-%4'G4-5*&-*+%/! 5&A'/! 5/0/! G4U!

I/+!L'&%/E&-*+I&!4-!4:!I/-4S&!04!:/+!:4+*&-4+!'4-/:4+!L48$4`/+!*-5*04-%/:4+!&!4-!

L/5*4-%4+!8$4!L&'!+$+!5&I&'A*:*0/04+!L'4+4-%/-!$-!/:%&!'*4+E&!8$*'g'E*5&!2!-&!+&-!

5/-0*0/%&+! /! 5*'$EF/6! ;&2! 4-! 0F/! +4! 5&-+*04'/! :/! 9&I&E'/=F/! )&IL$%/0/! f9)\! :/!

%W5-*5/! 04! 4:455*H-! +*4-0&! :/! 75&E'/=F/! 2! :/! @4+&-/-5*/! ?/E-W%*5/! f@?\!

T4''/I*4-%/+! 04! +4E$-0/! :F-4/! &! 4-! L/5*4-%4+! 4-! 8$*4-4+! 4+%W! 5&-%'/*-0*5/0&! 4:!

$+&!04!5&-%'/+%4!4-0&G4-&+&"[6!c/!45&E'/=F/!-&!+4!5&-+*04'/!$-/!%W5-*5/!04!5'*A/0&!

g%*:!2/!8$4!:/+!:4+*&-4+!I4-&'4+!04!V!5I!L$404-!L/+/'!=,5*:I4-%4!04+/L4'5*A*0/+"^C!

/54L%,-0&+4! 8$4! L/'/! :4+*&-4+! 4-%'4! V! 2! B6^! 5I! :/! 45&E'/=F/! 2! :/! 9)! +&-!

5&IL/'/A:4+!5&-!$-/!5&''4:/5*H-!/-/%&I&L/%&:HE*5/!aY!2!a"l"_!

B6V6!9b?b1@#Os#!)b?<D9#3#!

K*!A*4-!-&!T/2!E$F/+!8$4!*-0*8$4-!5$/:!4+!4:!I4S&'!L'&%&5&:&!L/'/!:/!'4/:*U/5*H-!04!

:/!9)C!T/2!/5$4'0&!4-!8$4!04A4!5&-%/'!5&-!/:!I4-&+!B!=/+4+(!D-/!L'*I4'/!=/+4!+*-!

5&-%'/+%4! L/'/! *04-%*=*5/'! 5/:5*=*5/5*&-4+! 2! %4S*0&! E'/+&! 2! &A%4-4'! $-/!

04%4'I*-/5*H-!A/+/:!04! :/+!$-*0/04+!04!;&$-+=*4:0!fD;\6!c/! =/+4!5&'%*5&kI40$:/'!

5&-!5&-%'/+%4!+4!$%*:*U/!L/'/!*04-%*=*5/'!:/!:4+*H-!'4-/:!2!G/:&'/'!+$!G/+5$:/'*U/5*H-C!

/-/%&IF/!G/+5$:/'!2!:/!/=45%/5*H-!G4-&+/!L&'!4:!%$I&'6!7+!5&-+*04'/0/!:/!=/+4!I,+!

*-=&'I/%*G/6!c/! =/+4!-4='&E',=*5/!&!4h5'4%&'/! %4'I*-/-!04!0/'! *-=&'I/5*H-!/54'5/!

04!I/+/+!'4-/:4+!8$4!-&!+4!T/-!*04-%*=*5/0&!5:/'/I4-%4!4-!:/!=/+4!L'4G*/!/04I,+!

04! &%&'E/'! *-=&'I/5*H-! /-/%HI*5/! +&A'4! 4:! +*+%4I/! 5&:45%&'"[C"d6! c&+! /+L45%&+!

L'*-5*L/:4+!L/'/!5/'/5%4'*U/'!$-/!:4+*H-!'4-/:!4-!:/!9)!+&-!+$!-/%$'/:4U/!8$F+%*5/!&!

+H:*0/!C!5/L%/5*H-!04!5&-%'/+%4C!A&'04+C!L'4+4-5*/!2!%*L&!04!5/:5*=*5/5*&-4+!2!%4S*0&!

E'/+&6!):,+*5/I4-%4!+4!T/!04=*-*0&!:/!5/L%/5*H-!04!5&-%'/+%4!5&I&!$-!/$I4-%&!04!

Page 11: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! VV!

/:! I4-&+! VY! D;! :$4E&! 04! :/! /0I*-*+%'/5*H-! 04:! 5&-%'/+%4! 4-0&G4-&+&"aC! +*-!

4IA/'E&! 5&-! 4:! /G/-54! 04! :/! %45-&:&EF/! 04! :/! 9)! 2! 4:! $+&! 04!I$:%*04%45%&'4+! :/!

4G/:$/5*H-!04!:/!5/L%/5*H-!4+!I,+!5&IL:*5/0/!4-5&-%'/-0&!5&-!='45$4-5*/!:4+*&-4+!

8$F+%*5/+!L+4$0&5/L%/-%4+C!T/::/UE&!/%'*A$*0&!/!:&+!4=45%&+!04!G&:$I4-!L'&I40*&!2!

4-0$'45*I*4-%&!04:!T/UC!+*4-0&!4:!E'/0&!04!L+4$0&5/L%/5*H-!I/2&'!I*4-%'/+!I,+!

L48$4`&+!+4/-!:&+!8$*+%4+"m6!#5%$/:I4-%4!+4!L&+%$:/!8$4!$-!5/IA*&!04!VYk"Y!D;!4+!

*-04%4'I*-/0&! 2! 4+%/'F/! *-0*5/0&! I/2&'! 4+%$0*&! 5&-! 45&E'/=F/! &! @?BY! BV6! c/!

L'4+4-5*/!04!5/:5*=*5/5*&-4+!4-!$-/!I/+/!'4-/:!+H:*0/!4+!+$E4+%*G&!04!I/:*E-*0/0C!

I*4-%'/+!8$4! +*! +4!L'4+4-%/! 4-!$-/! :4+*H-!8$F+%*5/! +*-! 4:4I4-%&+! +H:*0&+! +$E*4'4!

A4-*E-*0/0B"CBB6! 7:! T/::/UE&! 04! %4S*0&! E'/+&! +4! T/! 04! 4G/:$/'! 4-! :/+! *I,E4-4+!

L'45&-%'/+%4!I*0*4-0&! :/+!D;!4-!$-/!U&-/!04!A/S/!04-+*0/0!L'4=4'4-%4I4-%4!04!

$A*5/5*H-!54-%'/:!4-!:/!:4+*H-6!K*!:/+!D;!+&-!VY!&!*-=4'*&'4+!+4!L$404!/+4E$'/'!8$4!

+4!%'/%/!04!%4S*0&!E'/+&!T/5*4-0&!I$2!L'&A/A:4!4:!0*/E-H+%*5&!04!/-E*&I*&:*L&I/!

f#?c\B[CB^6! K4! 04A4! %4-4'! 4-! 5$4-%/! 8$4! :/+! :4+*&-4+! 5&'%*5/:4+! E'/-04+! L$404-!

5'454'!2!4-E:&A/'!E'/+/!L4'*'4-/:!&!04:!+4-&!&!A*4-!8$4!:4+*&-4+!4h%'/!4h%'/''4-/:4+!

5'4U5/-!4-!0*'455*H-! 54-%'/:!0/-0&! :/! =/:+/! *IL'4+*H-!04!&'*E4-! 5&'%*5/:"[6!7h*+%4!

-&%*5*/!04!))@!5&-!5&-%4-*0&!/0*L&+&C!:&+!5$/:4+!+&-!*-='45$4-%4+!2!4-!+$!I/2&'F/!

+4!/+&5*/-!/!:/!L'4+4-5*/!04!5/:5*=*5/5*&-4+!:/+!5$/:4+!-&!+$4:4-!L'4+4-%/'+4!4-!:&+!

#?cB_6! #+FC! +4! '45&I*4-0/! 5&-+*04'/'! I/:*E-/+! :/+! I/+/+! 8$4! 5&-%4-E/-! %4S*0&!

/0*L&+&! 2! 5/:5*=*5/5*&-4+"[6! 7:! b-5&5*%&I/! 5&''4+L&-04! /! $-/! :4+*H-! 4L*%4:*/:!

A4-*E-/!*-0*+%*-E$*A:4!04:!))@!L&'!*I,E4-4+C!+*-!4IA/'E&!L'4+4-%/!$-!L/%'H-!04!

5*5/%'*U! 54-%'/:! 4+%'4::/0/! 5/'/5%4'F+%*5&! 4-! $-! %4'5*&! 04! :&+! 5/+&+BdCBa6! .*I! 4%! /:!

L$A:*5/-! 4-! "YYm! $-/! '4G*+*H-! '4%'&+L45%*G/! +&A'4! ma! ?@<! 5&-! 5&-=*'I/5*H-!

T*+%&:HE*5/!04!VY!&-5&5*%&I/+!2!aa!))@!&A+4'G/-0&!$-/!*-G4'+*H-!+4EI4-%/'*/!04!

5&-%'/+%4!4-%'4!:/!=/+4!5&'%*5&I40$:/'!2!:/!=/+4!4h5'4%&'/!$+/-0&!9)!I$:%*04%45%&'!

4-!:&+!L'*I4'&+!f<tY6YYV\!4+%/A:45*4-0&!$-/!+4-+*A*:*0/0!04!aYl!2!4+L45*=*5*0/0!

04! mml! L/'/! 4:! 0*/E-H+%*5&! 04! &-5&5*%&I/Bm6! 7-! 5$/-%&! /! :/! 0*=4'4-5*/5*H-! 04!

+$A%*L&+! 04! ))@!I40*/-%4! 9)! ! KT4*'! +'% (#! L$A:*5/-! 4-! "YY^! $-/! '4G*+*H-! 04! ad!

L/5*4-%4+! 5&-! ))@! 4-! :/! 8$4! &A+4'G/-! 8$4! $-! [ml! 04! :&+! ))@! 04! 5W:$:/! 5:/'/!

L'4+4-%/-!$-!L/%'H-!T*L4'G/+5$:/'!I*4-%'/+!8$4!+&:&!4:!V^l!04!:&+!L/L*:/'4+!2!4:!

[l!04!:&+!5'&IH=&A&+!:&!T/54-!f<tY6YYV\!4!*04-%*=*5/-!8$4!4:!E'/0&!04!5/L%/5*H-!

04! 5&-%'/+%4! 4-%'4! :/! =/+4! 5&'%*5&I40$:/'! 2! :/! 4h5'4%&'/! =$4! +*E-*=*5/%*G/I4-%4!

0*+%*-%&! 4-%'4! 4+%/+! %'4+! G/'*40/04+6! #04I,+! 5&-5:$24-! 8$4! :/! L'4+4-5*/! 04!

Page 12: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! V"!

5/:5*=*5/5*&-4+! -&! =$4! 04! $%*:*0/0! L/'/! 4+%/A:454'! 4:! +$A%*L&! T*+%&:HE*5&[Y6!

<&+%4'*&'I4-%4! 4-! "YYd! uT/-E! +'% (#! '4/:*U/-! $-/! /-,:*+*+! '4%'&+L45%*G&! 04! VmB!

L/5*4-%4+! 5&-+45$%*G&+! fVma! %$I&'4+\! &A+4'G/-0&!8$4! 4:! mYl! :&+!))@!04! 5W:$:/!

5:/'/! %4-F/-! $-! L/%'H-! T*L4'G/+5$:/'! 2! 5/L%/5*H-! 04! 5&-%'/+%4! T4%4'&E4-4/!

I*4-%'/+!8$4!4:!d^l!04!:&+!))@!04!%*L&!L/L*:/'!=$4'&-!T*L&G/+5$:/'4+6!7:!mYl!04!

:/+!:4+*&-4+!8$4!4'/-!,G*0/I4-%4!5/L%/-%4+!f04=*-*0&!5&I&!5/L%/5*H-!I/2&'!/!V[Y!

D;\!5&''4+L&-0*4'&-!/!))@!04!5W:$:/!5:/'/C!5/'/5%4'F+%*5/!+4!&A+4'GH!4-!"^l!04!:&+!

5/'5*-&I/+!5'&IH=&A&+!2!+&:&!4-!4:!"l!04!:&+!L/L*:/'4+6!bA+4'G/-!/04I,+!8$4!:/!

L'4+4-5*/! 04! 5/:5*=*5/5*&-4+! %*4-4! $-! G/:&'! L'40*5%*G&! L&+*%*G&! 04! mal! L/'/!

0*+%*-E$*'!I/+/+!A4-*E-/+!04!I/:*E-/+!L4'&!+*-!8$4!4+%&!*IL:*8$4!L'40*55*H-!04!$-!

5&IL&'%/I*4-%&!%$I&'/:!/E'4+*G&[V6!7-!4:!5/+&!04!:/+!:4+*&-4+!'4-/:4+!8$F+%*5/+!+4!

T/! $%*:*U/0&! :/! 5:/+*=*5/5*H-! 04+5'*%/! L&'! J&+-*/q! 4-! Vma_"a! 4-! :/! 8$4! 0*5T/+!

:4+*&-4+! +4! 0*G*04-! 4-! [! E'$L&+! 4-! A/+4! /! +$+! 5/'/5%4'F+%*5/+! 4-! :/! 9)6!

<&+%4'*&'I4-%4! 4-! VmmBC! J&+-*/q! *-%'&0$54! $-/! I&0*=*5/5*H-! /:! /E'4E/'! :/!

5/%4E&'F/! iPPOj! f*-0*5/%*G&! 04! i:"##";% /,j\! L/'/! 0*=4'4-5*/'! :&+! 8$*+%4+! /:E&! I,+!

5&IL:4S&+!8$4!:/!5/%4E&'F/!PP!L4'&!8$4!-&!5$IL:4-!:&+!5'*%4'*&+!L/'/!+4'!*-5:$*0&+!

4-! :/! 5/%4E&'F/! PPP! ["6! 7+%/! 5:/+*=*5/5*H-! 4+! '4G*+/0/! L&'!p/''4-! +'% (#! 4-! "YY^! 2!

4+%*I/-! :&+! '*4+E&+! 04! I/:*E-*0/0! 4-! A/+4! /! $-/! '4G*+*H-! 04! m! /'%F5$:&+!

'4%'&+L45%*G&+!8$4!+4!L'4+4-%/-!4-!:/!%/A:/!V"dC[B6!!

!#$3#'4'G':3#-*E*0#0*1+'()'?&-+*#H'

:#.@' 34+5'*L5*H-! ?/:*E-*0/0!

I'#!+*IL:4!A4-*E-!52+%!o*%T!/!T/*':*-4!%T*-!o/::!%T/%!0&4+!-&%!5&-%/*-!+4L%/C!5/:5*=*5/%*&-+C!&'!+&:*0!5&IL&-4-%+6!P%!I4/+$'4+!/+!o/%4'!04-+*%2!/-0!0&4+!-&%!4-T/-54!o*%T!5&-%'/+%!I/%4'*/:6!

V6dl!

II'

#!A4-*E-!52+%!%T/%!I*ET%!5&-%/*-!/!=4o!T/*':*-4!%T*-!+4L%/6!O*-4!5/:5*=*5/%*&-+!I*ET%!A4!L'4+4-%!*-!%T4!o/::!&'!+4L%/6!D-*=&'I:2!T*ETk/%%4-$/%*&-!:4+*&-+!&=!tB!5I!%T/%!/'4!+T/'L:2!I/'E*-/%40!/-0!0&!-&%!4-T/-546!

Va6^l!

IIJ'

9T4+4!52+%+!5&-%/*-!I&'4!T/*':*-4!%T*-!+4L%/6!?*-*I/:!4-T/-54I4-%!&=!/!T/*':*-4!%T*-!+4L%$I!&'!o/::!5/-!A4!+44-!/-0!%T4'4!I*ET%!A4!I*-*I/:!%T*5q4-*-E!&=!%T4!+4L%/!&'!o/::6!9T4!52+%!I*ET%!5&-%/*-!-&0$:/'!5/:5*=*5/%*&-+!/-0!%T*5q!A$%!%T4'4!*+!-&!5&-%'/+%!4-T/-54I4-%6!9T4'4!/'4!-&!4-T/-5*-E!+&=%!%*++$4!4:4I4-%+6!9&%/::2!*-%'/'4-/:!-&-k4-T/-5*-E!T*ETk/%%4-$/%*&-!'4-/:!:4+*&-+!&=!:4++!%T/-!&'!48$/:!%&!B!5I!/'4!/:+&!*-5:$040!*-!%T*+!5/%4E&'26!!

vVa6^l!

III' 9T4+4!:4+*&-+!/'4!*-04%4'I*-/%4!52+%*5!I/++4+!%T/%!T/G4!%T*5q4-40!*''4E$:/'!o/::+!&'!+4L%/!*-!oT*5T!4-T/-54I4-%!5/-!A4!+44-6! BBl!

IK' 9T4+4!:4+*&-+!/'4!I&+%!:*q4:2!52+%*5!:4+*&-+!%T/%!5&-%/*-!4-T/-5*-E!+&=%!%*++$4!5&IL&-4-%+6! m"6^l!

Page 13: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! VB!

B6"!@7KbQ#Q)P#!?#1Qw9P)#!

c/! @?! L'4+4-%/! :/! E'/-! G4-%/S/! 04! 4G*%/'! :/+! '/0*/5*&-4+! *&-*U/-%4+! /04I,+! 04!

&='454'! $-! /:%&! 5&-%'/+%4! *-%'F-+45&! 4-! :&+! %4S*0&+! A:/-0&+! 4! *I,E4-4+!

I$:%*L:/-/'4+6!c&+!/'%4=/5%&+!04!L+4$0&5/L%/5*H-!&A+4'G/0/+!4-!:/!9)C!+&A'4!%&0&!

4-!:/+!?@<![[C[^C!-&!+$4:4-!0/'+4!4-!:/!@?"[C[_!L&'!:&!8$4!4+!:/!L'$4A/!5&-=*'I/%&'*/!

4-! 4:! 5/+&! 04! $-/! 9)! -&! 5&-5:$24-%46! c/! @?! 4+! /045$/0/! L/'/! :/! 04%455*H-! 04!

:4+*&-4+!'4-/:4+!8$F+%*5/+!2!+H:*0/+!5&-!L'45*+*H-!5&IL/'/A:4!&!+$L4'*&'!/!:/!9)[dC!

/04I,+! 04A*0&! /! +$! 5/L/5*0/0! 04! E4-4'/'! *I,E4-4+! I$:%*L:/-/'4+! L$404! +4'!

+$L4'*&'!/!:/!9)!L/'/!4+%/A:454'!4:!&'*E4-!04!$-/!I/+/!'4-/:!"[6!#:!5&IL/'/':/!5&-!

:/!75&E'/=F/C!:/!%W5-*5/!04!:/!@?!-&!04L4-04!%/-%&!04:!&L4'/'*&!2!:/!5/:*0/0!04!+$+!

*I,E4-4+!-&!+4!%/-!/=45%/0/!L&'!4:!T/A*%&!5&'L&'/:!04:!L/5*4-%46!<&'!5&-%'/L/'%4!:/!

@?!L'4+4-%/! :*I*%/5*&-4+!04A*0&!/! :/!L'&:&-E/0/!0$'/5*H-!04! :/! %W5-*5/C!+$!5&+%4!

4:4G/0&! 2! 5&-+45$4-%4I4-%4! +$! 0*+L&-*A*:*0/0! '4+%'*-E*0/6! #04I,+! +*! A*4-!

*-*5*/:I4-%4!4:!5&-%'/+%4!4-!A/+4!/!E/0&:*-*&!+4!L4-+H!*-&5$&C!'45*4-%4I4-%4!!+4!T/!

4+%/A:45*0&!4-!L/5*4-%4+!5&-!*-+$=*5*4-5*/!'4-/:!+&I4%*0&+!/!@?!:/!'4:/5*H-!4-%'4!:/!

/0I*-*+%'/5*H-!04!5&-%'/+%4!5&-!E/0&:*-*&!2!:/!=*A'&+*+!+*+%WI*5/!-4='HE4-/!C!8$4!+*!

A*4-! 4+! L&5&! ='45$4-%4! +4! 5&-+*04'/! L&%4-5*/:I4-%4! -&5*G/! 4! *-5:$+&! =/%/:[a6!

9'/0*5*&-/:I4-%4! :/! @?! +4! T/! :*I*%/0&! /! :&+! 5/+&+! 4-! 8$4! :/! 9)! 4+! *-5&-5:$+/C!

L/5*4-%4+!4-!8$*4-4+!:&+!5&-%'/+%4+!*&0/0&+!4+%,-!5&-%'/*-0*5/0&+!&!4-!:&+!8$4!+4!

04+4/!*-G4+%*E/'!:/!4h*+%4-5*/!04!$-!%'&IA&!4-!:/!G4-/!5/G/"dC!/$-8$4!g:%*I/I4-%4!

:/!*-%'&0$55*H-!04!:/!9)!5&-!I$:%*04%45%&'!T/!48$*L/'/0&!:/+!0&+!%W5-*5/+!4-!4+%4!

/+L45%&[m6! #5%$/:I4-%4C! /04I,+! 04! :/+! +45$4-5*/+! 04! @?! T/A*%$/:4+! 4+%,-! 4-!

4G/:$/5*H-! :/+! *I,E4-4+! L&-04'/0/+! L&'! 0*=$+*H-! f3pPC! $.<</&.")% ;+.!-'+$%

.6(!.)!=! :/+! 5$/:4+!I*04-!4:!I&G*I*4-%&!04! :/+!I&:W5$:/+!04!/E$/!4-! :&+! %4S*0&+!

A*&:HE*5&+6!7+%/!%W5-*5/C!*-*5*/:I4-%4!/L:*5/0/!4-!-4$'&*I/E4-C!+4!T/!$%*:*U/0&!4-!:/!

4G/:$/5*H-! =$-5*&-/:! 04! '*`&-4+! -/%*G&+! 2! %'/+L:/-%/0&+C! 4-! :/! 0*=4'4-5*/5*H-! 04!

T*0'&-4='&+*+!04!L*&-4='&+*+!!2!'45*4-%4I4-%4!4-!:/!*-G4+%*E/5*H-!04!I/+/+!'4-/:4+!

5&-!'4+$:%/0&+!L'&I4%40&'4+^Y6!!

B6B!7)b1@#Os#!

c/!45&E'/=F/!4+!$-/!T4''/I*4-%/!*IL&'%/-%4!4-!:/!4G/:$/5*H-!04!:/+!I/+/+!'4-/:4+C!

0*=4'4-5*/-0&! *I,E4-4+! 8$F+%*5/+! 04! +H:*0/+6! #-%4! :/! L'4+4-5*/! 04! $-/! :4+*H-!

8$F+%*5/!+4!04A4!04%4'I*-/'!+*!+4!%'/%/!04!$-!8$*+%4!+*IL:4!f#-45&*5&C!L/'404+!=*-/+C!

Page 14: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! V[!

=&'I/! '40&-04/0/! $! &G/:/0/C! '4=$4'U&! L&+%4'*&'C! /G/+5$:/'\! &! 5&IL:4S&! f</'40!

v"IIC! G/+5$:/'*U/0/C! -$I4'&+&+! %/A*8$4+! E'$4+&+! &! -&0$:/'4+! G/+5$:/'*U/0&+C!

5/:5*=*5/5*&-4+!*''4E$:/'4+!&!54-%'/:4+\!:&+!5$/:4+!'48$*4'4-!I/2&'!4+%$0*&!5&-!9)!

&!@?"[6!c4+!:4+*&-4+!+H:*0/+!+4!04+5'*A4-!4-!=$-5*H-!04!+$!45&E4-*5*0/0(!;*L4'k*+&k

T*L&!45&*5&!4-!5&IL/'/5*H-!5&-!:/!5&'%4U/!'4-/:6!D-/!:4+*H-!+H:*0/!&A+4'G/0/!L&'!

45&E'/=F/!04A4!+4'!4+%$0*/0/!+*4IL'4!L&'!&%'/!%W5-*5/!04!*I/E4-!2/!+4/!9)C!@?!&!

5&-! 75&E'/=F/! 5&-! 5&-%'/+%4! f)7DKC! >")'*(&'?+)-()3+$% /#'*(&")"!*(,-0\6! c/!

45&E'/=F/! 3&LL:4'! +4! T/! $%*:*U/0&! L/'/! 4G/:$/'! :/! G/+5$:/'*U/5*H-! 04! :/+! I/+/+!

'4-/:4+! L/'/! *-%4-%/'! 0*=4'4-5*/'! 4:! +$A%*L&! T*+%&:HE*5&6! D-! 4+%$0*&! L$A:*5/0&! 4-!

"YYd! 4G/:$H! "mm! I/+/+! '4-/:4+! '4%'&+L45%*G/I4-%4! 4-5&-%'/-0&! 8$4! 04! V_m!

I/+/+!'4-/:4+!5&-!+4`/:!0&LL:4'C!V^_!fm"l\!5&''4+L&-0*4'&-!/!))@!04!5W:$:/!5:/'/!

fb@!V_6mC!m^l!P)!a6dkB"6ax!L!tY6YYYV\6!7-!4:!I*+I&!4+%$0*&!+4!'4/:*U/!$-!/-,:*+*+!

L'&+L45%*G&! 04! md! L/5*4-%4+! 4-5&-%'/-0&! +4`/:! 3&LL:4'! 4-! ^[! faBl\! 04! :/+! _^!

I/+/+!'4-/:4+!8$4!%$G*4'&-!T*+%&:&EF/!04!))@!04!5W:$:/!5:/'/!fb@!&=!VY6aC!m^l!P)!

[6Yk"m6Yx! L! tY6YYYV\^V6! c/! 45&E'/=F/! +4! T/! $+/0&! %/IA*W-! 5&I&! 4G/:$/5*H-!

L'4&L4'/%&'*/!/:!L:/-*=*5/'!$-/!-4='45%&IF/!L/'5*/:! 5&I&!L:/-%*::/!04! :/!45&E'/=F/!

*-%'/&L4'/%&'*/6!!

B6[!7)b1@#Os#!)bQ!)bQ9@#K97!

K*! A*4-! :/! 45&E'/=F/! 4+! $-/! %W5-*5/! *I/E4-&:HE*5/! I$2! 0*=$-0*0/! L/'/! $-! E'/-!

-gI4'&!04!L/%&:&EF/+!2!8$4!/+&5*/0/!/:!3&LL:4'!/L&'%/!*-=&'I/5*H-!G/:*&+/!+&A'4!

:/! G/+5$:/'*U/5*H-! 2! ! :/! 5/'/5%4'*U/5*H-! 04! :4+*&-4+! =&5/:4+! '4-/:4+C! L'4+4-%/!

:*I*%/5*&-4+! 4-! 5$/-%&! /! :/! 04%455*H-! 04! =:$S&! :4-%&! &! =:$S&! 04! 4+%'$5%$'/+!

G/+5$:/'4+! 4-! +*%$/5*H-! L'&=$-0/! /+F! 5&I&! :/! *IL&+*A*:*0/0! 04! 04%45%/'!

/045$/0/I4-%4! :/!I*5'&G/+5$:/'*U/5*H-!%$I&'/:!&!L/'4-8$*I/%&+/^"6!)&I&!2/!+4!

T/!5&I4-%/0&C!/-%4!4:!T/::/UE&!04!$-/! :4+*H-!+H:*0/!L&'!45&E'/=F/!4+!-454+/'*/! :/!

'4/:*U/5*H-! 04! &%'/+! %W5-*5/+! 04! *I/E4-! 5&I&! :/! 9)! &! @?C! 4-! :/+! 5$/:4+! :/!

/0I*-*+%'/5*H-! 04! 5&-%'/+%4+! *-%'/G4-&+&+! L4'I*%4! 4G/:$/'! 5/'/5%4'F+%*5/+! 04! :/!

I/5'&! 2! I*5'&G/+5$:/'*U/5*H-! 04! :&+! H'E/-&+! 2! L&+*A:4+! %$I&'4+! +*4-0&!

=$-0/I4-%/:!:/!G/:&'/5*H-!04:!%*L&!04!5/L%/5*H-!L/'/!::4E/'!/:!0*/E-H+%*5&!=*-/:6!7-!

4+%4! 5&-%4h%&! :/! /L/'*5*H-! 04! :&+! 5&-%'/+%4+! 45&E',=*5&+! f)7\C! 5&-+%*%$*0&+! L&'!

I*5'&A$'A$S/+!04!E/+!4+%/A*:*U/0/+!T/!+$L$4+%&!$-/!'4G&:$5*H-!4-!4:!0*/E-H+%*5&!

45&E',=*5&!04!I$5T/+!4-=4'I40/04+66!7-!7$'&L/!4+%,-!/L'&A/0&+!"!5&-%'/+%4+!L/'/!

Page 15: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! V^!

$+&!'/0*&:HE*5&!/A0&I*-/:(!c4G&G*+%y!fK5T4'*-E\!8$4!4+%,!5&IL$4+%&!04!/*'4!5&-!

E/:/5%&+/! 2! ,5*0&! L/:IF%*5&! 5&I&! /E4-%4! %4-+*&/5%*G&! 2! K&-&M$4y! fJ'/55&\C!

5&IL$4+%&! L&'! T4h/=:$&'$'&! 04! /U$='4! 5&-! $-/! 5,L+$:/! 04! =&+=&:FL*0&6! c/! A/S/!

+&:$A*:*0/0! 04:! T4h/=:$&'$'&! 04! /U$='4! S$-%&! 5&-! +$! I/2&'! 4+%/A*:*0/0! L4'I*%4!

'4/:*U/'!4+%$0*&+!4-!%*4IL&!'4/:!5&-!K&-&M$4C!5$/-0&!+4!$%*:*U/!$-!F-0*54!I45,-*5&!

A/S&!+*-!04+%'$55*H-!04!:/+!I*5'&A$'A$S/+6!7:!5&IL$4+%&!:*+%&!L/'/!+$!*-2455*H-!+4!

&A%*4-4! %'/+! '45&-+%*%$*'! L&:G&! :*&=*:*U/0&! 5&-! ^55! 04! +$4'&! =*+*&:HE*5&C! 04! =&'I/!

8$4!V!I:!04!5&IL$4+%&!'45&-+%*%$*0&!5&-%*4-4!a!I:!04!I*5'&A$'A$S/+!04!KO_6!7:!

E/+! 8$4! 5&IL&-4! :/+! I*5'&A$'A$S/+! +4! 0*+$4:G4! 4-! 4:! L:/+I/C! /%'/G*4+/! L&'!

0*=$+*H-! L/+*G/! :/! I4IA'/-/! /:GW&:&k5/L*:/'! 2! 4+! 4:*I*-/0&! 4-! :/! '4+L*'/5*H-!

'45$L4',-0&+4!4-!4:!/*'4!4hT/:/0&!/! :&+!V^!I*-$%&+!5/+*!4:!VYYl!04:!T4h/=:&'$'&!

04!/U$='4!/0I*-*+%'/0&6!7+%&!+4!%'/0$54!4-!$-/!-$:/!%&h*5*0/0!'4-/:C!:&!8$4!:&!T/54!

4+L45*/:I4-%4!*-0*5/0&!4-!L/5*4-%4!5&-!*-+$=*5*4-5*/!'4-/:!5'H-*5/!fP@)\!&!/E$0/C!

0&-04!:&+!5&-%'/+%4+!*&0/0&+!L$404-!%4-4'!5&-%'/*-0*5/5*H-!'4:/%*G/6!K*-!4IA/'E&C!

%/IA*W-!*IL:*5/!8$4!-&!&L/5*=F5/! :/!GF/!$'*-/'*/!2/!8$4!-&!L'4+4-%/-!4:*I*-/5*H-!

'4-/:6!7+%,!'45&-&5*0/!+$!$%*:*0/0!L'*-5*L/:I4-%4!4-!:/!5/'/5%4'*U/5*H-!04!:4+*&-4+!

=&5/:4+!T4L,%*5/+C!4:!5&-%'&:!L&+%'/%/I*4-%&!L4'5$%,-4&!04!%$I&'4+!!2!:/!G/:&'/5*H-!

04! :/! L4'=$+*H-! L/'4-8$*I/%&+/! 04! 0*=4'4-%4+! H'E/-&+C! *-5:$24-0&! 4-=4'I40/0!

%'/$I,%*5/C! *-=455*&+/! &! *+8$WI*5/^B6! c&+! )7! -&! T/-! +*0&! /L'&A/0&+! 4-!

4IA/'/U/0/+! -*C! 4-! /:E$-&+! L/F+4+! f*-5:$*0&! 7+L/`/\C! 0$'/-%4! 4:! L4'F&0&! 04!

:/5%/-5*/6!Q&!T/!+*0&!/L'&A/0&!4:!$+&!*-%'/G4-&+&!04!K&-&G$4®!4-!L40*/%'F/6!34A4!4G*%/'+4! +$! $%*:*U/5*H-! "[T! /-%4+! 04! :/! :*%&%'*5*/! 4h%'/5&'LH'4/^[6! 7-%'4! :/+!

5&-%'/*-0*5/5*&-4+!04!4+%4!5&IL$4+%&!4+%,-!4:!+F-0'&I4!5&'&-/'*&!/E$0&!'45*4-%4C!

/-E*-/! *-4+%/A:4C! *-+$=*5*4-5*/! 5/'0*/5/! /E$0/! 2! :&+! %'/+%&'-&+! E'/G4+! 04:! '*%I&!

5/'0F/5&! 2/! 8$4! 4-! 4+%/+! +*%$/5*&-4+! 5:F-*5/+! :/+! '4/55*&-4+! /-/=*:,5%*5/+! &! 04!

G/+&0*:/%/5*H-!L$404-!+4'!4+L45*/:I4-%4!E'/G4+6!9/IA*W-!4+%,!5&-%'/*-0*5/0&!4-!

04'*G/5*&-4+! 5/'0F/5/+! 04'45T/k*U8$*4'0/C! T*L4'%4-+*H-! L$:I&-/'! /G/-U/0/C!

T*L4'%4-+*H-! +*+%WI*5/! -&! 5&-%'&:/0/! 2! 4-! L/5*4-%4+! 5&-! +F-0'&I4! 04! 0*+%'4++!

'4+L*'/%&'*&!04:!/0$:%&^^6!7-!5$/-%&!/!4:!$+&!04!)7DK!L/'/!4G/:$/'!I/+/+!'4-/:4+C!

:&+! L'*I4'&+! 4+%$0*&+! '4/:*U/0&+! 5&-! c4G&G*+%y! 4G*04-5*/'&-! $-/! I4S&'F/!

+*E-*=*5/%*G/! 4-! :/! 4G/:$/5*H-!04! :/! G/+5$:/'*U/5*H-! %$I&'/:^_! :&! 8$4!L4'I*%4! $-/!

0*+5'*I*-/5*H-! I/+! 5:/'/! 04! :&+! 8$*+%4+! '4-/:4+! +*IL:4+! 04! :&+! 5&IL:4S&+^d! 2!

04%45%/'!5/'/5%4'F+%*5/+!L'&L*/+!04!5/L%/5*H-!04!5&-%'/+%4!8$4!L4'I*%4-!$-/!I4S&'!

Page 16: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! V_!

0*=4'4-5*/5*H-!04!&%'/+!:4+*&-4+!+H:*0/+!A4-*E-/+!5&I&!:&+!/-E*&I*&:*L&I/+!&!:&+!

T/I/'%&I/+^a6!9/I/*!+'%(#!5&IL/'/'&-!4-!"YY^!:/!9)!G4'+$+!)7DK!4-!"m!L/5*4-%4+!

+&I4%*0&+! /! -4='45%&IF/6! bA+4'G/'&-! 8$4! :/! 9)! =/::H! 4-! 04I&+%'/'! 5/L%/5*H-! 04!

5&-%'/+%4! 4-! ^! L/5*4-%4+C! I*4-%'/+! 8$4! )7DK! 04I&+%'H! 5/L%/5*H-! 4-! :&+! "m!

L/5*4-%4+!*-5:$24-0&![!))@!L/L*:/'4+!8$4!=$4'&-!5/%/:&E/0&+!5&I&!/G/+5$:/'4+!4-!

:/!9)6!c&+!/$%&'4+!&A+4'G/-!8$4!)7DK!=$4!I/+!+4-+*A:4!8$4!:/!9)!fm[6[l!2!aa6ml!

'4+L45%*G/I4-%4\! /$-8$4! +$! 4+L45*=*5*0/0! =$4! I4-&'! f[^6^l! 2! d6dl!

'4+L45%*G/I4-%4\!L/'/!4:!0*/E-H+%*5&!04!))@!2!8$4!4+!g%*:!+&A'4!%&0&!4-!:/+!I/+/+!

'4-/:4+!T*L&G/+5$:/'4+^m6!O/-!+'%(#!L$A:*5/-!4-!"YYa!$-!4+%$0*&!4-!4:!5$/:!4G/:g/-!

d"! I/+/+! '4-/:4+! I4-&'4+! 04! ^! 5I! 5&-! [[! ))@! 5&-=*'I/0&+! L&'! /-/%&IF/!

L/%&:HE*5/6!7-! +$+! '4+$:%/0&+!04+%/5/-!8$4! :/!T*L4'5/L%/5*H-! %/'0F/! 5&-+%*%$24!4:!

T/::/UE&!I,+! '4:4G/-%4!L/'/!L'4045*'!))@!2!&A%*4-4-C!A/+,-0&+4!4-!4+%4! 5'*%4'*&!

$-/! +4-+*A*:*0/0! 2! 4+L45*=*5*0/0! 04! dd6Bl! 2! m_6[l! '4+L45%*G/I4-%46! )&-5:$24-!

8$4! )7DK! L$404! +4'! 4=45%*G&! 2! -454+/'*&! L/'/! '4/:*U/'! /045$/0/I4-%4! 4:!

0*/E-&+%*5&!0*=4'4-5*/:!04!$-/!:4+*H-!+H:*0/!04!L/'W-8$*I/!'4-/:!I4-&'!04!^!5I_Y6!

b%'&!4+%$0*&!'4/:*U/0&!L&'!PE-44!+'%(#!4-!"YVY!5&IL/'/!:/!4=*5/5*/!0*/E-H+%*5/!04!

)7DK! 5&-! 9)! 4-! V[B! L/5*4-%4+! 4-! %&0&+! :&+! 5$/:4+! +4! 0*+L&-F/! 5&-=*'I/5*H-!

T*+%&:HE*5/6!D-!aYl!=$4'&-!))@!5&-=*'I/0&+6!34+5'*A4-! :/!5/L/5*0/0!04!)7DK!4-!

04%4'I*-/'! I/:*E-*0/0! 5&-! $-/! +4-+*A*:*0/0C! 4+L45*=*5*0/0C! G/:&'! L'40*5%*G&!

L&+*%*G&C! G/:&'! L'40*5%*G&! -4E/%*G&! 2! L'45*+*H-! 04! mdlC! [^lC! mVlC! d^l! 2! mYl!

'4+L45%*G/I4-%46!#04I,+C!)7DK!:&E'H!$-!5&''45%&!4+%/0*/S4!4-!aBl!04!:&+!5/+&+!4-!

5&IL/'/5*H-!5&-!4:!_ml!:&E'/0&!L&'!:/!9)6!)&-5:$24-!8$4!)7DK!4+!+$L4'*&'!/!:/!9)!

%/-%&!4-!5/'/5%4'*U/'!5&I&!4-!4+%/0*/'!:/+!:4+*&-4+!'4-/:4+!+H:*0/+!2!8$F+%*5/+!fdl!

04! :&+! L/5*4-%4+\! 2! 8$4! L$404! '44IL:/U/'! /! :/! 9)! 4-! L/5*4-%4+! 8$4! L'4+4-%4-!

/:E$-/!5&-%'/*-0*5/5*H-!L/'/!+$!$+&_V!_"6!!

! !

Page 17: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! Vd!

!"# $%&'$()*# +),-%./+'&-*# 0)# 1-*#!"#"#$%&'"(&#$)&*+&,"#!7:!I/-4S&!04! :/+!?@<!+4!4-5$4-%'/!4-!L:4-&!L'&54+&!04!5/IA*&6!;/54!"Y!/`&+! :/!

4+%'/%4E*/!5&-+*+%F/!4-!'4/:*U/'!$-/!-4='45%&IF/!'/0*5/:!fQ@\!4-!:/!I/2&'F/!04!:&+!

5/+&+"6!#5%$/:I4-%4!0*+L&-4I&+!04!5&-&5*I*4-%&+!8$4!-&+!L4'I*%4-!/A&'0/'! :/+!

?@<!5&-+*04'/-0&!8$4!+4!%'/%/!04!$-!E'$L&!T4%4'&EW-4&!04!:4+*&-4+!5&-!0*+%*-%&+!

E'/0&+!04!/E'4+*G*0/0!L&'!:&!8$4!A/'/S/I&+!0*G4'+/+!/:%4'-/%*G/+!%4'/LW$%*5/+!8$4!

+4!0*=4'4-5*/-!A,+*5/I4-%4!4-!5$/-!/E'4+*G/+!4!*-G/+*G/+!+&-6!7-!4+%4!5&-%4h%&C!:/!

Q@!5&-+%*%$*'F/!$-!+&A'4!%'/%/I*4-%&!+*!5&-+*04'/I&+!:&+!5/+&+!4-!8$4!+4!%'/%/!04!

$-/!:4+*H-!A4-*E-/!&!04!$-/!:4+*H-!I/:*E-/!L4'&!04!A/S/!/E'4+*G*0/06!)&-+*04'/-0&!

/04I,+!8$4!:/!Q@!+4!T/!'4:/5*&-/0&!=$4'%4I4-%4!/!4-=4'I40/0!'4-/:!5'H-*5/!5&-!:/!

5&-+45$4-%4! I&'A*:*0/0! 2! I&'%/:*0/0! 5/'0*&G/+5$:/'! /+&5*/0/_B! 4+! 8$4!

/5%$/:I4-%4! T/2! $-/! 5:/'/! %4-04-5*/! /! $-! /A&'0/S4! i5&-+4'G/0&'! 04! -4='&-/+j!

f@+,-*")?&,(*.)!% (,,*"(3-+&\! 8$4! *-5:$24! :/! -4='45%&IF/! L/'5*/:! fQ<\C! %W5-*5/+!

/A:/%*G/+!5&I&!:/!5'*&/A:/5*H-!&!:/!'/0*&='45$4-5*/!2!L'&%&5&:&+!04!G*E*:/-5*/!/5%*G/6!

[6V!Q7O@7)9b?s#!@#3P)#c!

)&-+*04'/0/! T/54! "! 0W5/0/+! 4:! %'/%/I*4-%&! 4+%,-0/'! 04! 5/+*! %&0/+! :/+! I/+/+!

'4-/:4+!04!L&+*A:4!4%*&:&EF/!I/:*E-/!2/!8$4! :/!Q<!+4! '4+4'G/A/!L/'/! :&+! 5/+&+!04!

'*`H-! +&:*%/'*&C! %$I&'4+! A*:/%4'/:4+! 2! 4-! 4:! 5/+&! 04! P@)"6! c/! Q@! +4! /+&5*/! /!

'45$''4-5*/+!04:!&'04-!04!Vk"l!2!$-/!+&A'4G*0/!5,-54'!4+L45F=*5/!/!^kVY!/`&+!04!

m_kmYl!'4+L45%*G/I4-%4C!0/%&+!8$4!+&-!5&IL/'/A:4+!5&-!:/!Q<!%/-%&!4-!%W5-*5/+!

/A*4'%/+! 5&I&! :/L/'&+5HL*5/+VYC_[6! c/+! 5&IL:*5/5*&-4+! $'&:HE*5/+! I/2&'4+! 5HI&!

T4I&''/E*/!5&-!'48$4'*I*4-%&!04!%'/-+=$+*H-!&!=F+%$:/!$'*-/'*/!+4!L'4+4-%/-!4-!$-!

VCBl!I*4-%'/+!8$4! :/+!-&!$'&:HE*5/+!4-!^Cml_^6!M/'*&+! =/5%&'4+!T/-! *-=:$*0&!L/'/!

8$4!/5%$/:I4-%4!:/!Q<!T/::/!04+L:/U/0&!/!:/!Q@!5&I&!4:!/A&'0/S4!04!L'*I4'/!:F-4/!

4-!4:!I/-4S&!04!:/+!?@<(!

V6 @4+$:%/0&!&-5&:HE*5&!5&IL/'/A:4!4-!%&0&+!:&+!+$A%*L&+!T*+%&:HE*5&+_^k_m6!!

"6 7-%'4! 4:! "Yk"^l! 04! :/+!?@<+! 5&''4+L&-04-! /! :4+*&-4+! A4-*E-/+C! _YkdYl!

5&''4+L&-04-!/!%$I&'4+!*-0&:4-%4+!5&-!A/S&!L&%4-5*/:!I4%/+%,+*5&!2!+&:&!4:!

"Yk"^l!%*4-4!5/'/5%4'F+%*5/+!/E'4+*G/+!4-!4:!4+%$0*&!T*+%&:HE*5&"C"BC_^6!

Page 18: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! Va!

B6 <&+*A*:*0/0!04!'45*0*G/!5&-%'/:/%4'/:!L&+%4'*&'!_^6!

[6 )'45*4-%4!4G*04-5*/!4-!5$/-%&!:/!'4:/5*H-!04!:/!Q@!5&-!:/!P@)dYCdVCd"!

K*-! 4IA/'E&C! /! L4+/'! :/+! '45&I4-0/5*&-4+! /5%$/:4+! :/! Q@! +*E$4! +*4-0&! 4:!

L'&540*I*4-%&! I,+! 0*=$-0*0&"CdB6! 7-! "YY_! ?*::4'! +'% (#! L$A:*5/-! $-/! '4G*+*H-!

4-%'4!Vmaa!2!"YYV!8$4!*-5:$24!V[6_[d!L/5*4-%4+!5&-!I/+/+!'4-/:4+!I4-&'4+!/!

d5I6!34+5'*A4-!8$4!+&:&!4:!m6_l!=$4'&-!%'/%/0&+!5&-!Q<C!/$-8$4!+4!&A+4'G/!$-!

*-5'4I4-%&! L'&E'4+*G&! 04:! $+&! 04! :/!Q<C! &A+4'G/-0&![C_l!4-!Vmaa!I*4-%'/+!

8$4! 4-!"YYV! :/!Q<!/:5/-UH! 4:! VdC_ld[6!D-/!L&+*A:4! 4hL:*5/5*H-! /:! L4'+*+%4-%4!

L'40&I*-*&!04!:/!Q@!4+!8$4!:/!Q<!4+!%W5-*5/I4-%4!I,+!5&IL:4S/!2/!8$4!*IL:*5/!

'45&-+%'$55*H-! '4-/:6! #04I,+C! :/! Q@! 5/+*! +*4IL'4! L$404! '4/:*U/'+4! L&'! GF/!

:/L/'&+5HL*5/! :&!8$4! :/!T/54!L'4=4'*A:4!L&'!/:E$-&+!5*'$S/-&+d^6!7-!$-!4+%$0*&!

L$A:*5/0&!4-!"YY_!L&'!;$/-E!+'%(#! +4!4G/:g/-!__"!L/5*4-%4+!8$4! %*4-4-!?@<!

5&-! -*G4:4+! 04! 5'4/%*-*-/! L:/+I,%*5/! f)<\! -&'I/:! 2! '*`H-! 5&-%'/:/%4'/:!

/L/'4-%4I4-%4!+/-&!4-!:/+! *I,E4-4+!8$4!+&-!+&I4%*0&+!/!Q<!&!Q@6!bA+4'G/-!

8$4!$-!"_l!04!:&+!L/5*4-%4+!%4-F/-!P@)!4+%/0*&!B!L'4G*&!/!:/!5*'$EF/!/:!4G/:$/'!

4:!=*:%'/0&!E:&I4'$:/'!2!8$4!/!:&+!B!/`&+!_^l!04!:&+!L/5*4-%4+!+&I4%*0&+!/!Q@!

%4-F/-! P@)! 4+%/0*&! B! I*4-%'/+! 8$4! +&:&! $-! "Yl! 04! :&+! +&I4%*0&+! /! Q<! :/!

L/045F/-d"6!

[6" Q7O@7)9b?s#!<#@)P#c!

c/!Q<!T/! +*0&!04=*-*0/! 5&I&! :/! %W5-*5/!A"#$%1'()$(*$! L/'/! :/!I/2&'F/! 04! :&+!

L/5*4-%4+!L&'! :/!#+&5*/5*H-!#I4'*5/-/!04!D'&:&EF/"C_^6!c/!#+&5*/5*H-!7$'&L4/!

04!D'&:&EF/!:/!5&-+*04'/!:/!L'*I4'/!:F-4/!04!%'/%/I*4-%&!/$-8$4!+4!'45&-&54-!B!

+*%$/5*&-4+! 4-! :/! 5$/:4+! +4! L'4=*4'4! :/! Q@(! 9$I&'! :&5/:I4-%4! /G/-U/0&C!

*IL&+*A*:*0/0! 04! '4+455*H-! L/'5*/:! L&'! :&5/:*U/5*H-! 04+=/G&'/A:4! 2! 04%4'*&'&!

+*E-*=*5/%*G&! 04:! 4+%/0&! E4-4'/:! 04:! L/5*4-%4d_6! c/! Q<! *IL:*5/! :/! 4+5*+*H-! 04:!

%$I&'!5&-!$-!L48$4`&!I/'E4-!04!%4S*0&!-&'I/:!L'4+4'G/-0&!%&0&!:&!L&+*A:4!4:!

L/'W-8$*I/! '4-/:6! K4! T/! 04+5'*%&! $-/! I/2&'! ='45$4-5*/! 04! 5&IL:*5/5*&-4+!

$'&:HE*5/+!4-!:/!Q<!4-!5&IL/'/5*H-!5&-!:/!Q@!5&I&!=$E/!$'*-/'*/!2!T4I&''/E*/!

L&+%! 8$*'g'E*5/dd6!D-! 4+%$0*&! '4/:*U/0&! 4-!"YYd! 5&IL/'H!"_a!Q<!G4'+$+!"dB!

Q@! 4-! I/+/+! '4-/:4+! I4-&'4+! 04! ^! 5I6! 34+5'*A4-! 0*+5'4%/+! 0*=4'4-5*/+! 4-!

5&IL:*5/5*&-4+!5&I&!T4I&''/E*/!+4G4'/!fB6Vl!G+6!V6"l\C! =$E/!$'*-/'*/!f[6[l!

G+6!Yl\!2!-454+*0/0!04!'4*-%4'G4-5*H-!f[6[lG+6!"6[l\da6!

Page 19: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! Vm!

[6B 9w)QP)#K!#Jc#9PM#K!

c/! /A:/5*H-! L&'! '/0*&='45$4-5*/! f@O\! 2! :/! 5'*&/A:/5*H-! f)#\! +&-! 4I4'E4-%4+!

%W5-*5/+!IF-*I/I4-%4!*-G/+*G/+!5&-+4'G/0&'/+!04!-4='&-/+!L/'/!4:!I/-4S&!04!

:/+! ?@<! 4-! L/5*4-%4+! 5&-! 5&I&'A*:*0/04+! *IL&'%/-%4+! 8$4! :&+! T/54-! L&5&!

5/-0*0/%&+! L/'/! $-! /A&'0/S4! 8$*'g'E*5&6! 9/IA*W-! +4! 5&-+*04'/-! 5&I&! $-/!

I/-*&A'/!04!'4+5/%4!4-!5/+&!04!'45$''4-5*/!04+L$W+!04!$-/!Q<!&!4-!L/5*4-%4+!

+4:455*&-/0&+!5&-!4-=4'I40/0!I$:%*=&5/:"6!#IA/+! %W5-*5/+!+4!L$404-!'4/:*U/'!

L&'!GF/!L4'5$%,-4/!E$*/0/!L&'!75&E'/=F/C!75&E'/=F/! 5&-!5&-%'/+%4C!9)!&!@?x!&!

L&'! GF/! :/L/'&+5HL*5/C! :/! 5$/:! +4! $%*:*U/! 4-! 5/+&! 04! +4'! -454+/'*&! I&G*:*U/'!

4+%'$5%$'/+! /02/54-%4+dm6! 7h*+%4-! /04I,+! &%'/+! %W5-*5/+! /A:/%*G/+! 8$4! +4!

5&-+*04'/-! /g-! 4-! =/+4! 4hL4'*I4-%/:! 5&I&! :/! /A:/5*H-! L&'! I*5'&&-0/+C!

/A:/5*H-! L&'! :/+4'C! /A:/5*H-! '/0*&8$*'g'E*5/! f>0B+*9).<+\! 2! /A:/5*H-! L&'!

$:%'/+&-*0&!=&5/:!04!/:%/!*-%4-+*0/0!f;POD\d_6!!

[6B6V #Jc#)PzQ!<b@!@#3PbO@7)D7Q)P#!

c/! /A:/5*H-!L&'!@O! 5&-+*+%4! 4-! :/! /L:*5/5*H-!04!$-/! 5&''*4-%4! 4:W5%'*5/! 4-!$-!

'/-E&!04!'/0*&='45$4-5*/!8$4!L'&0$54!-45'&+*+!L&'!5&/E$:/5*H-!4-! :/+!5W:$:/+!

%$I&'/:4+6!K$!/L:*5/5*H-!4-!:/+!I/+/+!'4-/:4+!5&I*4-U/!4-!VmmdaY6!K4!/L:*5/!/!

%'/GW+! 04! $-/! /E$S/k4:45%'&0&! 8$4! 5&-G*4'%4! :/+! &-0/+! 04! '/0*&='45$4-5*/! 4-!

5/:&'! L'&0$5*4-0&! :/! 04+-/%$'/:*U/5*H-! 04! :/+! L'&%4F-/+! 54:$:/'4+! 2! :/!

04+*-%4E'/5*H-! 04! :/! I4IA'/-/! 54:$:/'6! </'/! :&E'/'! 4+%4! 4=45%&! +4! '48$*4'4!

/:5/-U/'!%4IL4'/%$'/+!4-%'4!^Y!2!VYY{)!4-!%&0&!4:!G&:$I4-!%$I&'/:!0$'/-%4![k

_! I*-$%&+! 04! I/-4'/! 04! E4-4'/'! 0/`&+! *''4G4'+*A:4+6! Q&! +4! '45&I*4-0/!

+$L4'/'!:&+!VYY{)!2/!8$4!L'&0$54!5/'A&-*U/5*H-!2!G/L&'*U/5*H-!04:!%4S*0&!5&-!

4:!5&-+45$4-%4!/$I4-%&!04! :/! *IL40/-5*/!8$4!0*+I*-$24!4:! =:$S&!04!4-4'EF/!2!

:*I*%/!4:!'/0*&!04!/A:/5*H-aV6!c&+!G/+&+!'4-/:4+!L$404-!/5%$/'!5&I&!0*+*L/0&'4+!

04!5/:&'C!0*=*5$:%/-0&!/:5/-U/'!:/!%4IL4'/%$'/!04+4/0/!L&'!:&!8$4!:&+!%$I&'4+!

4h&=F%*5&+!L$404-!+4'!I4S&'!%'/%/0&+!8$4!:&+!54-%'/:4+a"6!7:!G&:$I4-!04:!%4S*0&!

-45'&+/0&!04L4-04!04:!5/:*A'4!2!:/!5&-=*E$'/5*H-!04:!4:45%'&0&C!04!:/!*-%4-+*0/0!

04! :/! 5&''*4-%4! 2! +$! 0$'/5*H-! /+F! 5&I&! 04! :/+! 5/'/5%4'F+%*5/+! 04:! %4S*0&6! #+F!

4h*+%4-! 0*=4'4-%4+! +*+%4I/+!L/'/! /L:*5/'! :/! '/0*&='45$4-5*/! 8$4! +4! 0*=4'4-5*/+!

A,+*5/I4-%4!4-!4:!%*L&!2!-gI4'&!04!/E$S/+!2!4-!4:!5&-%'&:!4-!A/+4!/!I40*5*H-!

04! :/! %4IL4'/%$'/! 4-! :/! L$-%/! 04! :/! /E$S/! &! 04! :/! *IL40/-5*/! :&! 5$/:4+! +4!

Page 20: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "Y!

L'4+4-%/-!4-!:/!%/A:/!"!&A%4-*0/!04!:/!'4G*+*H-!04!7+%4A/`4U!+'%(#!'4/:*U/0/!4-!

"YYm!aV6!

!#$3#'5@'7"*+0*2#3)-'-*-.)8#-'()'C#(*&E")0;)+0*#'0&8)"0*#3*L#(&-'

A#"0#' M3)0."&(&' 7&.)+0*#' N)+)"#(&"' >/;%#-' B)-*1+'

925&!

)&&:k%*L|!5&-!5*'5$:/5*H-!*-%4'-/!04!/E$/!

"YYp! )&-%'&:/!*IL40/-5*/! Vd!E/$E4! bG&*04/!04!

B5I!

@P9#!?40*5/:!K2+%4I+!

K%/'J$'+%y6!K4!/A'4!4-!G/'*&+!L$-U&-4+!

"^Yp! )&-%'&:/!%4IL4'/%$'/!

m!/E$S/+!04!0*=4'4-%4+!%/I/`&+!

7+=W'*5/+!04!"!/!d!5I!

J&+%&-!K5*4-%*=*5+!

c4M44-y6!K4!/A'4!4-!=&'I/!04!L/'/E$/+!

"YYp! )&-%'&:/!*IL40/-5*/!

"!/E$S/+!0*=4'4-%4+!

7+=W'*5/!04!!"!/!^!5I!

!

7-! I&04:&+! /-*I/:4+! $%*:*U/-0&! L&'5*-&+! +4! T/-! 04+5'*%&! :&+! 5/IA*&+!

/-/%&I&L/%&:HE*5&+!L&+%4'*&'4+!/!:/!@O6!7+%&+!5/IA*&+!*-5:$24-!/$I4-%&!04!:/!

4&+*-&=*:*/!L:/+I,%*5/C!LW'0*0/!04!:/!*-%4E'*0/0!04:!A&'04!54:$:/'C!A&''&+*0/0!04!

:/!5'&I/%*-/!-$5:4/'!2!T4I&''/E*/! *-%4'+%*5*/:6!#:! %4'54'!0F/!+4!04+/''&::/!$-/!

-45'&+*+!L&'!5&/E$:/5*H-!5&-!:*+*+!-$5:4/'!2!$-!*-=*:%'/0&!*-=:/I/%&'*&!4-%'4!:/!

U&-/!%'/%/0/!2!4:!L/'W-8$*I/!+/-&6!c/!04E4-4'/5*H-!-$5:4/'!+4!5&IL:4%/!4-!4:!

0F/!V[6!;/5*/!4:!0F/!BY!:/!0*+%&'+*H-!04!:/!/'8$*%45%$'/!04!:/!U&-/!4+!5&IL:4%/!2!

-&!+4!'45&-&54-! :/+!5/'/5%4'F+%*5/+!04:!L/'W-8$*I/!'4-/:6!7:! =&5&!-45'H%*5&!+4!

'4/A+&'A4!5&IL:4%/I4-%4!/!:&+!mY!0F/+aB6!?/%:/E/!L'4+4-%/!4-!"YY"!$-!4+%$0*&!

4-!4:!5$/:!+4!'4/:*U/!$-/!/A:/5*H-!L&'!@O!*-%'/&L4'/%&'*/!/!VY!L/5*4-%4+!L'4G*&!/!

$-/! -4='45%&IF/! '/0*5/:! &! L/'5*/:6! bA%*4-4-! 5&-=*'I/5*H-! T*+%&:HE*5/! 04!

/A:/5*H-!5&IL:4%/!4-!a!%$I&'4+a[6!

[6B6V6V!PQ3P)#)PbQ7K!37!#Jc#)PzQ!<b@!@O!

</'/!$-/!/045$/0/!/A:/5*H-!+4!04A4!%4-4'!4-!5$4-%/!5&-+*04'/5*&-4+!4-!5$/-%&!

/!:/!/-/%&IF/!'4-/:!0/0&!:/!54'5/-F/!04!4+%'$5%$'/+!-&A:4+!5&I&!:/!G/+5$:/%$'/!

'4-/:! 2! 4:! $'W%4'C! %4-0*4-0&! 4-! 5$4-%/! 8$4! +4! '45&I*4-0/! $-! I/'E4-! 04!

+4E$'*0/0! 04! YC^kV5Ia^x! 5&-+*04'/5*&-4+! =*+*&:HE*5/+! 4-! 5$/-%&! /! :/! 4:4G/0/!

L4'=$+*H-!'4-/:!8$4!/5%g/!5&I&!0*=$+&'!04!5/:&'C!0*=*5$:%/-0&C!L'*-5*L/:I4-%4!

4-! %$I&'4+! 54-%'/:4+C! /:5/-U/'! :/! %4IL4'/%$'/! -454+/'*/! L/'/! $-/! /A:/5*H-!

5&''45%/6! </'/! 4G*%/'! 4+%4! 4=45%&! 2! '4/:*U/'!I4S&'! :/! @O! 4-! 4+%&+! 5/+&+C! +4! T/!

Page 21: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "V!

$%*:*U/0&! :/! 4IA&:*U/5*H-! L'4G*/! 04:! %$I&'! 5&-! A$4-&+! '4+$:%/0&+aVCa_6! c/+!

5/'/5%4'F+%*5/+! 04:! %$I&'! 5&-+%*%$24-! &%'&! /+L45%&! =$-0/I4-%/:(! 4:! %/I/`&!

%$I&'/:!04A4!+4'!I4-&'!8$4!4:!0*,I4%'&!5/L/U!04!-45'&+/'!04:!+*+%4I/!04!@O!

8$4!+4!L&+4/6!c&+!%$I&'4+!4h&=F%*5&+!'&04/0&+!04!E'/+/!+&-!:&+!I,+!=/G&'/A:4+C!

2/!8$4!:/+!L'&L*40/04+!/*+:/-%4+!04!:/!E'/+/!L4'I*%4-!/:5/-U/'!2!I/-%4-4'!/:%/+!

%4IL4'/%$'/+6! K4Eg-! :/! 4hL4'*4-5*/! '4L&'%/0/! L&'! 14'G/*+! +'% (#! 4-! "YY^!

'4/:*U/0/! 4-! 4:!;&+L*%/:!14-4'/:! 04!?/++/5T$+4%%+C! J&+%&-C! 4-!a^!L/5*4-%4+! 2!

VYY! %$I&'4+! /:! '4/:*U/'! $-! /-,:*+*+! I$:%*G/'*/A:4! 4-5$4-%'/-! 8$4! %/-%&! 4:!

%/I/`&! %$I&'/:! 5&I&! +$! $A*5/5*H-! =$4'&-! L'40*5%&'4+! *-04L4-0*4-%4+! 4-!

5$/-%&! /:! '4+$:%/0&!04! :/! /A:/5*H-6! 9$I&'4+!I4-&'4+! 04!B! 5I!2!-&! 54-%'/:4+!

=$4'&-! L'40*5%&'4+! *-04L4-0*4-%4+! 04! $-/! /A:/5*H-! 5&IL:4%/6! 7:! [[l! 04! :&+!

%$I&'4+!4-%'4!B!2!^!5I!fV_!04!B_\!'48$*'*4'&-!I/+!04!$-/!+4+*H-!/A:/%*G/!L/'/!

/:5/-U/'! $-/! -45'&+*+! 5&IL:4%/! I*4-%'/+! 8$4! :/! $A*5/5*H-! L4'*=W'*5/! =$4!

L'40*5%&'! +*E-*=*5/%*G&!04!-45'&+*+! 5&IL:4%/!04+L$W+!04! 5$/:8$*4'!-gI4'&!04!

+4+*&-4+! :&!8$4! =$4!/%'*A$*0&!/:!2/!5&I4-%/0&!4=45%&!/*+:/-%4!04:! %4S*0&!E'/+&!

L4'*'4-/:! 2! :/!I4-&'! 0*+*L/5*H-! 04! 5/:&'! L'&G&5/0&! L&'! :&+! G/+&+! '4-/:4+! 4-!

%$I&'4+!54-%'/:4+adCaa6!!

c&+! L/5*4-%4+! +4:455*&-/0&+! L/'/! '4/:*U/5*H-! 04! /A:/5*H-! L4'5$%,-4/! 04A4-!

%4-4'! $-! 5&IL:4%&! 4+%$0*&! *I/E4-&:HE*5&! 2/! +4/! 5&-! 9)! 5&-%'/+%/0&! &! @Q?6!

</'/!/:5/-U/'!'4+$:%/0&+!5$'/%*G&+!4:!%$I&'!-&!04A4!5&IL'&I4%4'!:/!=/+5*/!04!

14'&%/C! :/!G4-/!'4-/:!-*! %4-4'!/04-&L/%F/+!+&+L45T&+/+!f9Vk9B/!4-!4:! +*+%4I/!

9Q?\6! 7-! 5/+&! 04! 4-=4'I40/0! 0*+4I*-/0/! :/! /A:/5*H-! L$404! *-0*5/'+4! 5&I&!

5*'$EF/!5*%&'40$5%&'/!fC+B/#D.)!\!&!5&I&!I/-*&A'/!L/:*/%*G/!L/'/!4:!I/-4S&!04!

0&:&'!&-5&:HE*5&!&!T4I/%$'*/am6!!

[6B6V6"!)bQ9@#PQ3P)#)PbQ7K!37!#Jc#)PzQ!<b@!@O!

c/+!5&-%'/*-0*5/5*&-4+!L/'/!:/!@O!*-5:$24-(!5&/E$:&L/%F/+C!*-=/'%&!04!I*&5/'0*&!

'45*4-%4C!/-E*-/!*-4+%/A:4!&!L'&54+&!/E$0&!5&I&!$-/!*-=455*H-!/5%*G/!+4G4'/6!c/!

L'4+4-5*/!04!$'W%4'!&!*-%4+%*-&!/!I4-&+!04!V!5I!04!:/!U&-/!04!/A:/5*H-!L$404!

5&-%'/*-0*5/'! :/! %W5-*5/! L4'5$%,-4/! L4'&! -&! :/! :/L/'&+5HL*5/6! K4! T/! 04+5'*%&!

L/'/!4G*%/'!4+%&+!L'&A:4I/+C!%W5-*5/+!04!*-+%*:/5*H-!04!/E$/!4+%W'*:C!+&:$5*H-!04!

04h%'&+/! /:! ^lC! )b"! &! /*'4! 4-%'4! 4:! %$I&'! 2! :&+! H'E/-&+! G45*-&+! aVCad! 6! c&+!

Page 22: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! ""!

L/5*4-%4+! 8$4! -&! 04+44-! &! 8$4! -&! L$40/-! 5$IL:*'! 5&-! 4:! +4E$*I*4-%&!

*I/E4-&:HE*5&!L&+%4'*&'!-&!+4!5&-+*04'/-!A$4-&+!5/-0*0/%&+mY6!!

[6B6V6B!)b?<cP)#)PbQ7K!37!c#!#Jc#)PzQ!<b@!@O!

c/+! 5&IL:*5/5*&-4+! 04! :/! /A:/5*H-! L&'! @O! +&-! L&5&! ='45$4-%4+! 2! L$404-! +4'!

0*G*0*0/+!4-!^!5/%4E&'F/+adCmVCm"(!

V6 ;4I&'',E*5/+!

"6 c4+*H-!04!+*+%4I/!5&:45%&'!f5&I&!4+%4-&+*+!$'4%4'/:\!

B6 c4+*H-!04!H'E/-&+!54'5/-&+!

[6 c4+*H-!-4$'&I$+5$:/'!fQ4$'&L'/h*/\!

^6 c4+*&-4+!5$%,-4/+!

K*E$*4-0&!5&-!:/!4hL4'*4-5*/!'4L&'%/0/!L&'!14'G/*+!+'%(#! C! :/!5&IL:*5/5*H-!I/+!

5&Ig-! 4+! :/! T4I&''/E*/C! :/! 5$/:! 5&-+%*%$24! $-! L'&A:4I/! 5:F-*5&! 4-!

/L'&h*I/0/I4-%4! $-!_l6! <$404! &5$''*'! 4-! 4:! 4+L/5*&! L4'*-4='F%*5&! 2n&! 4-! 4:!

+*+%4I/! 5&:45%&'C! :&! 8$4! 4-! &5/+*&-4+! L$404! ::4E/'! /! :/! -454+*0/0! 04! :/!

*-+%/:/5*H-!04!$-!+%4-%!$'4%4'/:6!7-!0&+!L/5*4-%4+! =$4!-454+/'*/! :/! %'/-+=$+*H-!

04!5&-54-%'/0&+!T4I,%*5&+!L4'&!4-!-*-E$-&!+4! '45$''*H!/! :/! 5*'$EF/6!7-! :&+!^!

L/5*4-%4+! :/! T4I&''/E*/! =$4! 0*/E-&+%*5/0/! 0$'/-%4! 4:! L'&540*I*4-%&6! D-!

L/5*4-%4! L'4+4-%H! $'*-&I/! 2! :4+*H-! $'4%4'/:! =$4! I/-4S/0&! 5&-! 0'4-/S4!

L4'5$%,-4&!2!5/%W%4'!-4='&k$'4%4'/:6!D-!L/5*4-%4!L'4+4-%H!4+%4-&+*+!$'4%4'/:!2!

=$4! %'/%/0&! 5&-!-4='&+%&IF/! 2! +%4-%6!Q&!T$A&! :4+*&-4+! *-%4+%*-/:4+6!34+5'*A4-!

8$4! 0&+! L/5*4-%4+! L'4+4-%/'&-! 0&:&'! -4$'&L,%*5&! 2! =$4'&-! 04! 0*=F5*:! I/-4S&!

*-*5*/:! L4'&! +4! '4+&:G*4'&-! 4+L&-%,-4/I4-%4! 4-! :&+!I4+4+! L&+%4'*&'4+6! K4Eg-!

J/q4'! +'% (#! 4+%4! 5$/0'&! +4! L'4+4-%/! I/2&'I4-%4! 5$/-0&! 4:! %$I&'! 4+%,! I$2!

/0T4'*0&! /! :/! L/'40! /A0&I*-/:! &! /:! 0*/='/EI/mB6! O*-/:I4-%4! '4L&'%/-!

8$4I/0$'/+!04!L'*I4'!2!+4E$-0&!E'/0&!4-!$-!L/5*4-%4!adCmV6!!

[6B6V6[!1Ds#!P?#17Qbcz1P)#!

c/+! %W5-*5/+! I,+! $%*:*U/0/+! L/'/! E$*/'! :/! /A:/5*H-! L&'! @O! 5&-+*+%4-! 4-! :/!

$%*:*U/5*H-! 04! DKC! 9)C! @Q?! &! )7DK6! #5%$/:I4-%4! -&! 0*+L&-4I&+! 04! 4+%$0*&+!

8$4!5&IL/'4-!:&+!'4+$:%/0&+!4-%'4!4+%/+!I&0/:*0/04+mY6! !!

Page 23: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "B!

#6 7)b1@#Os#!)bQM7Q)PbQ#c6!c/!45&E'/=F/!+*IL:4!L$404!+4'!04!$%*:*0/0!

L/'/!0*'*E*'! :/!/E$S/!04-%'&!04:!%$I&'!L4'&!-&!4+!4=*5/U!L/'/!G/:&'/'! :/!

4h%4-+*H-! 04! :/! /A:/5*H-m[6! 9*4-4! :/! G4-%/S/! 04! '4/:*U/'! $-/!

I&-*%&'*U/5*H-! 4-! %*4IL&! '4/:! 04! :/! /A:/5*H-! 2! -&! $%*:*U/! '/0*/5*H-!

*&-*U/-%4! +*-! 4IA/'E&! 4+! $-/! L'$4A/! &L4'/0&'k04L4-0*4-%4! ! 2! +$!

'4-0*I*4-%&! L$404! 4+%/'! 5&-0*5*&-/0&! L&'! 4:! T/A*%&! 5&'L&'/:! 04:!

L/5*4-%4C!:/!L'4+4-5*/!04!E/+!*-%4+%*-/:!&!04!$-!/+/!04!*-%4+%*-&!8$4!04A4!

+4'! 4G*%/0&m^6! K*-! 4IA/'E&! g:%*I/I4-%4! G/'*&+! /$%&'4+! +$+%4-%/-! +$!

$%*:*0/0!5&-!'4+$:%/0&+!5&IL/'/A:4+!/!:/!9)!4-!5$/-%&!/!5&IL:*5/5*&-4+!

2!'4+$:%/0&+!/!:/'E&!L:/U&m_kma6!

J6 9b?b1@#Os#! )b?<D9#3#6! 7:! 9)! +4! /+&5*/! /! I4-&+! 5/IA*&+! 4-! 4:!

L/%'H-! 04! *I/E4-! 04! :/! I/+/! '4-/:! %'/%/0/C! +*-! 4IA/'E&! :/!

T*L4'04-+*0/0! %$I&'/:! 2! 4:! E/+! E4-4'/0&! 0$'/-%4! :/! /A:/5*H-! L$404!

:*I*%/'! :/! G*+$/:*U/5*H-mm6! c/! L'4+4-5*/! 04! %$I&'! '4+*0$/:! L$404! +4'!

04%45%/0/! I40*/-%4! :/! /0I*-*+%'/5*H-! 04! 5&-%'/+%4! 2/! 8$4! :/+! U&-/+!

%$I&'/:4+! G*/A:4+! I&+%'/',-! 5/L%/5*H-! I*4-%'/+! 8$4! :/+! U&-/+! 04!

-45'&+*+!-&! :&!T/',-VYY6! K*-!4IA/'E&C! ! :/! *-2455*H-!04! 5&-%'/+%4!L$404!

'4/:*U/'!+&:&!$-/!G4U!L&'!5/0/!+4+*H-!04!/A:/5*H-!L&'!:&!8$4!/:5/-U/'!$-/!

/A:/5*H-! 5&IL:4%/! L$404! %/'0/'! T/+%/! [! T&'/+ad! +$I/0&! /! 8$4! 4-!

/:E$-&+! %*L&+! 04! ))@! -&! 5/L%/-%4+! 04! 5&-%'/+%4! :/! /0I*-*+%'/5*H-! 04!

4+%4!-&!L4'I*%4!'4/:*U/'!$-/!I&-*%&'*U/5*H-!/045$/0/!04:!L'&54+&ad6!c/!

+4'*4! '4L&'%/0/! L&'! 14'G/*+! +'% (#! 4-! "YY^! 04! VYY! %$I&'4+! 4-! a^!

L/5*4-%4+!4-!8$*4-4+!+4!'4/:*U/!/A:/5*H-!L&'!@O!E$*/0&!L&'!9)!04+5'*A4!

$-!m"l!04!/A:/5*H-!5&IL:4%/!4-!%$I&'4+!I4-&'4+!04!B!5I!/:5/-U/-0&!

4:! VYYl! 5&-! :/! +4E$-0/! +4+*H-ad6! O4'/q*+! +'% (#! '4L&'%/-! 4-! "YVY! $-/!

+4'*4!04!Bm!%$I&'4+!4-%'4!VCB!2!dC^5I!2!&A%*4-4-!$-/!+&A'4G*0/!:*A'4!04!

'45*0*G/!04!aml!/!^!/`&+VYV6!!

)6 @7KbQ#Q)P#!QD)c7#@!?#1Qw9P)#6!c/!@Q?!+4!T/!L&+*5*&-/0&!5&I&!

$-&! 04! :&+! I4S&'4+! +*+%4I/+! L/'/! E$*/'! :/! /A:/5*H-! L&'! @O!

L'*-5*L/:I4-%4! L&'! +$! /:%&! 5&-%'/+%4! *-%'F-+45&! 4-! %4S*0&+! A:/-0&+C! +$!

5/L/5*0/0!04!E4-4'/'!G4'0/04'/+!*I,E4-4+!I$:%*L:/-/'4+C!2!L&'!&='454'!

:/! L&+*A*:*0/0! 04! '(*!+'.)!! $%*:*U/-0&! +45$4-5*/+! =:$&'&+5HL*5/+6! c/!

/A:/5*H-!5&IL:4%/!+4! :&E'/!/:!'4IL:/U/'! :/+!+4`/:4+! *+&!&!T*L4'*-%4-+/+!

Page 24: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "[!

4-!9"o!04:!))@!L&'!U&-/+!+*-!+4`/:6!7:!%$I&'!'4+*0$/:!+4!04%45%/!L&'!:/!

L4'+*+%4-5*/!04!U&-/+!5&-!+4`/:!*+&!&!T*L4'*-%4-+/+!2!4:!/L:*5/0&'!L$404!

+4'! '4L&+*5*&-/0&! L/'/! $-/! -$4G/! +4+*H-! +*-! :/! -454+*0/0! 04! /L:*5/'!

I40*&+! 04! 5&-%'/+%4! '4L4%*0/I4-%4mm6! K4! T/! '4L&'%/0&! m"kVYYl! 04!

/A:/5*H-!5&IL:4%/!5&-!$-/!+&:/!+4+*H-!/A:/%*G/!E$*/0&!L&'!@Q?VY"6!

36 7)b1@#Os#! )bQ!)bQ9@#K976! c/! '45*4-%4! /L/'*5*H-! 04! :&+!I40*&+! 04!

5&-%'/+%4! 45&E',=*5&+! T/! +*E-*=*5/0&! $-/! '4G&:$5*H-! 4-! 5$/-%&! /! :/+!

L&+*A*:*0/04+!04!:/!45&E'/=F/!2!+$+!/:5/-54+!2!L4'+L45%*G/+!=$%$'/+!4+%,-!

/g-!L&'!04G4:/'+46!uT/&!+'%(#!L$A:*5/-!4-!"YVV!$-/!+4'*4!04!dB!L/5*4-%4+!

5&-!%$I&'4+!04!VCd!/!^Ca5IC!0*G*04-!0&+!E'$L&+!04!L/5*4-%4+!/!8$*4-4+!

+4!:4+!L'/5%*5H!/A:/5*H-!L&'!@OC!$-!E'$L&!5&-%'&:/0&!L&'!)7DK!2!4:!&%'&!

L&'! 45&E'/=F/! 5&-G4-5*&-/:! 2! '4/:*U/-! 9)! /! :&+! d! 0F/+6! @4L&'%/-! $-/!

/A:/5*H-!5&IL:4%/!4-!m[C_l!04:!E'$L&!5&-!)7DK!2!04!a_CVl!4-!4:!E'$L&!

04! 45&E'/=F/! f,tYCY^\6! c/! +&A'4G*0/! E:&A/:! =$4! 04! VYYl! 0$'/-%4! $-!

+4E$*I*4-%&! L'&I40*&! 04! ""!I4+4+! f'/-E&! 04! V"k["!I4+4+\!I*4-%'/+!

8$4! 4:! =*:%'/0&! E:&I4'$:/'!-&! %$G&!0*=4'4-5*/+! +*E-*=*5/%*G/+! /:! 5/A&!04!

$-! +4E$*I*4-%&! 04! V"! I4+4+6! )&-! 4+%&+! '4+$:%/0&+! 5&-5:$24-! 8$4! :/!

/A:/5*H-! L&'! '/0*&! ='45$4-5*/! E$*/0/! L&'! )7DK! L4'I*%4! $-/!

I&-*%&'*U/5*H-!i4-!%*4IL&!'4/:j!04!:/!U&-/!04!/A:/5*H-VYB6!!

! !

Page 25: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "^!

!"#$!"#$%&'()*+$,-.),'%*/*!"#!$%&'#!()*($+(+,$+#'%"(!"#$%&'(")*+"*,)-*.)-)-!!"#$%"&'!"#$"%&'()"*+&,-"(&./&0+1,(!23(!"#$%&!'()'*($"!c/! P@)! 4+%,! L'4+4-%4! 4-! 4:! VVl! 04! :/! L&A:/5*H-! E4-4'/:! /0$:%/! 2! 4:! Vdl! 04! :/!

L&A:/5*H-! I/2&'! 04! _Y! /`&+VY[6! b%4'&! +'% (#! L$A:*5/-! 4-! "YVY! 4:! i7+%$0*&!

7L*04I*&:HE*5&!04!:/!P-+$=*5*4-5*/!@4-/:!4-!7+L/`/j!4-!4:!+4!/-/:*U/!$-/!I$4+%'/!

04!"6d[_!L4'+&-/+!I/2&'4+!04!"Y!/`&+6!7-!4+%4!4+%$0*&!04+5'*A4!$-/!L'4G/:4-5*/!

E4-4'/:!04!P@)!4+%/0*&!B!&!I/2&'!04!_Cal!L/'/!:/!L&A:/5*H-!E4-4'/:!2!04!"Yl!4-!

L4'+&-/+!I/2&'4+!04!_[!/`&+VY^6! c/! P@)! +4!T/! /+&5*/0&!/! /$I4-%&!04:! '*4+E&!04!

T&+L*%/:*U/5*H-C!4G4-%&+!5/'0*&G/+5$:/'4+!2!I&'%/:*0/0!04!5$/:8$*4'!4%*&:&EF/VY_CVYd!

2! I*4-%'/+! 8$4! 0*G4'+&+! 4+%$0*&+! T/-! 04I&+%'/0&! 8$4! :/! -4='45%&IF/! '/0*5/:!

5&-+%*%$24!$-!=/5%&'!04!'*4+E&!*-04L4-0*4-%4!L/'/!04+/''&::/'!P@)d"CVYa!4:!/A&'0/S4!

5&-+4'G/0&'! 04! -4='&-/+! 5&-! -4='45%&IF/! L/'5*/:! +4! T/! *IL$4+%&! 5&I&! 4:! !"#$%

&'()$(*%5$/-0&!4+!%W5-*5/I4-%4!L&+*A:4!2/!8$4!T/!04I&+%'/0&!:/!L'4+4'G/5*H-!04!

:/! =$-5*H-! '4-/:! 2! '4+$:%/0&+! &-5&:HE*5&+! +*I*:/'4+! /! :/! Q@! /! :/'E&! L:/U&VYm6! 7-!

5$/-%&! /! :/+! %W5-*5/+! /A:/%*G/+! 2! +$! 5/L/5*0/0! 5&-+4'G/0&'/!04!-4='&-/+C! 4h*+%4-!

G/'*&+! 4+%$0*&+! 8$4! +$+%4-%/-! +$! '&:! L'&%45%&'! 04! :/! =$-5*H-! '4-/:6! c$5/+! +'% (#!

L$A:*5/-!4-!"YYa!$-!4+%$0*&!'4%'&+L45%*G&!8$4!*-5:$24!"["!L/5*4-%4+!+&I4%*0&+!/!

%'/%/I*4-%&! L'*I/'*&! L&'! $-/!?@<! $-*:/%4'/:! 5&-! '*`H-! 5&-%'/:/%4'/:! -&'I/:! 2/!

+4/! 5&-!Q@! fa_! L/5*4-%4+\C! Q<! fa^! L/5*4-%4+\! &! /A:/5*H-! L&'! @O! fdV! L/5*4-%4+\x!

5/:5$:/-! :/! L'4G/:4-5*/! 04! P@)! 4+%/0*&! B! L'4G*&! /! %'/%/I*4-%&! 2! /! :&+! B! /`&+! 04!

+4E$*I*4-%&C!'4L&'%/-0&!$-/!L'4G/:4-5*/!L'4!%'/%/I*4-%&!04!P@)!4+%/0*&!B!&!I/2&'!

04! "_Cdl! fB_! L/5*4-%4+\! +*-! 0*=4'4-5*/+! +*E-*=*5/%*G/+! 4-! 5$/-%&! /! =*:%'/0&!

E:&I4'$:/'!4-%'4!:&+!B!E'$L&+6!)&-!:&+!L/5*4-%4+!8$4!/:5/-U/-!$-!+4E$*I*4-%&!04!B!

/`&+! '4/:*U/-! $-! /-,:*+*+! I$:%*G/'*/-%4! &A+4'G/-0&! 8$4! :/! Q@! 4+! $-! =/5%&'!

*-04L4-0*4-%4! L/'/! 4:! 04+/''&::&! 04! P@)! 4+%/0*&! B! &! L4&'! 5&IL/'/0&! 5&-! Q<! &!

/A:/5*H-! L&'! @O! f;@! B[6BC! m^l! P)! [6"a}"d^! /-0! VY6mC! m^l! P)! V6B_}aa6dC!

'4+L45%*G/I4-%4\VVY6!!#:%$-'4-04!+'%(#!L$A:*5/-!4-!"YVV!$-/!+4'*4!'4%'&+L45%*G/!04!

Page 26: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "_!

_^! L/5*4-%4+! I&-&'4-&+! 5&-! $-/! ?@<C! 04! :&+! 5$/:4+! "m! =$4'&-! %'/%/0&+! 5&-!

5'*&%4'/L*/!2!B_!L&'!@O!4-!=&'I/!L4'5$%,-4/!2!E$*/0&+!L&'!9)!5&-!$-!+4E$*I*4-%&!

04! V^CV! 2! BaCa! I4+4+! '4+L45%*G/I4-%46! @4L&'%/-! 8$4! -&! T$A&! 0*=4'4-5*/+!

4+%/0F+%*5/I4-%4!+*E-*=*5/%*G/+!4-!4:!=*:%'/0&!E:&I4'$:/'!04!/IA&+!E'$L&+!0$'/-%4!

4:!+4E$*I*4-%&VVV6!

K*!A*4-!T/2!5&-+4-+&!4-!8$4!/g-! =/:%/-!4+%$0*&+!/! :/'E&!L:/U&!8$4!5&-=*'I4-!+$+!

'4+$:%/0&+C! :/+! %W5-*5/+! /A:/%*G/+! 5&A'/-! 5/0/! G4U! I/+! *-%4'W+! 4-! :/! 5&I$-*0/0!

$'&:HE*5/! *-%4'-/5*&-/:! 4-! 4:! %'/%/I*4-%&! 04! ?@<+6! 7+%&! L'*-5*L/:I4-%4! L&'! +$!

5/L/5*0/0! 04! L'4+4'G/5*H-! 04! :/! =$-5*H-! '4-/:! 5&-!I4-&'!I&'A*:*0/0! 8$4! :/! Q<!

/A*4'%/!&!:/L/'&+5HL*5/!5&-!A$4-&+!'4+$:%/0&+!&-5&:HE*5&+!4-!+4'*4+!04!^!/`&+!04!

+4E$*I*4-%&VV"6!7-!:/!9/A:/!B!+4!'4+$I4-!:&+!'4+$:%/0&+!*-*5*/:4+!04!:&+!L'*-5*L/:4+!

4+%$0*&+!04!?@<+!%'/%/0/+!5&-!'/0*&='45$4-5*/6!

!#$3#'O@'7"*+0*2#3)-')-.;(*&-'()'AC7-'."#.#(&-'0&+'"#(*&E")0;)+0*#'mY@'

>;.&"'P'#Q&' !;8&")-R7#0*)+.)-' !#8#Q&'S08T' >$3#0*1+')U*.&-#'*+*0*#3'SVT'

W#/&"*#'S5XXYT' V"[nVY[! YC_k"Ca!f"Cd\! VYY!f%$I&'4+!t!BC_5I\!![d!f%$I&'4+!t!BCd5I\!

?"))+'S5XXYT' VY^nmd! VCVk_Ca!fBC"\! dm!

N)",#*-'S5XXZT' VYYna^! VCVkaCm!fBC"\!VYY!f%$I&'4+!t!B5I\!!m"!f%$I&'4+!Bk^5I\!!"^!f%$I&'4+!v!^5I\!

J#"")3'S5XXOT' B^n"Y! YCmkBC_!fVCd\! VYY![;'S5XXOT' B^n"m! Vk[!f"C"\! m[!

A#P&'S5XXOT' B"nB"! Vk^!f"C_\! md!!

!

! !

Page 27: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "d!

!

!""#$%&'()*+'$,)$"-!).+"/0*"1-!Z@4'\$%).*,&-]'

V6 7G/:$/'! 4:! 4=45%&! 4-! :/! =$-5*H-! '4-/:! 04! :/! /A:/5*H-! L&'! '/0*&='45$4-5*/!

E$*/0&!L&'!)7DK!04!I/+/+!'4-/:4+!L48$4`/+!/:!/`&!04!+4E$*I*4-%&6!

"6 M/:&'/'! :/! %W5-*5/! 04! /A:/5*H-! L&'! @O! E$*/0/! 5&-! )7DK! 4-! 5$/-%&! /! +$!

5/L/5*0/0! /A:/%*G/! *-*5*/:! 2! /! :/! %/+/! 04! '45*0*G/! %$I&'/:! /! $-! /`&! 04!

+4E$*I*4-%&6!

B6 34+5'*A*'!:/+!5&IL:*5/5*&-4+!04!:/!/A:/5*H-!L&'!@O!E$*/0/!L&'!)7DK6!

[6 @4L&'%/'!:&+!'4+$:%/0&+!04!:/!#-/%&IF/!L/%&:HE*5/!4-!:&+!5/+&+!8$4!+4!T/::/!

&A%4-*0&!A*&L+*/6!

Z@5'7#0*)+.)-'P'A6.&(&-]''

Z@5@4'7>:IM^!M['

Z@5@4@4'7"&0)()+0*#'

)&-+%*%$24-! :/! A/+4! 04:! 4+%$0*&' $-/! +4'*4! 5&-+45$%*G/! 04! L/5*4-%4+! +&I4%*0&+! /!

/A:/5*H-! L4'5$%,-4/! 04! $-/! I/+/! '4-/:! E$*/0/! L&'! 45&E'/=F/! 5&-%'/+%/0/!

'4/:*U/0&+!4-!4:!;&+L*%/:!D-*G4'+*%/'*&!M/::!3Z;4A'&-!f;M;\!4-%'4!4:!V!04!4-4'&!04!

"YY^!2!4:!V!04!I/'U&!"YVV6!!

c&+!L/5*4-%4+!8$4!+4!/%*4-04-!4-!4:!;M;!+4!5&''4+L&-04-!=$-0/I4-%/:I4-%4!5&-!

+$!,'4/!04!*-=:$4-5*/!4-!4:!,'4/!04!E(*3+#")(%@"*$!2!/8$4::&+!8$4!+&-!04'*G/0&+!04!

T&+L*%/:4+!5&I/'5/:4+!8$4!04L4-04-!04!W:6!!

Z@5@4@5':"*.)"*&-'()'[)3)00*1+'

</5*4-%4+!8$4!L&'!+$!40/0!/G/-U/0/!2n&!5&I&'A*:*0/04+!-&!+&-!A$4-&+!5/-0*0/%&+!

L/'/! $-/! *-%4'G4-5*H-! 8$*'g'E*5/! 5&-! /-4+%4+*/! E4-4'/:! /! S$*5*&! 04:! $'H:&E&!

%'/%/-%4! 2! 8$4! L'4+4-%/-! $-/! I/+/! '4-/:! I4-&'! 04! [5I! 04! 0*,I4%'&! I/2&'!

04I&+%'/0/!L&'!9)!&!@Q?6!#! %&0&+! :&+!L/5*4-%4+! +4! :4+! '4/:*U/!$-/!)7DK!L'4G*/!

L/'/!5&IL'&A/'!:/!G*/A*:*0/0!04!:/!%W5-*5/!+4Eg-!:/+!5/'/5%4'F+%*5/+!/-/%HI*5/+!04:!

Page 28: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "a!

L/5*4-%4! 2! 04:! %$I&'6! c&+! L/5*4-%4+! 8$4! +&-! 4:4E*0&+! 5$4-%/-! 5&-! $-/! )7DK!

=/G&'/A:4!2!!=*'I/-!4:!5&-+4-%*I*4-%&!*-=&'I/0&!+4!+4:455*&-/-6!

Z@5@4@O':"*.)"*&-'()')U03;-*1+'

K4! 4h5:$24-! 04:! 4+%$0*&! :&+! L/5*4-%4+! 8$4! 5$4-%4-! 5&-! I4-&+! 04! $-! /`&! 04!

+4E$*I*4-%&! 4-! 5&-+$:%/+! 4h%4'-/+!04!$'&:&EF/!04:!;M;!&!8$4!-&! 5$4-%4-! 5&-! :/!

*-=&'I/5*H-!IF-*I/!04!-*G4:4+!04!)<!L'4G*&!/:!%'/%/I*4-%&!2!$-!/`&!L&+%4'*&'!/!W:!

&!8$4!-&!5$4-%4-!5&-!4:!+4E$*I*4-%&!'/0*&:HE*5&!4-!=&'I/!04!*-=&'I4+!'/0*&:HE*5&+!

2n&!/554+&!/!:/+!*I,E4-4+6!'

Z@5@5'A_!\9\'

K4!&A%*4-4!4:! :*+%/0&!04!L/5*4-%4+!+&I4%*0&+!/!@O!04!:/!A/+4!04!0/%&+!04:!+4'G*5*&!

04!$'&:&EF/!04:!;M;6!!

Z@5@5@4'K#"*#$3)-''

V6 70/0!/:!I&I4-%&!04!:/!@O!

"6 K4h&!

B6 ):/+*=*5/5*H-!04!'*4+E&!8$*'g'E*5&!04!:/!#+&5*/5*H-!#I4'*5/-/!04!#-4+%4+*/!

f#K#\!

[6 9/I/`&!I/+/!'4-/:!

^6 )'4/%*-*-/!<:/+I,%*5/!f*-*5*/:C!/!:&+!_!I4+4+!2!/:!/`&\!2!O*:%'/0&!E:&I4'$:/'!

f*-*5*/:C!/!:&+!_!I4+4+!2!/:!/`&\!8$4!+4!5/:5$:/!+4Eg-!:/!45$/5*H-!04:!4+%$0*&!

8"$.<.3('.")%"<%C.+'%.)%7+)(#%C.&+(&+!f?3@3\VVB(!

' JN')-.*8#(&`'4YZ'U'S:7TG4a4ZD'U'S)(#(TGXa5XO'U'SXaYD5'-*'-)U&'E)8)+*+&T'U'S4a54X'-*'"#L#'+)/"#T@'

_6 ):/+*=*5/5*H-! 04! :/! *-+$=*5*4-5*/! '4-/:! +4Eg-! @('.")(#% 9.$)+0% :/)$('.")%

>#(&&.<.3('.")VY[%f9/A:/![\6!

!#$3#'D@':3#-*E*0#0*1+'()'3#'I+-;E*0*)+0*#'")+#3'-)/b+'3#'^#.*&+#3'c*(+)P'J;+(#.*&+@'

M-.#(*&' 9)-0"*20*1+' JN'S8B'2&"'8*+;.&'2&"'4aYO85T'G' @*4+E&!*-5'4I4-%/0&!L/'/!P@)! v!_Y!f5&-!=/5%&'4+!04!'*4+E&!L/'/!P@)\!4' 3/`&!'4-/:!5&-!O1!-&'I/:!&!4:4G/0&! v!am!5' 3/`&!'4-/:!5&-!0*+I*-$5*H-!:4G4!04:!O1! _Y!/!am!O' 3*+I*-$5*H-!I&04'/0/!04:!O1! BY!/!^m!D' 3*+I*-$5*H-!+4G4'/!04:!O1! V^!/!"m!Z' O/::&!'4-/:! t!V^!f&!0*,:*+*+\!

!

Page 29: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "m!

d6 Q{!04!+4+*&-4+!'48$4'*0/+!L/'/!/A:/5*H-!%&%/:!

a6 #A:/5*H-!5&IL:4%/!*-*5*/:!!f+*!&!-&\!

m6 <'4+4-5*/!04!5&IL:*5/5*&-4+!+4Eg-!5:/+*=*5/5*H-!04!):/G*4-k3*-0&!

VY6 9*4IL&!04!T&+L*%/:*U/5*H-!f4-!0F/+\!

VV6 #-/%&IF/!</%&:HE*5/!

V"6 @45*0*G/!4-!5&-%'&:4+!/!:&+!B!2!V"!I4+4+!L&'!)7DK!2n&!9)!

VB6 ?4%,+%/+*+!4-!5&-%'&:4+!/!:&+!B!2!V"!I4+4+!L&'!)7DK!2n&!9)!

V[6 ?&'%/:*0/0!E:&A/:!2!5,-54'!4+L45F=*5/!

!

! !

Page 30: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! BY!

!"""#$%&'()*+,-'!Y@4''9#.&-'/)+)"#3)-'

7-%'4!4-4'&!04!"YYm!2!I/'U&!04!"YVV!+4!T/-!+&I4%*0&!/!/A:/5*H-!L4'5$%,-4/!L&'!

'/0*&='45$4-5*/!04!%$I&'!'4-/:!$-!%&%/:!04![B!L/5*4-%4!f[d!%$I&'4+\!4-!4:!;&+L*%/:!

D-*G4'+*%/'*&!M/::!3Z;4A'&-6!34!4::&+!+4!4h5:$24-!_!L/5*4-%4+!!L&'!-&!5&-%/'!5&-!4:!

+4E$*I*4-%&! 5:F-*5&! 4+%/A:45*0&! L/'/! 4+%4! 4+%$0*&! 4-! 5$/-%&! /! /-,:*+*+! 04!

:/A&'/%&'*&! 2! L'$4A/+! 04! *I/E4-6! <&'! %/-%&! 4-! :&+! '4+$:%/0&+! +4! /-/:*U/-! Ba!

L/5*4-%4+!f[V!%$I&'4+\6!K4!$%*:*U/!L/'/!4:!/-,:*+*+!:/!*-=&'I/5*H-!&A%4-*0/!/!%'/GW+!

04!:/+!T*+%&'*/!5:F-*5/!4-!=F+*5&!+&:*5*%/0/!/:!04L/'%/I4-%&!04!/'5T*G&+!04:!T&+L*%/:!

/+F!5&I&!:/!*-=&'I/5*H-!04!:/!T*+%&'*/!5:F-*5/!!4:45%'H-*5/6!!!

c&+! L/5*4-%4+! *-E'4+/-! 4:! 0F/! L'4G*&! /! :/! '4/:*U/5*H-! 04:! L'&540*I*4-%&6! 9&0&+!

5$4-%/-! 5&-! $-! /-,:*+*+! L'4&L4'/%&'*&! 8$4! -&! 04I$4+%'/! T/::/UE&+! 8$4!

5&-%'/*-0*8$4-! :/! /A:/5*H-6! 7:! L'&54+&! +4! '4/:*U/! 4-! :/! +/:/! 04! 45&E'/=F/+! A/S&!

+40/5*H-! '4/:*U/0/! L&'! $-! IW0*5&! /-4+%4+*H:&E&6! <&+%4'*&'! /:! L'&540*I*4-%&! 4:!

L/5*4-%4! '4%&'-/! /! +$! T/A*%/5*H-! I/-%4-*W-0&+4! 4-! '4L&+&! /A+&:$%&! 0$'/-%4! _!

T&'/+6!#:!0F/!+*E$*4-%4!+4!'4/:*U/!$-!T4I&E'/I/!L&+%4'*&'!/!:&!5$/:!+4!*-0*5/!/:%/!+*!

-&!T/2!5&-%'/*-0*5/5*H-!L/'/!4::&6!

Y@5'9#.&-'()8&/"FE*0&-'

c/! 40/0! L'&I40*&! =$4! 04! d[Ca! /`&+! f^"kam\C! 5&-! $-/! 0*+%'*A$5*H-! L&'! +4h&! 04!

B_Cal!=4I4-*-&!2!_BC"l!I/+5$:*-&6!#:!/L:*5/'!:/!5:/+*=*5/5*H-!#K#!+4!&A+4'G/!8$4!

$-!^Yl!04!:&+!L/5*4-%4+!+&-!#K#!"C!["l!#K#!B!2!!al!#K#![C!-&!T/A*4-0&!L/5*4-%4+!

5:/+*=*5/0&+!5&I&!#K#!V!-*!#K#!^6!!7-!:/!9/A:/!^!+4!'4+$I4-!:&+!0/%&+!04I&E',=*5&+6!

!#$3#'Z@'9#.&-'()8&/"FE*0&-'

Edad 74,9 (52-89)

Sexo Fem 14 (36,8)

Masc 24 (63,2)

Clasificación ASA

2 19 (50%)

3 16 (42%)

4 3 (8%)

Page 31: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! BV!

Y@O':&8&"$*3*(#()-'

D-!^Yl!04!:&+!L/5*4-%4+!L'4+4-%H!5&I&!/-%45404-%4!$-/!L/%&:&EF/!&-5&:HE*5/!2!04!

4::&+! $-! BaCal! 5&''4+L&-04! /! $-/! -4&L:/+*/! 04:! /L/'/%&! $'*-/'*&6! d! L/5*4-%4+!

fVaC[l\! +&-! I&-&''4-&+! /:! *-*5*&! 04:! 4+%$0*&C! 04! 4::&+! B! L/5*4-%4+! +&-!

%'/+L:/-%/0&+!'4-/:4+!04!:&+!5$/:4+!"!L/5*4-%4+!L'4+4-%/-!$-!%$I&'!4-!'*`H-!-/%*G&!

2!$-&!4-!4:!*-S4'%&6!c/!L'4G/:4-5*/!04!P@)!+4!5&I4-%/!4-!4:!/L/'%/0&!d6_6!7-!:/!%/A:/!

_!+4!'4+$I4-!:&+!0/%&+!04!5&I&'A*:*0/06!

!#$3#'d@':&8&"$*3*(#()-'

"#$%&%'%#$%!(#&()*+,&(!+29;<547! =>!?@ABC!

<&+*%*G&! Vm!f^Yl\!

"#$%&%'%#$%!(#&()*+,&(!

-.()*+,&(!

Q4E/%*G&! BV!faVC_l\!

<&+*%*G&! d!fVaC[l\!

/(#(.%#(!Q4E/%*G&! BV!faVC_l\!

<&+*%*G&! d!fVaC[l\!

'

Y@D':#"#0.)"<-.*0#-'.;8&"#3)-'

7:! %/I/`&! %$I&'/:! =$4! 04! "Cm5I! 4-! L'&I40*&! fVk[C[5I\C! +*4-0&! Vd! 04'45T&+!

f[VC^l\C! "B! *U8$*4'0&+! f^_CVl\! 2! V! 04! $-! *-S4'%&! '4-/:! f"C[l\6! Ba! %$I&'4+!

fm"Cdl\!=$4'&-!$-*:/%4'/:4+!I*4-%'/+!8$4!B!fdCBl\!=$4'&-!A*:/%4'/:4+6!7-!:/!%/A:/!d!

+4!04+E:&+/!4:!%/I/`&!%$I&'/:!4-!5$/-%&!/!:/!='45$4-5*/!04!L'4+4-%/5*H-6!

!#$3#'Y'

!#8#Q&'S08T' J")0;)+0*#'

4' V!

5' VY!

5ae' "!

5af' V!

O' V[!

Oa5' V!

OaD' V!

Oae' V!

D' m!

DaD' V!

!&.#3' [V!

Page 32: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! B"!

Y@Z':#"#0.)"<-.*0#-'()3'2"&0)-&'

k QgI4'&!04!/A:/5*&-4+(!34=*-*0/+!5&-!4:!-gI4'&!04!G454+!8$4!+4!5&:&5/! :/!

/E$S/! L/'/! '4/:*U/'! :/! /A:/5*H-! 4-! $-/! +4+*H-! 04! /A:/5*H-6! 7-! B_! %$I&'4+!

fadCal\!+4!'4/:*UH!+&:&!$-/!/A:/5*H-!f%$I&'4+!04!V!/![C[5I\!I*4-%'/+!8$4!

4-!B!&L&'%$-*0/04+!+4!'4/:*UH!0&+!G454+6!;$A&!$-!5/+&!4-!8$4!+4!4=45%$/'&-!

B!/A:/5*&-4+!f%$I&'!04!B5I\!2!&%'&!5/+&!5&-![!f9$I&'!04!BCa5I\!6!!

k #A:/5*H-! 5&IL:4%/! *-*5*/:(! 34=*-*0/! 5&I&! :/! /$+4-5*/! 04! 5/L%/5*H-! 04!

5&-%'/+%4! 4-0&G4-&+&! /:! =*-/:*U/'! 4:! L'&540*I*4-%&6! K4! :&E'H! $-/! /A:/5*H-!

5&IL:4%/!4-!Bm!%$I&'4+!fm^CVl\6!34!:/+!"!:4+*&-4+!4-!:/+!8$4!-&!+4!:&E'H!:/!

/A:/5*H-! 5&IL:4%/! f[Cml\! $-/! I40F/! "5I! 2! :/! &%'/! B5I6! c/! L'*I4'/! -&!

I&+%'H!5/L%/5*H-!04!5&-%'/+%4!4-!4:!5&-%'&:!/!:&+!B!I4+4+!5&-!9)!2!)7DK!-*!

%/IL&5&!4-!4:!5&-%'&:!/-$/:6!c/!+4E$-0/!:4+*H-!=$4!%'/%/0/!/!:&+!B!I4+4+!/:!

4G*04-5*/'!5'45*I*4-%&!04!YCB5I!'4+L45%&!/!:/!:4+*H-!*-*5*/:!4-!4:!5&-%'&:6!K4!

'4/:*UH! $-/! +4+*H-!04!@O! 5&-! /A:/5*H-! 5&IL:4%/C! +*-! 4G*04-5*/'+4! :4+*&-4+!

'4+*0$/:4+!-*! '45*0*G/+!4-!4:! 5&-%'&:!L&+%4'*&'6!7-!-*-E$-&!04! :&+! 5/+&+! +4!

&A%$G&!I/%4'*/:!L/'/!/-/%&IF/!L/%&:HE*5/6!

k 3F/+! 04! T&+L*%/:*U/5*H-! L&+%4'*&'! /:! L'&540*I*4-%&(! 7:! L'&I40*&! 04!

T&+L*%/:*U/5*H-! =$4! 04! VC"! 0F/+6! Ba! L/5*4-%4+! L$0*4'&-! I/'5T/'! /:! 0F/!

+*E$*4-%4!04!:/!*-%4'G4-5*H-!fm"Cdl\C!"!:&!T*5*4'&-!/:!+*E$*4-%4!2!$-!L/5*4-%4!

+4!I/-%$G&!*-E'4+/0&!0$'/-%4!a!0F/+!L&'!$-/!5&IL:*5/5*H-6!!!

k J*&L+*/(! K4! &A%$G&! I$4+%'/! L/'/! /-/%&IF/! L/%&:HE*5/! 4-! Va! %$I&'4+!

f[BCml\! 5&-! /E$S/! T$45/! 04! A*&L+*/! %*L&! %'$k5$%6! 7-! :&+! 5/+&+! 8$4! 4:!

/A&'0/S4!+4!'4/:*UH!%'/-+T4L,%*5&!+4!&L%H!L&'!-&!'4/:*U/'!A*&L+*/6!!

k )&IL:*5/5*&-4+(![!L/5*4-%4+!fVYCal\!L'4+4-%/'&-!/:E$-/!5&IL:*5/5*H-!8$4!

4-! B! 5/+&+! =$4! $-! T4I/%&I/! 04%45%/0&! L&'! 45&E'/=F/! 0$'/-%4! 4:!

L'&540*I*4-%&6! 7-! "! 04! 4::&+! 4:! I/-4S&! +&:&! 5&-+*+%*H! 4-! '4L&+&! I/+!

L'&=*:/h*+!/-%*A*H%*5/!2!=$4'&-!0/0&+!04!/:%/!/:!0F/!+*E$*4-%4!04!:/!'4/:*U/5*H-!

04! :/! /A:/5*H-! f1'/0&! PP! ):/G*4-k3*-0&\6! 7:! &%'&! L/5*4-%4! %$G&! 8$4! +4'!

%'/-+=$-0*0&! 5&-! 0&+! $-*0/04+! 04! 5&-54-%'/0&+! E:&A$:/'4+! 4-! $-/!

&L&'%$-*0/0C! +4! /0I*-*+%'H! L'&=*:/h*+! /-%*A*H%*5/! 2! +4! I/-%$G&! *-E'4+/0&!

0$'/-%4! a! 0F/+! f1'/0&! PP! ):/G*4-k3*-0&\6! D-! L/5*4-%4! '4*-E'4+H! L&'! $-!

5$/0'&! =4A'*:! 8$4! +4! 4+%$0*H! 4-! $'E4-5*/+! 5&-! 9)! 8$4! 04I&+%'H! $-/!

5&:455*H-! *-%'//A0&I*-/:! 04! ^! 5I! 8$4! =$4! I/-4S/0/! 5&-! /-%*A*H%*5&+!

Page 33: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! BB!

4-0&G4-&+&+! f1'/0&! PP! ):/G*4-k3*-0&\6! K4! '4E*+%'H! $-! 5/+&! 04! /-$:/5*H-!

'4-/:!$-/!04%45%/0/!/:!/`&!04!+*-!5/$+/!&A+%'$5%*G/!4G*04-%4!L&'!:&!8$4!&L%H!

L&'!I/-4S&!4hL45%/-%46!

Y@d'J;+0*1+'C)+#3'

c&+!G/:&'4+!04!)<!2!O*:%'/0&!E:&I4'$:/'!4+%*I/0&!fI40*/!2!I40*/-/\!&A%4-*0&+!04!

:/!L'*I4'/!f*-*5*/:\C!+4E$-0/!f_!I4+4+\!2!%4'54'/!fV"!I4+4+\!I40*5*H-!+4!4hL'4+/-!

4-!:/!%/A:/!a6!7:!=*:%'/0&!E:&I4'$:/'!L'&I40*&!/-%4+!04!:/!'4/:*U/5*H-!04!:/!/A:/5*H-!

=$4! 04! ^aCVVIcnI*-nVCdB"! fV^kVVdIcnI*-nVCdB"\C! I*4-%'/+! 8$4! /:! /`&! 04!

+4E$*I*4-%&!=$4!04!^dC^BIcnI*-nVCdB"!fakVBdIcnI*-nVCdB"\6!!

c&+!E',=*5&+!V!2!"!'4+$I4-!:/+!I40*5*&-4+!04!)<!2!O1!4-!:/+!%'4+!I40*5*&-4+6!

!#$3#'e@'A)(*#''SI:'fZVT'P'8)(*#+#'S25Zg'2YZT'()':")#.*+*+#'23#-8F.*0#'S8/R(BT'P'E*3."#(&'/3&8)";3#"'S8BR8*+R4aYO5T@'

'A)(*0*1+'

N3&$#3'<'*I4'/! K4E$-0/! 94'54'/!

:7'

Media (IC 95%) 1.3 (1.1 ; 1.5) 1.4 (1.1 ; 1.8) 1.5 (1.1 ; 1.9) 1.4 (1.2 ; 1.6)

?40*/-/!fL"^xLd^\! V6V!fY!6m!x!V6^\! V6V!fY6m^!xV6m\! V6V!fY6mB!x!V6d\! V6V!fY6m!x!V6d\!!

JN'

Media (IC 95%) 58,11 (50 ; 66) 56 ( 45 ; 67) 57,53 (48 ; 67) ^d!f!^"!x!_B\!

?40*/-/!fL"^xLd^\! _Y!f![Y!x!dB\! ^_!f!B[!x!dB\! ^a!f!Ba!x!dY\! ^a!f!Ba!x!dB\!

!

Page 34: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! B[!

N"FE*0&'4@''9*#/"#8#'()'0#%#-'2#"#':")#.*+*+#'23#-8F.*0#'S8/R(BT@'

!N"FE*0&'5@''9*#/"#8#'()'0#%#-'2#"#'J*3."#(&'N3&8)";3#"'S8BR8*+R4aYO5T@'

!

c/! 0*+%'*A$5*H-! 04! L/5*4-%4+! +4Eg-! :/! 5:/+*=*5/5*H-! 04! P@)! 04! :/!@('.")(#% 9.$)+0%

</)$('.")!L'4G*&!/:!%'/%/I*4-%&!2!/:!/`&!04!+4E$*I*4-%&!+4!L'4+4-%/-!4-!:/+!%/A:/+!

m!2!VY!'4+L45%*G/I4-%46!34!4::/+!+4!04+L'4-04!8$4!:/!L'4G/:4-5*/!04!P@)!4+%/0*&!B!

&!I/2&'! 4+! 04! [[C^l! L'4G*&! /:! %'/%/I*4-%&!I*4-%'/+! 8$4! /:! /`&! 04! '4/:*U/0/! :/!

/A:/5*H-!4+!04![dC"l6!K4!&A+4'G/!$-!/$I4-%&!04!:&+!4+%/0*&+!04!P@)![!2!^!04!VYC^l!

L'4G*&!/:!%'/%/I*4-%&!/!""C"l!$-!/`&!04+L$W+6!!

!

!

Page 35: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

!#$3#'f@'7"),#3)+0*#'()'IC:'2"),*&'#'3#'#$3#0*1+'

M-.@'IC:' J")0;)+0*#' 7&"0)+.#%)'

V! B! dCam!

"! V_! ["CVV!

B! V^! BmC[d!

[! B! dCam!

^! V! "C_B!

!

!#$3#'4X@'7"),#3)+0*#'()'IC:';+'#Q&'2&-.)"*&"'#'3#'#$3#0*1+'

M-.@'IC:' J")0;)+0*#' 7&"0)+.#%)'

V! B! aCBB!

"! V[! BaCam!

B! VV! BYC^_!

[! ^! VBCam!

^! B! aCBB!

!

</'/!04%4'I*-/'!+*!4+%/+!0*=4'4-5*/+!+&-!4+%/0F+%*5/I4-%4!+*E-*=*5/%*G/+!+4!'4/:*UH!

$-! I&04:&! 04! '4E'4+*H-! I*h%&! %&I/-0&! 4-! 5$4-%/! G/'*/5*&-4+! *-0*G*0$/:4+6! K4!

4+%/A:45*H! $-! ,?2(#/+! I4-&'! &! *E$/:! /! YCY^! L/'/! 5&-+*04'/'! $-! '4+$:%/0&!

4+%/0F+%*5/I4-%4!+*E-*=*5/%*G&6!c/+!%/A:/+!VV!2!V"!'4+$I4-!4:!I&04:&!/L:*5/0&!/!)<!

2!O1!'4+L45%*G/I4-%46!7:!*-%4'54L%&!4+!4:!L'&I40*&!4-!:/!L'*I4'/!I40*5*H-!2!5/0/!

=*:/! I$4+%'/! :/! 0*=4'4-5*/! 04! :/! G/'*/A:4! 5&-! 4:! G/:&'! *-*5*/:C! +$! *-%4'G/:&! 04!

5&-=*/-U/!2!4:%,?2(#/+!04!5&IL/'/5*H-6!!

Q&! +4! &A+4'G/'&-! 0*=4'4-5*/+! 4+%/0F+%*5/I4-%4! +*E-*=*5/%*G/+! 4-! :&+! I&04:&+!

'4/:*U/0&+! L/'/! )<! -*! L/'/! O1! /:! 4G/:$/'! G/'*/5*&-4+! *-0*G*0$/:4+! 04! :/+! %'4+!

I40*5*&-4+!-*!%/IL&5&!4-!:/!4G/:$/5*H-!E:&A/:!f,rYC"aaY!L/'/!)<!2!,r!YCa""^!4-!4:!

5/+&!04!O1\6!7:!E',=*5&!B!'4L'4+4-%/! :/!4G&:$5*H-!04! :/!I40*/-/!04!O1!4-! :/+! %'4+!

I40*5*&-4+!'4/:*U/0/+!2!:&+!*-%4'G/:&+!04!5&-=*/-U/!fm^l\!'4+L45%*G&+6!

! !

Page 36: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! B_!

!#$3#'44@'C)/")-*1+'AB'()')E)0.&-'8*U.&-'2#"#':")#.*+*+#'73#-8F.*0#'

K#"*#$3)'9*E)")+0*#'

>"*.86.*0#'

SfZV'I+.)",#3&'()'

0&+E*#+L#T'!"#$%&'(

!"#$%&''

/3&$#3'

)$*+'(,-.$(

A)(*0*1+'

<'*I4'/! Y! k! k!

YC"aaY!K4E$-0/! YCVV! fkYCV[x!YCB^\! YCBmB[!

94'54'/! YCVd! fkYCY[x!YCBa\! YCVVa[!

I+.)"0)2.&' ! VCBV! fVCY^x!VC^a\! k! !

)$*+'($%'$+/*-$(

M+.")G'9)-,@'!<2*0#@'S0**1(

02+$341T'YCdV!fYCVY\!

C)-*(;#3'9)-,@'!<2*0#@'S0**1(

02+$341T'YC[^!fYCY[\!

!

!#$3#'45@'C)/")-*1+'AB'()')E)0.&-'8*U.&-'2#"#'J*3."#(&'N3&8)";3#"'

K#"*#$3)'9*E)")+0*#'

>"*.86.*0#'

SfZV'I+.)",#3&'()'

0&+E*#+L#T'

!"#$%&'( !"#$%&''

/3&$#3'

)$*+'(5-.$(

A)(*0*1+'

<'*I4'/! Y! k! k!

YCa""^!K4E$-0/! kVC[^! fk_CBax!BC[m\! YC^_^a!

94'54'/! VCYY! fk^C"[x!BC"[\! YC_[BB!

I+.)"0)2.&' ! ! f[mCa[x!__CBa\! ! !

)$*+'(6%'$+/*-$(

M+.")G'9)-,@'!<2*0#@'S0**1(

02+$341T'"[CY^!f"Cmd\!

C)-*(;#3'9)-,@'!<2*0#@'S0**1(

02+$341T'aCmd!fYCa[\!

!

Page 37: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! Bd!

N"FE*0&'O@'M,&3;0*1+'()'3#'8)(*#+#'()'J*3."#(&'N3&8)";3#"'

!

!

!

!

!

!

!

!

d6d!#-/%&IF/!</%&:HE*5/!

K4!&A%$G&!I$4+%'/!L/'/!/-/%&IF/!L/%&:HE*5/!4-!Va!%$I&'4+!f[BCml\6!34!4::&+C!4-!

V"!:4+*&-4+!f__l\!+4!5&-=*'I&!/:Eg-!%*L&!04!))@!:&!8$4!5&''4+L&-04!/:!"_Cal!04:!

%&%/:!04!%$I&'4+!%'/%/0&+6!c/!%/A:/!VY!'4+$I4!+$+!'4+$:%/0&+!2! :/+!='45$4-5*/+!04!

5/0/!%*L&!T*+%&:HE*5&6!!

!#$3#'4X@'!*2&-'h*-.&31/*0&-'()'3&-'.;8&")-'$*&2-*#(&-'

!*2&'i*-.&31/*0&' J")0;)+0*#' 7&"0)+.#%)'

)/'5*-&I/!)'&IH=&A&! V! ^C_!

)/'5*-&I/!9$A$:/'!?$5*-&+&! V! ^C_!

)/'5*-&I/!04!5W:$:/+!5:/'/+! [! ""C"!

)/'5*-&I/!L/L*:/'!@4-/:! _! BBCB!

b-5&5*%&I/! B! V_Cd!

b%'&! B! V_Cd!

!

d6a6!9$I&'!'4+*0$/:!

34=*-*0/!5&I&!:/!/L/'*5*H-!04!$-/!%$I&'/5*H-!8$4!!5/L%/!5&-%'/+%4!!2/!+4/!4-!)7DK!

2n&!9)!/! :&+! %'4+!I4+4+!04!$-/!/A:/5*H-! 5&IL:4%/6!9&0&+! :&+!L/5*4-%4+! *-5:$*0&+!

%4-F/-!5&-%'&:!/!:&+!B!I4+4+!5&-!$-/!L'$4A/!04!*I/E4-C!2/!+4/!)7DKC!9)!&!/IA/+6!!

7:! daC_l!04! :&+! L/5*4-%4+! +4! 5&-%'&:H! 5&-!9)C! ^"l! 5&-! )7DK! 2! "ml! 5&-! /IA/+!

Page 38: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! Ba!

%W5-*5/+6!;$A&!0&+!5/+&+!04!%$I&'!'4+*0$/:6!D-&!4-!$-/! :4+*H-! *-*5*/:!04!"!5I!4-!

'*`H-! *U8$*4'0&!8$4! +4! %'/%H! 5&-!$-/! +4+*H-!/A:/%*G/!04! :/! 5$/:!-&! +4! '4L&'%/'&-!

5&IL:*5/5*&-4+6! ! c/! :4+*H-! '4+*0$/:! =$4! 04! VC"5I! 2! +4! %'/%H! I40*/-%4! $-/! +&:/!

+4+*H-!04!@O!+*-!5&IL:*5/5*&-4+6!7:!+4E$-0&!5/+&!04!%$I&'!'4+*0$/:!=$4!$-/!:4+*H-!

*-*5*/:!04!B5I!%'/%/0/!5&-!0&+!+4+*&-4+!!04!@O!+*-!5&IL:*5/5*&-4+6!!7-!4:!5&-%'&:!04!

:&+!B!I4+4+!+4!04%45%H!$-/!:4+*H-!'4+*0$/:!04!"!5I!8$4!=$4!%'/%/0/!5&-!$-/!+4+*H-!

04! @O! +*-! 5&IL:*5/5*&-4+6! Q&! +4! &A%$G&! I/%4'*/:! L/'/! /-/%&IF/! L/%&:HE*5/! 4-!

-*-E$-&!04!:&+!0&+!5/+&+6!7-!/IA&+!5/+&+!:/!:4+*H-!'4+*0$/:!=$4!04%45%/0/!L&'!)7DK!

2!9)6!!

d6m6!@45*0*G/!

34=*-*0/!5&I&!:/!/L/'*5*H-!04!$-/!%$I&'/5*H-!8$4!!5/L%/!5&-%'/+%4!!2/!+4/!4-!)7DK!

2n&! 9)! V"! I4+4+! :$4E&! 04! $-/! /A:/5*H-! 5&IL:4%/! &! 04! $-/! :4+*H-! '4+*0$/:!

L&+%4'*&'I4-%4! %'/%/0/6! ! 9&0&+! :&+! L/5*4-%4+! *-5:$*0&+! %4-F/-! 5&-%'&:! /! :&+! V"!

I4+4+! 5&-! $-/! L'$4A/! 04! *I/E4-C! 2/! +4/! )7DKC! 9)! &! /IA/+6! 7:! __Cdl! 04! :&+!

L/5*4-%4+!+4!5&-%'&:H!5&-!9)C!^"l!5&-!)7DK!2!"_l!5&-!/IA/+!%W5-*5/+6!#:!/`&!04!

+4E$*I*4-%&!-&!+4!04%45%/'&-!:4+*&-4+!+$E4+%*G/+!04!'45*0*G/!%$I&'/:!6!

d6VY6!!?4%,+%/+*+!

Q*-E$-&!04!:&+!L/5*4-%4+!%4-F/!*I,E4-4+!+$E4+%*G/+!04!I4%,+%/+*+!/:!I&I4-%&!04:!

0*/E-H+%*5&6!34! :&+!L/5*4-%4+! /!8$*4-4+! +4! '4/:*UH!4+%$0*&!04!4h%4-+*H-!I40*/-%4!

9)!%&'/5&k/A0&I*-/:!0$'/-%4!4:!+4E$*I*4-%&!fdaC_l!/!:&+!%'4+!I4+4+!2!__Cdl!4-!4:!

5&-%'&:!/-$/:\!-*-E$-&!L'4+4-%H!:4+*&-4+!+$E4+%*G/+!04!'45*0*G/!%$I&'/:6!

d6VV6!?&'%/:*0/0!

#:!/`&!04!+4E$*I*4-%&!+4! '4E*+%'H!$-/!I&'%/:*0/0!E:&A/:!04!V[C_l!f_!L/5*4-%4+\6!

34! 4::&+! [! =/::45*4'&-! L&'! 5/$+/! -&! /%'*A$*A:4! /! $-/! 4-=4'I40/0! &-5&:HE*5/!

I*4-%'/+! 8$4! :&+! 0&+! '4+%/-%4+! =/::45*4'&-! L&'! 5/$+/! &-5&:HE*5/! L4'&! -&!

'4:/5*&-/0&!/:!,IA*%&!$'&:HE*5&6!!

! !

Page 39: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! Bm!

!"#$%!&'(&!)*!7:!%'/%/I*4-%&!04!:/+!?@<+!+4!4-5$4-%'/!4-!L:4-/!=/+4!04!4G&:$5*H-6!c/+!&L5*&-4+!

%4'/LW$%*5/+! L/'/! 4:! I/-4S&! 04! 4+%/+! :4+*&-4+! +4! *-5'4I4-%/-! 5&-! '/L*04U6! c/+!

/:%4'-/%*G/+! G/'F/-! 04+04! L'&%&5&:&+! 04! G*E*:/-5*/! /5%*G/! T/+%/! 5*'$EF/! '/0*5/:C!

L/+/-0&!L&'!$-/!+4'*4!04!%W5-*5/+!/A:/%*G/+!5&I&!:/!@O!2!5'*&%4'/L*/!/0I*-*+%'/0/+!

L&'!GF/!L4'5$%,-4/!&!8$*'g'E*5/C!/A*4'%/!&!:/L/'&+5HL*5/6!#5%$/:I4-%4!:/!Q<!+4!T/!

*IL$4+%&!5&I&!4:!-$4G&!!"#$%&'()$(*$!4-!4:!%'/%/I*4-%&!04:!))@!4-!4+%/0*&!9V!/:!

04I&+%'/'! +$! *E$/:0/0! 4-! 5$/-%&! /! 4=*5/5*/! &-5&:HE*5/! /:! 5&IL/'/':/! 5&-! :/!

-4='45%&IF/!'/0*5/:!L4'&!4G*%/-0&!:/!E'/-!LW'0*0/!04!I/+/!'4-/:!8$4!4+%/!*IL:*5/_^6!

c/+! %W5-*5/+! /A:/%*G/+! 5&I&! :/! @OC! +4! T/-! L&+*5*&-/0&! 5&I&! $-/! *-%4'4+/-%4!

L&+*A*:*0/0! %4'/LW$%*5/! 4-! L/5*4-%4+! 8$4! L&'! +$+! 5&I&'A*:*0/04+! &! 40/0! -&! +&-!

A$4-&+! 5/-0*0/%&+! L/'/! $-! %'/%/I*4-%&! 8$*'g'E*5&C! +*-! 4IA/'E&! :/! 5&I$-*0/0!

$'&:HE*5/! 2! &-5&:HE*5/! '45:/I/-! /g-! '4+$:%/0&+! /! :/'E&! L:/U&! ! L/'/! G/:*0/'! +$!

+4E$'*0/0! 2! +&A'4! %&0&! +$+! '4+$:%/0&+! &-5&:HE*5&+6! 7+%4! L$-%&! /5%$/:I4-%4! 4+!

*IL&'%/-%4!%4I/!04!04A/%4!

7-!-$4+%'&!4+%$0*&!+4!+&I4%4-!/!/A:/5*H-!L4'5$%,-4/!L&'!@O!Ba!L/5*4-%4+!4-%'4!^"!

2!am!/`&+C!5&-!$-!L'&I40*&!04!40/0!04!d[!/`&+C!5/+*!%&0&+!4::&+!#K#!"!&!B!5&-!$-!

%/I/`&!%$I&'/:!L'&I40*&!04!"Cm5I6! !K*!5&-+*04'/I&+!8$4! :/!4hL45%/%*G/!04!G*0/!

4+%*I/0/! 4-! L4'+&-/+! 04! d^! /`&+! 4-! 4:!I$-0&! *-0$+%'*/:*U/0&! 4+! 04! VY! /`&+C! :/!

L'4+4'G/5*H-! 04! :/! =$-5*H-! '4-/:! 4-! 4+%4! E'$L&! 04! L/5*4-%4+! 4+!I/-0/%&'*/! /! :/!

T&'/! L:/-*=*5/'! 5$/:8$*4'! L'&540*I*4-%&! 2/! +4/! 04! 5/',5%4'! 0*/E-H+%*5&! &!

%4'/LW$%*5&VV[! %&I/-0&! 4-! 5$4-%/! 8$4! :/! L'&A/A*:*0/0! 04! $-/! 0*+I*-$5*H-! 04:!

=*:%'/0&! E:&I4'$:/'!I4-&'! /! [^!I:nI*-nVCdB"! 04! '45*4-%4! /L/'*5*H-! /$I4-%/! $-!

B_l!4-!L/5*4-%4+!+&I4%*0&+!/!Q@!4-!5&IL/'/5*H-!04:!^l!&A+4'G/0&!4-!L/5*4-%4+!

4-!8$*4-4+!+4!T/!L'/5%*5/0&!$-!/A&'0/S4!5&-+4'G/0&'!04!-4='&-/+d"6!7-!4:!m^l!04!

L/5*4-%4+!+4!:&E'H!$-/!/A:/5*H-!5&IL:4%/!*-*5*/:!5&-!$-/!+&:/!5&:&5/5*H-!04!:/!/E$S/!

4-! adl! 04! :&+! 5/+&+6!?/+! 04:! mdl! 04! :&+! L/5*4-%4+! =$4'&-! 0/0&+! 04! /:%/! /:! 0F/!

+*E$*4-%4! L&+%4'*&'! /:! L'&540*I*4-%&6!34! :&+! [! L/5*4-%4+! 8$4! L'4+4-%/'&-! /:E$-/!

5&IL:*5/5*H-C!T$A&!B!8$4!L'4+4-%/'&-!$-!T4I/%&I/!8$4!+4!'4+&:G*H!5&-!'4L&+&!2!

/-%*A*H%*5&+6! 7:! 5$/'%&! L/5*4-%4! L'4+4-%H! $-! 5$/0'&! =4A'*:! 04I&+%',-0&+4! $-/!

5&:455*H-! /A0&I*-/:! 04! ^5I! I40*/-%4! 9)! /A0&I*-/:! V[! 0F/+! L&+%4'*&'! /! :/!

Page 40: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! [Y!

/A:/5*H-6! K4! %'/%/A/! 04! $-/! I/+/! 04! BC[5I! 4-! '*`H-! *U8$*4'0&! %'/%/0&! 5&-! 0&+!

/A:/5*&-4+! :&E'/-0&! 5&IL:4%/! 2! +*-! 5&IL:*5/5*&-4+! *-*5*/:4+6! 7:!I/-4S&! 5&-+*+%*H!

4-! %'/%/I*4-%&!/-%*A*H%*5&!4-0&G4-&+&!2!$-/!G4U!/=4A'*:!2!/+*-%&I,%*5&!5&-%*-$H!

%'/%/I*4-%&!&'/:!/IA$:/%&'*&!&A+4'G/-0&!'4+&:$5*H-!04! :/!5&:455*H-!I40*/-%4!9)!

/:! I4+! 04! %4'I*-/0&! 4:! %'/%/I*4-%&6! 7+%4! I*+I&! L/5*4-%4! L'4+4-%H! 4-! 4:! 9)! 04!

5&-%'&:! /! :&+! V"! $-/! $'4%4'&T*0'&-4='&+*+! 5&-! /-$:/5*H-! '4-/:! 4-! :/! 5$/:! -&! +4!

04I&+%'H! 5/$+/! &A+%'$5%*G/! I40*/-%4! @4-&E'/I/! P+&%HL*5&6! K$! O1! L'4G*&! /! :/!

/A:/5*H-!4'/!04!^"CV!I:nI*-nVCdB"!2!/!:&+!V"!I4+4+!4'/!04![_C^!I:nI*-nVCdB"!L&'!

:&!8$4!&L%H!L&'!$-/!5&-0$5%/!5&-+4'G/0&'/6!!

#04I,+! 04! 8$4! :&+! L/5*4-%4+! *-5:$*0&+! 4-! 4:! 4+%$0*&! +&-! 4-! E4-4'/:! 04! 40/0!

/G/-U/0/C!&A+4'G/I&+!$-/!/:%/!L'4G/:4-5*/!04!P@)!fI/2&'!/:![[l!04!P@)!4+%/0*&!B!

&! I/2&'\C! :&! 8$4! 4+! 5&-5&'0/-%4! 5&-! :&+! 5'*%4'*&+! 04! +4:455*H-! 04! L/5*4-%4+! /!

8$*4-4+!+4!&='454!$-/!%W5-*5/!/A:/%*G/!5&I&!/:%4'-/%*G/!/!:/!5*'$EF/!2!8$4!4+!I/2&'!

/! :&! '4L&'%/0&!L&'!c$5/+!+'%(#! 8$4!04+5'*A4-!$-/!L'4G/:4-5*/!04! P@)!4+%/0*&!B!&!

I/2&'!4-!%&'-&!/:!"^lVVY6!7+%/!0*=4'4-5*/!4+%,!*-=:$4-5*/0/!L&'!4:!T45T&!04!8$4!4-!

4:!4+%$0*&!04!c$5/+!+'%(#!4:!L'&I40*&!04!40/0!+4!4-5$4-%'/!4-!%&'-&!/!:&+!_Y!/`&+6!!

)&I&!2/!T4I&+!5&I4-%/0&C!:/!L'4+4'G/5*H-!04!:/!=$-5*H-!'4-/:!4+!$-!L'*&'*0/0!4-!

G*+%/+!/!$-/!I4S&'!5/:*0/0!04!G*0/!2!0*+I*-$5*H-!04!4G4-%&+!5/'0*&G/+5$:/'4+VYd!2!

I/+! /g-! 5$/-0&! +4! %'/%/! 04! L/5*4-%4+! /0$:%&+! I/2&'4+C! 5&-! *IL&'%/-%4+!

5&I&'A*:*0/04+!&!5&-!P@)!L'4G*/6!7-!4+%4!+4-%*0&C!G/'*&+!4+%$0*&+!+4!T/-!'4/:*U/0&!

L/'/!4G/:$/'!4:! *IL/5%&!+&A'4!:/!=$-5*H-!'4-/:!04!:/!/A:/5*H-!L&'!@O6!@/I/-!+'%(#!

'4/:*U/-! $-/! 5&IL/'/5*H-! '4%'&+L45%*G/! 04! [d! L/5*4-%4+! %'/%/0&+! I40*/-%4!

/A:/5*H-!L&'!@O!fBa!L4'5$%,-4/+!2!m! :/L/'&+5HL*5/+\!2!["!L/5*4-%4+! %'/%/0&+!5&-!

Q<! /A*4'%/! 8$4! L'4+4-%/A/-! $-/! ?@<! 4-! '*`H-! +&:*%/'*&! /-/%HI*5&! fa"l! L&'!

-4='45%&IF/! '/0*5/:! +45$-0/'*/! /! ))@\6! 7:! E'$L&! %'/%/0&! 5&-! @O! %4-F/! $-/! 40/0!

L'&I40*&!I/2&'!f!_^Cm!G+!^mC_!/`&+C!,rYCYB\C!$-/!I/2&'!5:/+*=*5/5*H-!#K#!fB!G+!"C!

,FYCYV\! 2! $-/! %/+/! 04! =*:%'/0&! E:&I4'$:/'! I4-&'! /:! 5&IL/'/':&! 5&-! 4:! E'$L&!

+&I4%*0&! /! Q<! f[_6^! G+! ^^6m! IcnI*-nV6dBI"! ,r! Y6Y[\6! 7:! %/I/`&! %$I&'/:! =$4!

I/2&'! 4-! 4:! E'$L&! 04! Q<! fB6m! G+! "6a! 5IC! ,r! Y6YYV\6! 7-! %&0&+! :&+! L/5*4-%4+!

+&I4%*0&+! /!Q<! +4! '4/:*UH! *+8$4I*/! ='F/! 5&-!$-!L'&I40*&! 04! "d!I*-$%&+! fVBk[d!

I*-\6! #:! /`&! 04! +4E$*I*4-%&C! :&+! L/5*4-%4+! +&I4%*0&+! /! Q<! L'4+4-%/'&-! $-/!

0*+I*-$5*H-! 04:! O1! 5/:5$:/0&! L&'! :/! 45$/5*H-! 04!?3@3!04! "[C^!I*4-%'/+! 8$4! 4:!

Page 41: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! [V!

E'$L&! 04! @O! L'4+4-%H! $-/! 0*+I*-$5*H-! 04! VYC[l! f,rYCYV\6! #:! 4G/:$/'! +&:&!

L/5*4-%4+!8$4!L'4+4-%/A/-!:4+*&-4+!4-%'4!"!2![!5I!:/+!0*=4'4-5*/-!+4!I/-%$G*4'&-!

5&-! $-/! 0*+I*-$5*H-! 04:! O1! 04! ""C[l! 4-! 4:! E'$L&! 04! Q<! ='4-%4! /:! VVC"l! 04!

0*+I*-$5*H-! &A+4'G/0&! 4-! E'$L&! +&I4%*0&! /! @O! f,rYCYYB\VV^6! X&$-E! +'% (#!

5&IL/'/'&-! '4%'&+L45%*G/I4-%4! :/! /A:/5*H-! L4'5$%,-4/! 5&-%'/! :/! :/L/'&+5HL*5/!

I40*/-%4!@O!4-!$-!%&%/:!04!"ma!L/5*4-%4+!fBV_!%$I&'4+\!+*-!4-5&-%'/'!0*=4'4-5*/+!

+*E-*=*5/%*G/+! 4-! 5$/-%&! /! 5&IL:*5/5*&-4+C! =$-5*H-! '4-/:! -*! 4-! 4:! '4+$:%/0&!

&-5&:HE*5&!/!:&+!B!/`&+!04!+4E$*I*4-%&!f<'&A/A*:*0/0!:*A'4!04!'45$''4-5*/!04!m[l!

4-!4:!/A&'0/S4!:/L/'&+5HL*5&!='4-%4!/:!VYYl!L4'5$%,-4&C!,r!YCV_C!4-!L/5*4-%4+!5&-!

I/:*E-*0/0! 04I&+%'/0/! 4-! :/! A*&L+*/! *-*5*/:\VV_6! 7-! -$4+%'&! 4+%$0*&C! +*! A*4-! +4!

&A+4'G/! /:! /`&!04! +4E$*I*4-%&!$-!0*+5'4%&! /$I4-%&! 4-! :&+! G/:&'4+!04! 5'4/%*-*-/!

L:/+I,%*5/!2!$-/!:4G4!0*+I*-$5*H-!04:!=*:%'/0&!E:&I4'$:/'C!/+&5*/0&!/!$-!/$I4-%&!

04:! VVCdl! 04! :/! L'4G/:4-5*/! 04! P@)! 4+%/0*&+! [! 2! ^C! 4+%/+! 0*=4'4-5*/+! -&! =$4'&-!

4+%/0F+%*5/I4-%4! +*E-*=*5/%*G/+! 4-! -$4+%'&! I&04:&! 04! '4E'4+*H-! I*h%&! 8$4!

5&-+*04'/!:/+!0*=4'4-5*/+!*-0*G*0$/:4+!2!:/+!E:&A/:4+6!!!

7:! 5&-%'&:! &-5&:HE*5&! :&E'/0&! L&'! :/+! %W5-*5/+! /A:/%*G/+! 4+! /5%$/:I4-%4! $-!

*IL&'%/-%4!%4I/!04!04A/%4!4-!:/!:*%4'/%$'/!*-%4'-/5*&-/:6!c/+!+4'*4+!L$A:*5/0/+!-&!

+$4:4-! %4-4'! %*4IL&+! 04! +4E$*I*4-%&+! I/2&'4+! 04! ^! /`&+! L&'! :&! 8$4! +$+!

5&-5:$+*&-4+!04A4-!+4'!*-%4'L'4%/0/+!5&-!I4+$'/6!K*!A*4-!-$4+%'&!4+%$0*&!L'4+4-%/!

$-! +4E$*I*4-%&! 5&'%&! 04! V"!I4+4+C! 4-! -*-Eg-! L/5*4-%4! +4! 4G*04-5*H! '45*0*G/! -*!

I4%,+%/+*+C!-*!%/IL&5&!5&-+%/%/I&+!I$4'%4+!/+&5*/0/+!/!$-/!-4&L:/+*/!$'&:HE*5/6!!

;$A&! 0&+! 5/+&+! 04! :4+*H-! '4+*0$/:! 4-! 4:! 5&-%'&:! 04! :&+! %'4+!I4+4+! 4G*04-5*/0&+!

%/-%&!L&'!9)!5&I&!L&'!)7DK! :/+!8$4! =$4'&-! '4k%'/%/0/+! +*-! 5&IL:*5/5*&-4+!2! +*-!

-$4G/+!:4+*&-4+!4-!4:!5&-%'&:!/-$/:6!!

K*!5&-+*04'/I&+!8$4! :/!/A:/5*H-!L&'!@O!&!L&'!5'*&%4'/L*/!+&-!%W5-*5/+!8$4! ::4G/-!

%/-! +&:&! $-&+! VY! /`&+! 4-! :/! L',5%*5/! 5:F-*5/! 4+! 04! 4+L4'/'! 8$4! T&2! L&'! T&2! +$+!

'4+$:%/0&+! 4+%W-! 4-! L:4-/! 4G/:$/5*H-6! 34! I&I4-%&! -&! 4h*+%4-! 4-+/2&+! 5:F-*5&+!

/:4/%&'*&+! 8$4! 5&IL/'4-! $-/! %W5-*5/! /A:/%*G/! 5&-%'/! 5*'$EF/! &! G*E*:/-5*/! /5%*G/C!

/$-8$4!+*!0*+L&-4I&+!04!/:E$-/+!+4'*4+!04!5/+&+!8$4!5&IL/'/-!@O!5&-%'/!Q<6!!

#:!4G/:$/'!:/!:*%4'/%$'/!0*+L&-*A:4C!:&+!'4+$:%/0&+!L$A:*5/0&+!+&-!0*+L/'4+!4-%'4!:/+!

0*+%*-%/+!+4'*4+6!9$'-/!+'%(#!L$A:*5/-!4-!"YYm!$-/!'4G*+*H-!'4%'&+L45%*G/!04!B_!Q<!

:/L/'&+5HL*5/+C!B_!/A:/5*&-4+!L&'!5'*&/A:/5*H-!2!"m!L&'!@O6!9'/+!$-!+4E$*I*4-%&!04!

Page 42: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! ["!

"[! I4+4+! '4L&'%/-! $-/! +&A'4G*0/! :*A'4! 04! 4-=4'I40/0! 04! VYYx! _mCm! 2! BBC"l!

'4+L45%*G/I4-%4! f,rYCYYV\VVd6! <&'! &%'/! L/'%4! $-! 4+%$0*&! L$A:*5/0&! 4-! "YVY! L&'!

9/q/q*!+'%(#!5&IL/'/-!'4%'&+L45%*G/I4-%4!4:!'4+$:%/0&!&-5&:HE*5&!04!^[!L/5*4-%4+!

+&I4%*0&+!/!Q@C!VY!L/5*4-%4+!/!Q<!2!^V!L/5*4-%4+!/!/A:/5*H-!L&'!@O!!4-5&-%'/-0&!

$-/!+&A'4G*0/!:*A'4!04!4-=4'I40/0!/!^!/`&+!04!m^C!d^!2!mal!'4+L45%*G/I4-%4VVa6!

K4Eg-! O/004E&-! 2! )/0040$C! 4+%/+! 0*=4'4-5*/+! +4! L$404-! 4hL:*5/'! L&'! G/'*/+!

'/U&-4+VVm(!!

V6!K4+E&+!04!+4:455*H-!

! V6V6!M/'*/A:4+!%/+/+!04!5&-=*'I/5*H-!T*+%&:HE*5/!L'4G*&!/:!%'/%/I*4-%&6!

! V6"!DA*5/5*H-!2!%/I/`&!%$I&'/:!G/'*/A:4!4-%'4!:/+!+4'*4+6!!

"6!3*=4'4-%4+!04=*-*5*&-4+!04!=/::&!04!%'/%/I*4-%&(!

! "6V6!#IA*E$/!0*+%*-5*H-!4-%'4!'45*0*G/!:&5/:!='4-%4!/!=/::&!04!%'/%/I*4-%&6!

! "6"6!M/'*/A:4+!5'*%4'*&+!L/'/!04=*-*'!:/!'45*0*G/!:&5/:!f*I,E4-4+C!A*&L+*/\6!

B6!M/'*/5*&-4+!%W5-*5/+(!

! B6V6!@4/:*U/5*H-!04!:/!%W5-*5/!L&'!'/0*H:&E&+!4-!/:E$-&+!%'/A/S&+!2!L&'!!! !!!!!!!!$'H:&E&+!4-!&%'&+6!

! B6"6!#A&'0/S4(!#A*4'%&C!:/L/'&+5HL*5&!&!L4'5$%,-4&6!!

! B6B6!7hL4'*4-5*/!04:!54-%'&!

! B6[6!1$F/!*I/E4-&:HE*5/(!@Q?C!9)C!7)b!&!)7DK6!

! B6^6!9*L&!04!/-4+%4+*/(!#-4+%4+*/!E4-4'/:!2!+40/5*H-!*-%'/G4-&+/6!

! B6_6!9W5-*5/!04!/A:/5*H-(!QgI4'&!04!+4+*&-4+!/A:/%*G/+!2!0$'/5*H-6!

7-! 4:! 4+%$0*&! 04! 9/q/q*C! L'&A/A:4I4-%4! :/! +&A'4G*0/! :*A'4! 04! 4-=4'I40/0! 4+%/!

+&A'40*I4-+*&-/0/!4-!4:!E'$L&!04!@O!2/!8$4!+&:&!4:!"BC^l!04!:/+!:4+*&-4+!%'/%/0/+!

L&'! @O! %4-F/-! 5&-=*'I/5*H-! L&'! A*&L+*/! 04! I/:*E-*0/0! I*4-%'/+! 8$4! %&0/+! :/+!

:4+*&-4+!%'/%/0/+!L&'!Q@!%4-F/-!5&-=*'I/5*H-!L/%&:HE*5/!04!))@6!

c&+! 4+%$0*&+! /5%$/:I4-%4! 0*+L&-*A:4+! 8$4! 4G/:g/-! 4:! '4+$:%/0&! &-5&:HE*5&! 04! :/!

/A:/5*H-!L&'!@O!/!I40*/-&!L:/U&!5&I*4-U/-!L$A:*5/'+4!4-!"YY^!5$/-0&!?53&$E/:!

+'%(#!04+5'*A4-!+$!4hL4'*4-5*/!4-!V_!L/5*4-%4+!2!"Y!%$I&'4+!I4-&'4+!04!^5I!5&-!

5&-=*'I/5*H-!T*+%&:HE*5/!04!))@!2!$-!IF-*I&!04![!/`&+!04!+4E$*I*4-%&6!@4L&'%/-!

$-/! +&A'4G*0/! :*A'4! 04! '45*0*G/! 04! mVl! +*-! L'4+4-%/'! 5/+&+! 04! I&'%/:*0/0!

Page 43: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! [B!

4+L45F=*5/! -*! /L/'*5*H-! 04! I4%,+%/+*+V"Y6! 7-! "YYd! u/E&'*/! +'% (#! L$A:*5/-! 4:!

%'/%/I*4-%&!I40*/-%4!/A:/5*H-!L4'5$%,-4/!L&'!@O!04![a!%$I&'4+!5&-!5&-=*'I/5*H-!

T*+%&:HE*5/!04!))@!4-![V!L/5*4-%4+!5&-!$-/!I40*/!04!+4E$*I*4-%&!04!^_!I4+4+!2!

$-! %/I/`&! %$I&'/:! L'&I40*&! 04! "C_5I! fYCdkaC"5I\6! 34+5'*A4-! dl! 04! =/::&! 04!

%'/%/I*4-%&C! [l! 04! '45*0*G/! C! dl! 04! I4%,+%/+*+! 2! V! $-/! I$4'%4! L&'! 5/$+/!

&-5&:HE*5/C! 5&-! $-/! +&A'4G*0/! :*A'4! 04! '45*0*G/! 04! aal6! Q&! T$A&! '45*0*G/! 4-!

L/5*4-%4+!5&-!:4+*&-4+!I4-&'4+!04![5IV"V6!!7-!"YVY!9'/52!+'%(#%L$A:*5/-!$-/!+4'*4!

04!"[B!?@<+!%'/%/0/+!I40*/-%4!/A:/5*H-!L&'!@O!f<4'5$%,-4/!2!:/L/'&+5HL*5/\!5&-!

$-! %/I/`&! %$I&'/:!L'&I40*&!04!"C[5I!2! +4E$*I*4-%&!L'&I40*&!04!"d!I4+4+6! K*!

5&-+*04'/I&+!+&:&!:&+!Vdm!%$I&'4+!5&-!5&-=*'I/5*H-!T*+%&:HE*5/!04!))@!'4L&'%/-!

$-/! +&A'4G*0/! :*A'4!04! '45*0*G/!04!mYlC! :*A'4!04!I4%,+%/+*+!04!m^l!2! +&A'4G*0/!

5,-54'!4+L45F=*5/!04!mmlV""6!!

#:! /-/:*U/'! :&+! L'*-5*L/:4+! 4+%$0*&+! 8$4! 5$4-%/-! 5&-! $-! +4E$*I*4-%&! /:!I4-&+! /!

I40*/-&! L:/U&! f'4+$I*0&+! 4-! :/! %/A:/! VV\! %4-4I&+! 8$4! :/! %/+/! 04! '45*0*G/! 4+%,!

*-=:$4-5*/0/!L'*-5*L/:I4-%4!L&'!0&+!/+L45%&+C!L'*I4'&!:/!5&-=*'I/5*H-!T*+%&:HE*5/!

04!))@!L'4G*&!/:!%'/%/I*4-%&C!2/!8$4!+*!5&-+*04'/I&+!8$4!$-!"Yk"^l!04!:/+!?@<!

5&''4+L&-04-!/!:4+*&-4+!A4-*E-/+_^!:/!*-5:$+*H-!04!4+%/+!:4+*&-4+!4-!:&+!5&-%'&:4+!

&-5&:HE*5&+! /$I4-%/! =/:+/I4-%4! :/! +&A'4G*0/! :*A'4! 04! '45*0*G/6! X! +4E$-0&! :/!

04=*-*5*H-!04!'45*0*G/x!+*!5&-+*04'/I&+!5&I&!%/:!:4+*&-4+!8$4!4-!4:!L'*I4'!5&-%'&:!

04I$4+%'/-!5/L%/5*H-!04!5&-%'/+%4!4-!:/!9)!&!)7DK!:/!+&A'4G*0/!:*A'4!04!'45*0*G/!

G/'F/! 4-%'4! BB6"! /! aal! I*4-%'/+! 8$4! +*! +4! 5&-+*04'/! 5&I&! '45*0*G/! $-/! :4+*H-!

5/L%/-%4! 8$4! /L/'454! L&+%4'*&'! /! $-/! L'$4A/! 8$4! 4G*04-5*/! $-/! /A:/5*H-!

+/%*+=/5%&'*/C!0*5T/!G/'*/A:4!/$I4-%/!/!mYkm^lVVm!

!

!

!

!

6

Page 44: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

!"#$"%&&'%%()*+),%-)%.",/,%-)%01#$+."-",%%,/#*)%"#$".+23%-)%415/*),%*)3"$),%5)-+"34)%67%./3%,)81+5+)34/%"%5)-+"3/%0$"9/'%%

Autor año Nº Pac

Nº Tm

Seguimiento promedio (meses)

Tamaño tumoral

promedio (cm)

Malignidad demostrada por biopsia

(%)

Abordaje Ablación

incompleta (%)

Sobrevida libre de

recidiva local (%)

Sobrevida libre de

metástasis (%)

Mortalidad específica

(%)

Sobrevida global (%)

McDougal et al 2005 16 20 55 3,2 100 Perc - 91 100 0 68,7

Zagoria et al 2007 41 48 56 2,6 (0,7-8,2) 100 Perc 12 88 93 2,4 66

Levinson et al 2008 18 18 57,4 (41-80) 2,1 (1-4) 51,6 Perc 3 79,9 100 0 58,3

Mylona et al 2009 18 18 31,2 (12-72) 3,5 - Perc 30 89,9 89 16 72,2

Ferakis et al 2010 31 39 61 (36-84) 3,1 (1,3-7,5) 0 Perc 10 89 100 0 84

Tracy et al (subgrupo con

biopsia positiva) 2010 160 179 27 (1,5-90) 2,4 100 Perc. y

Lap. 3 90 95 1 85

Kim et al 2011 49 49 31,7 2,4 (1-5) 10 Perc. y Lap. 14 94 100 0 100

Page 45: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "#!

$%&'!()*+,%'!-.*'&%(/%+!*(&(!,'.*(&(&!0-)%-/%()!)+&-+)!+)!1(!(/(%'.2(!%3.'&(14!5-!

6-+/! %'0')! 1')! %&(6(7')!0',3.+/%(/! 1')! %(.(8')! %3.'&(1+)9!*',')!0-:+&+/,-(/!)3!

1',(1-;(,-</9! *+)(&! 0+! =3+! )+! >(! *')%31(0'! =3+! 0-:+&+/,-()! 0+! +)%+! ?! '%&')!

*(&@.+%&')! 0+! 1(! (/(%'.2(! %3.'&(1! *3+0+! -/:13-&! +/! +1! AB-%'! -/-,-(1! 0+! 3/!

%&(%(.-+/%'! ()2! ,'.'! +/! )3! &+)31%(0'! (! 1(&C'! *1(;'DEF9DE"4! G+,-+/%+.+/%+! )+! >(!

0-:3/0-0'! 1(! ,1()-:-,(,-</! G4H4I4J4K! LG4H4I4J4K4!"#$%&'(#)&*!+,'&#M! *&'*3+)%(! *'&!

N3%-O'P! ?! Q;;'! +/! ERRS! LT-C3&(! DMDE#! ?! 1(! ,1()-:-,(,-</! U4J4V4Q4J4! L-&#'$#&.)/0#!

12$#,)2! .34! 5/(#32/'32! 62#4! 7'&! .3! 13.)'(/,.8! 98.22/7/,.)/'3M! *&'*3+)%(! *'&!

T-,(&&(! #)! .8DEW4! H1! G4H4I4J4K4! 2,'&#! ,'/)-)%+! +/! 3/! )-)%+.(! 0+! *3/%3(,-</! *(&(!

,(&(,%+&-;(&! 1(! (/(%'.2(! &+1+P(/%+! 0+! 1')! %3.'&+)! &+/(1+)! ,'/)-0+&(/0'!

*&-/,-*(1.+/%+! )3! %(.(8'9! 36-,(,-</! ?! *&':3/0-0(04! V+! +)%(! :'&.(! )+! 1'C&(!

+)%(/0(&-;(&! 1')! &+*'&%+)! ,-+/%2:-,')! ,(%(1'C(/0'! )+CX/! 1(! *3/%3(,-</! :-/(1! ,'.'!

0+!,'.*1+B-0(0!6(7(!L"YWM9!.+0-(!LZYSM!?!(1%(!LDRYDEM4!

!"#$%&'()'*)+),)-).)'!"#$%&'"(%)*+,&%")''

!

Page 46: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "W!

5-! 6-+/! +)%(! ,1()-:-,(,-</! +)%@! )-+/0'! (.*1-(.+/%+! +P(13(0(! +/! ,()')! 0+!

/+:&+,%'.2(! &(0-,(1! '! *(&,-(19! (6-+&%(9! 1(*(&'),<*-,(! ?! &'6<%-,(! +/! ,3(/%'! (! )3!

3%-1-0(0! +/! 1(! %'.(! 0+! 0+,-)-'/+)DEZ! ?! ,'.'! *&+0-,%'&! 0+! ,'.*1-,(,-'/+)! *')%!

=3-&X&C-,()DE[!0+!.'.+/%'!)'1'!3/!+)%30-'!1(!(*1-,(!%A,/-,()!(61(%-P()4!G+?+)!#)!.8!

&+(1-;(/!3/!(/@1-)-)!&+%&')*+,%-P'!0+!FS!*(,-+/%+)!)'.+%-0')!(!3/(!%A,/-,(!(61(%-P(!

*'&! 3/(! .()(! &+/(14! H1! ),'&+! *&'.+0-'! :3+! 0+! W! L"YDRM4! K(! 0-)%&-63,-</! *'&!

,'.*1+7-0(0! :3+!6(7(!ER!*(,-+/%+)! L#D9F\M9!.'0+&(0(!DZ! L"F9W\M!?! (1%(! E! L#9DM4!

5+-)!LD#\M!*(,-+/%+)!+B*+&-.+/%(&'/!3/(!&+,-0-P(!1',(19!0+!+11')!#!L[F9F\M!%+/2(/!

%3.'&+)! 0+! .'0+&(0(! ,'.*1+7-0(0! .-+/%&()! =3+! +1! &+)%(/%+! :3+! 0+! 6(7(!

,'.*1+7-0(04! H/! ,3(/%'! (! ,'.*1-,(,-'/+)9! "! LDR\M! *(,-+/%+)! *&+)+/%(&'/! 3/(!

,'.*1-,(,-</!.+/'&!L]1(P-+/!DYEM!?!D!LF\M!3/(!,1()-:-,(,-</!.(?'&!L]1(P-+/!FY"M!

%'0')!1')!,3(1+)!%+/2(/!%3.'&+)!0+!.'0+&(0(!,'.*1+7-0(04!K')!(3%'&+)!,'/,13?+/!

=3+!+1!2,'&#!G4H4I4J4K4!*3+0+!(?30(&!(!*&+0+,-&!1(!*')-6-1-0(0!0+!&+,-0-P(!1',(1!?!0+!

,'.*1-,(,-'/+)!(3/=3+!:(1%(/!+)%30-')!=3+!(6(1+/!+)%')!>(11(;C')DES4!!

^1%-.(.+/%+! )+! >(/! *361-,(0'! +)%30-')! =3+! 63),(/! ,'.*(&(&! +1! &+)31%(0'!

'/,'1<C-,'! 0+! %A,/-,()! (61(%-P()! :&+/%+! (! 1(! IU4! I3+P(.+/%+! 1')! &+)31%(0')! )'/!

P(&-(61+)4! U(&(! +P(13(&! +)%')! +)%30-')! >(?! =3+! %+/+&! +/! ,3+/%(! (1C3/')! :(,%'&+)!

=3+! *3+0+/! -/03,-&! (! +&&'&4! K(! ,'.*(&(,-</! 0-&+,%(! 0+! 1(! )'6&+P-0(! 1-6&+! 0+!

+/:+&.+0(0!+/%&+!+)%()!0')!%A,/-,()!*3+0+!)'6&++)%-.(&!1(!+:-,(,-(!0+!1()!%A,/-,()!

(61(%-P()!?(!=3+!1()!)+&-+)!,'/!IU!C+/+&(1.+/%+!-/,13?+/!*(,-+/%+)!,'/!1+)-'/+)!0+!

.(?'&! %(.(8'! ?! ,'/! )+C3-.-+/%')! 0+! .(?'&! 03&(,-</4! U'&! ,'/%&(*(&%+9! 1(!

)'6&+P-0(!C1'6(1!%-+/0+!(!)+&!.(?'&!+/!1()!)+&-+)!0+!IU!?(!=3+!-/,13?+/!*(,-+/%+)!

.()!7<P+/+)!,'/!.+/'&!,'.'&6-1-0(04!!

5%+&/!#)!.8!,'.*(&(/!"R!*(,-+/%+)!%&(%(0')!.+0-(/%+!(61(,-</!*'&!GT!:&+/%+!(!FZ!

%&(%(0')!,'/!IU4!K')!%(.(8')!%3.'&(1+)!/'!*&+)+/%(&'/!0-:+&+/,-()!)-C/-:-,(%-P()!

+/%&+!(.6')!C&3*')!L.+0-(!0+!E9"!,.M4!K(!&+,-0-P(!1',(1!)+!0+:-/-<!,'.'!3/(!1+)-</!

,(*%(/%+! 0+! ,'/%&()%+! *')%+&-'&! (! 3/(! (61(,-</! ,'.*1+%(4! G+*'&%(/! 0')! ,()')! 0+!

&+,-0-P(!+/!,(0(!C&3*'9!)-/!*&+)+/%(&!.'&%(1-0(0!,@/,+&!+)*+,2:-,(!.-+/%&()!=3+!1(!

)'6&+P-0(!1-6&+!0+!+/:+&.+0(0!(!F!(8')!/'!*&+)+/%<!0-:+&+/,-()!+)%(02)%-,(.+/%+!

)-C/-:-,(%-P()!,'/)-0+&(/0'!)'1'!1()!1+)-'/+)!,'/!>-)%'1'C2(!0+!]]G!LSD9"\!*(&(!GT!

?!S#9E\!*(&(!IU9!$_R9#[M4! K')! (3%'&+)! ,'/,13?+/!=3+! 1')! &+)31%(0')!'/,'1<C-,')!

+/%&+!+)%()!0')!%A,/-,()!)'/!,'.*(&(61+)!(!F!(8')!0+!)+C3-.-+/%'DFR4!!

Page 47: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "Z!

G+,-+/%+.+/%+!$1`+/?!#)!.8DFD!*361-,(/!3/!+)%30-'!&+%&')*+,%-P'!0+!FZ!*(,-+/%+)!

)'.+%-0')! (! (61(,-</! *+&,3%@/+(! *'&! GT! LU+&,3%@/+(! '! 1(*(&'),<*-,(M! :&+/%+! FZ!

*(,-+/%+)!)'.+%-0')!(!IU9!%'0')!,'/!3/!)+C3-.-+/%'!.(?'&!(!#!(8')!L.+0-(!0+!W9#!

(8')! *(&(! GT! ?! W9D! *(&(! IUM! ?! ,'/! ,'/:-&.(,-</! >-)%'1<C-,(! 0+! ]]G4! I'! >36'!

0-:+&+/,-()! )-C/-:-,(%-P()! +/! ,3(/%'! (! %(.(8'! %3.'&(19! >-)%'1'C2(! /-! +%/-(9! )-/!

+.6(&C'! 1')!*(,-+/%+)!)'.+%-0')!(!GT!+&(/!.(?'&+)!LWF9[! :&+/%+!(!#"9[!(8')9!$_!

R9RRDM!?! %+/2(/!3/(!,1()-:-,(,-</!J5J!.(?'&! LU3/%(7+!aD!0+!S"9W\!P)!Z#9Z\M4!J1!

,'.*(&(&! 1(! (61(,-</! *'&! GT! :&+/%+! (! 1(! IU9! 0+),&-6+/! =3+! /'! >36'! 0-:+&+/,-()!

)-C/-:-,(%-P()! +/! 1(! )'6&+P-0(! C1'6(1! (! #! (8')! LSZ9E\! P)! DRR\! &+)*+,%-P(.+/%+9!

$_R9FDM9! /-! +/! 1(! )'6&+P-0(! ,@/,+&! +)*+,2:-,(! LSZ9E\! P)! DRR\9! $_R9FDM9! /-! +/! 1(!

)'6&+P-0(!1-6&+!0+!+/:+&.+0(0!L[S9E\!P)![S9E\M9!)'6&+P-0(!1-6&+!0+!&+,-0-P(!1',(1!

SD9Z\! P)! S"9W\9! $_! R9SWM! /-! 1(! )'6&+P-0(! 1-6&+! 0+!.+%@)%()-)! LSZ9E\! P)! SD9[\9!

$_R9F#M4! K')! (3%'&+)! ,'/,13?+/! =3+! 1(! (61(,-</! *'&! GT! *&+)+/%(! &+)31%(0')!

+=3-P(1+/%+)! (! 1(! IU4! 5-/! +.6(&C'9! P(&-()! 1-.-%(,-'/+)! 0+! +)%+! &+,-+/%+! +)%30-'!

0-:-,31%(/!1(!,'&&+,%(!-/%+&*&+%(,-</!0+!)3)!&+)31%(0')4!U&-.+&'!/'!)+!0+),&-6+/!1')!

,&-%+&-')! *(&(! ()-C/(&! 1')! *(,-+/%+)! (! 3/! %&(%(.-+/%'! '! (1! '%&'9! /-! ()*+,%')! 0+! 1(!

(/(%'.2(!%3.'&(1!LG4H4I4J4K4!'!UJ4V4Q4J4M9!)'1'!)+!0+),&-6+!=3+!(!1')!*(,-+/%+)!,'/!

%3.'&+)! ,+/%&(1+)! '! +/0':2%-,')! )+! 1+)! ':&+,-<! *&-.+&(.+/%+! 3/! (6'&0(7+!

1(*(&'),<*-,'! ?(! )+(! IU! '! GT! 1'! =3+! C+/+&(! 3/! -.*'&%(/%+! )+)C'! 0+! )+1+,,-</4!

5+C3/0'! 1(!.3+)%&(! 0+!*(,-+/%+)! ,'&&+)*'/0+! (1! #F\!0+1! %'%(1! 0+! *(,-+/%+)! ,'/!

>-)%'1'C2(!0+!]]G!*'&!,3(/%'!3/!/X.+&'!-.*'&%(/%+!0+!*(,-+/%+)!:3+&'/!+B,13-0')!

*'&! /'! ,'/%&(! ,'/! +1! )+C3-.-+/%'! +)%(61+,-0'! LFR\M9! .3+&%+! *'&! ,(3)(! /'!

&+1(,-'/(0(!(/%+)!0+!,3.*1-&!+1!%-+.*'!0+!)+C3-.-+/%'!LD#9Z\M!'!*'&!1(!*&+)+/,-(!

0+!3/!%3.'&!.+%(,&</-,'!LD9"\M4!J)29!+1!+)%30-'!0+!$1`+/?!%-+/+!3/(!.3+)%&(!0+!

*(,-+/%+)! +B%&+.(0(.+/%+! )+1+,,-'/(0(4! ! b+&,+&'9! 0(0'! +1! %(.(8'! 0+! .3+)%&(!

&+03,-0'! ()',-(0'! (! 3/! *+=3+8'! /X.+&'! 0+! +P+/%')! 1')! (3%'&+)! ,(1,31(/! 3/(!

*'%+/,-(! 0+! ED\! *(&(! 0+%+,%(&! 0-:+&+/,-()! 0+1! DR\! +/! 1(! P(&-(61+! 0+! )'6&+P-0(!

1-6&+!0+!.+%@)%()-)!L':),'(#!*&-.(&-'M4!!

T-/(1.+/%+9! +1! .+%(Y(/@1-)-)! &+(1-;(0'! *'&! N3/O1+! #)! .8! +/! ERR[DFE! -/,13?+! SS!

+)%30-')!?!W"ZD!.()()!&+/(1+)!0+!1()!,3(1+)!#RFZ!)'/!%&(%(0()!.+0-(/%+!IU9!"SW!

*'&! (61(,-</! *'&! ,&-'%+&(*-(! ?! WRZ!.+0-(/%+! (61(,-</! *'&! GT!.-+/%&()! =3+! FFD!

1+)-'/+)! )+!.(/%3P-+&'/! +/! P-C-1(/,-(! (,%-P(4! K(! &+,-0-P(! 1',(1! :3+! 0+:-/-0(! ,'.'!

,3(1=3-+&!,(*%(,-</!0+!,'/%&()%+! !0+)*3A)! 1(! %+&(*-(! -/-,-(14!J)29! 1(!.+/'&!%()(!0+!

Page 48: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "[!

&+,-0-P(! )+! '6)+&P<! ,'/! 1(! IU! LE9W\M! ,'.*(&(0'! ,'/! 1(! ,&-'%+&(*-(! L"9W\M! ?! 1(!

(61(,-</!*'&!GT!LDD9Z\M9!(!*+)(&!0+!=3+!1')!%3.'&+)!-/,13-0')!+/!+1!*&-.+&!C&3*'!

%+/2(/!.(?'&!%(.(8'!LF9EW,.9!E9WS,.!?!E9#W,.!&+)*+,%-P(.+/%+M!?!,'/!3/!.(?'&!

*+&-'0'! 0+! )+C3-.-+/%'! L#"! P)! DW9"! P)D[9F!.+)+)! &+)*+,%-P(.+/%+M4! ]'.*&(/0'!

,'/! 1(! IU9! (1! &+(1-;(&! +1! (/@1-)-)! .31%-P(&-(/%+! )+! &+P+1<! 3/! &-+)C'! &+1(%-P'!

)-C/-:-,(%-P(.+/%+!)3*+&-'&!0+!&+,-0-P(!1',(1!Z9"#!*(&(!1(!,&-'%+&(*-(!?!DE9EF!*(&(!

1(! GT9! .-+/%&()! =3+! 1(! )'6&+P-0(! ,@/,+&! +)*+,2:-,(! :3+&'/! .3?! +1+P(0')! ?! )-/!

0-:+&+/,-()! )-C/-:-,(%-P()! +/%&+! 1()! %&+)! .'0(1-0(0+)4! 5-/! +.6(&C'! 1')! (3%'&+)!

0+),&-6+/! -.*'&%(/%+)! 0-:+&+/,-()! .+%'0'1<C-,()! +/%&+! 1()! %&+)! .'0(1-0(0+)! +/!

,3(/%'!(!+0(0!0+!1')!*(,-+/%+)!L$cR9RRDM9!%(.(8'!%3.'&(1!L$cR9RRDM!?!%-+.*'!0+!

)+C3-.-+/%'! L$cR9RRDM! ?! (0+.@)! >(,+/! &+:+&+/,-(! (! -.*'&%(/%+)! )+)C')! 0+!

)+1+,,-</!+B-)%+/%+)!+/!,3(/%'!(! 1(!(*1-,(,-</!0+!+)%()!%A,/-,()! 1'!,3(1!0-:-,31%(! 1(!

-/%+&*&+%(,-</!0+!1()!)+&-+)!?!)+!,'/,3+&0(!,'/!1')!)+)C')!*&'*-')!0+!,(0(!)+&-+!*'&!

)+*(&(0'!0+! 1')!=3+!+1!.+%(Y(/@1-)-)!)+!,'.*'/+! -/,13-0'! 1(!*&'*-(!0+:-/-,-</!0+!

&+,-0-P(!1',(14!!

!H/!,3(/%'!(! 1(!.'/-%'&-;(,-</!&(0-'1<C-,(!,'/!]HQ5!3%-1-;(0(!+/!/3+)%&'!+)%30-'!

+B-)%+/! *',')! +)%30-')! =3+! 1(! 3%-1-;(/! +/! ,'.*(&(,-</! ,'/! 1(! b]! '! GId4! 53!

3%-1-;(,-</!,'.-+/;(!,'/!+1! %&(6(7'!*361-,(0'!*'&! e'>/)'/!#)!.8! +/!ERR#DFF4!H/!A1!

)'.+%+/!(!#!,+&0')!0+!+B*+&-.+/%(,-</!(!(61(,-</!*'&!GT!1(*(&'),<*-,(9!)+!+P(1X(!

1(! (61(,-</! C+/+&(0(! *'&! ]HQ5! %&(/)0+&.-,(! ?! *')%+&-'&.+/%+! )+! +B%-&*(/! 1')!

&-8'/+)!,'.*(&(/0'!+1!%(.(8'!.+0-0'!*'&!]HQ5!?!+1!'6)+&P(0'!0-&+,%(.+/%+!+/!

+1! &-8</! )-/! +/,'/%&(&! 0-:+&+/,-()! )-C/-:-,(%-P()! +/%&+! 1()! 0')! .+0-,-'/+)4! K')!

(3%'&+)! ,'/,13?+/! =3+! ]HQ5! *(&+,+! )+&! 3/(!.'0(1-0(0! *&+,-)(! *(&(! P(1'&(&! 1')!

0+:+,%')! *&'03,-0')! *'&! 1(! (61(,-</! *'&! GT4! U')%+&-'&.+/%+! +/! ERDD! f>('! #)! .8!

,'.*(&(/!]HQ5!:&+/%+!(!+,'C&(:2(!,'/P+/,-'/(1!,'/!%()()!0+!(61(,-</!,'.*1+%(!0+!

S"9W\!P)!["9D\!L*cR9R#M!*(&(!%3.'&+)!.+/'&+)!0+!"!,.!?!0+![F9F\!:&+/%+!(!"R\!

+/!1+)-'/+)!.(?'&+)!0+!"!,.!(1!,'/%&'1(&1()!,'/!b]!Z!02()!*')%+&-'&!(!1(!(61(,-</4!

H/!/3+)%&'!+)%30-'9!ES\!0+!1')!*(,-+/%+)!%3P-+&'/!,'/%&'1!%(/%'!,'/!b]!,'.'!,'/!

]HQ5! (! 1')! F!.+)+)! *')%+&-'&! (! 1(! (61(,-</9!.-+/%&()! =3+! +/! +1! ,'/%&'1! (/3(1! 3/!

EF\! 0+! 1')! *(,-+/%+)! )+! &+(1-;(&'/! (.6()! %A,/-,()4! K()! 0')! 1+)-'/+)! &+)-03(1+)!

0+%+,%(0()! (! 1')! F! .+)+)! )+! 0+%+,%(&'/! *'&! (.6()! %A,/-,()4! J,%3(1.+/%+! 1')!

.A%'0')!0+!)+C3-.-+/%'!&(0-'1<C-,'!%&()!1(!(61(,-</!)+!+/,3+/%&(/!+/!+P(13(,-</4!

Q/!+)%30-'!&+(1-;(0'!*'&!g+-C>%!#)!.8!+P(13<!+1!,'/%&'1!&(0-'C&@:-,'!0+!DRS!dGU)!

Page 49: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! "S!

)'.+%-0()! (! (61(,-</! *'&! GT! *+&,3%@/+(4! 5+! &+(1-;<! 3/! ,'/%&'1! (! 1')! W! .+)+)!

.+0-(/%+!b]!'!GId!?!)+!,'.*(&<!,'/!3/!,'/%&'1!>-)%'*(%'1<C-,'4!5+!'6%3P-+&'/!WE!

,()')!0+!(61(,-</!,'.*1+%(!*'&!b]hGId!L[#\M!.-+/%&()!=3+!*'&!6-'*)-(!)'1'!)+!

'6%3P-+&'/!E"!LW"9[\M!(1!,'/%&'1!0+!1')!W!.+)+)4!!

K()! 1-.-%(,-'/+)! *&+)+/%+)! +/! +)%+! +)%30-'! )'/! )-.-1(&+)! (! 1()! ,'.+/%(0()! *(&(!

'%&')4! H1! ,(&@,%+&! &+%&')*+,%-P'9! +1! &+03,-0'! %-+.*'! 0+! )+C3-.-+/%'! ?! 0+! ,()')!

'61-C(/! (! -/%+&*&+%(&! /3+)%&')! &+)31%(0')! ,'/! .'0+&(,-</9! )3.(0'! (! =3+! 1(!

(/(%'.2(!%3.'&(1!/'!:3+!0',3.+/%(0(!,'/!3/!.A%'0'!+)%(/0(&-;(0'4!5-/!+.6(&C'!

,&++.')! =3+! /3+)%&(! 0+),&-*,-</! (*'?(! 1(! >-*<%+)-)! *1(/%+(0(! *'&! '%&')!

-/P+)%-C(0'&+)! +/! &+1(,-</! (! 1()! P-&%30+)! =3+! ':&+,+! 1(! (61(,-</! *+&,3%@/+(!

.+0-(/%+!GT!+/! %&(%(.-+/%'!0+! 1()!dGU)!+/!*(,-+/%+)!)+1+,,-'/(0')!+/!,3(/%'!(!

)3)!&+)31%(0')!'/,'1<C-,')!(X/!+/!+P(13(,-</!*+&'!(*(&+/%+.+/%+!:(P'&(61+)!?!)3)!

+B,+1+/%+)!&+)31%(0')!:3/,-'/(1+)!,(0(!P+;!.()!+P-0+/%+)4!!

!

! !

Page 50: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! #R!

!"#!"#!$%&'"#(&!H1!.(/+7'! 0+! 1()!dGU! *&+)+/%(! -.*'&%(/%+)! ,(.6-')! +/! 1')! X1%-.')! ER! (8')4! H1!

.(?'&!,'/',-.-+/%'!0+!)3!>-)%'1'C2(9!>-)%'&-(!/(%3&(19!,(&(,%+&2)%-,()!&(0-'1<C-,()!

+! -/:13+/,-(!*&'/')%-,(!*+&.-%+!>'?! ,'/)-0+&(&! %&(%(.-+/%')!.+/')! -/P()-P')! +/!

*(,-+/%+)!0+1!(%'!&-+)C'!=3+!/'!)'/!,(/0-0(%')!(!,-&3C2(4!J,%3(1.+/%+!1')!+)%30-')!

0-)*'/-61+)!(P(1(/!+1!3)'!0+!1(!(61(,-</!*'&!GT!*+&,3%@/+(!*(&(!+1!%&(%(.-+/%'!0+!

%3.'&+)!&+/(1+)!.+/'&+)!0+!"!,.9!)-/!+.6(&C'!+)%')!+)%30-')!+/!C+/+&(1!,'/)-)%+/!

+/! )+&-+)!0+! ,()')!*+=3+8()!?! ,'/! %-+.*')!0+! )+C3-.-+/%'! &+03,-0')!*'&! 1'!=3+!

(X/!/'!0-)*'/+.')!0+! +P-0+/,-(! :3+&%+!=3+! )3)%+/%+!*&'%','1')!0+! (,%3(,-</! +/!

6()+!(!+)%')4!J!*+)(&!0+!+11'9!)-!>(?!,'/)+/)'!+/!=3+!1(!(61(,-</!*+&,3%@/+(!*'&!GT!

+)! 3/! *&',+0-.-+/%'! )+C3&'! +/! ,3(/%'! (! )3)! ,'.*1-,(,-'/+)! ?! +/! ,3(/%'! )3!

,(*(,-0(0! 0+! *&+)+&P(,-</! 0+! 1(! :3/,-</! &+/(19! 1'! ,3(1! %(.6-A/! )+! '6)+&P(! +/!

/3+)%&')!&+)31%(0')4!K')!%&(6(7')!P+/-0+&')!0+6+/!,'/)-0+&(&!P(&-')!()*+,%')!*(&(!

=3+! )3)! &+)31%(0')! *3+0(/! )+&! P(1-0(0')i! j/,13-&! )'1'! 1+)-'/+)! ,'/! >-)%'1'C2(!

,'/:-&.(0(! 0+! ]]G9! %-+.*')! 0+! )+C3-.-+/%'! 0+! DR! (8')9! +)%(/0(&-;(,-</! 0+!

(/(%'.2(!&+/(1!L*'&!+7+.*1'!(*1-,(/0'!1(!,1()-:-,(,-</!G4H4I4J4K4M!?!0+:-/-,-</!,1(&(!

0+!1')!,'/,+*%')!0+!1+)-</!&+)-03(1!?!&+,-0-P(4!b(.6-A/!=3+0(!*'&!0+:-/-&!,3(1!+)!1(!

.+7'&! .A%'0'! 0+! .'/-%'&-;(,-</! 0+! 1(! (61(,-</9! 1')! %-+.*')! ?! 1')! .A%'0')! 0+!

)+C3-.-+/%'! L&(0-'1<C-,')! ?h'! >-)%'*(%'1<C-,')M! 0+! )+C3-.-+/%'! *')%+&-'&4!

T-/(1.+/%+9! +/! 6()+! (! %'0'! 1'! (/%+&-'&.+/%+! +B*3+)%'9! ,'-/,-0-.')! ,'/! 1'!

+B*&+)(0'!*'&!k'&-/!?!J11(:i!JX/!=3+0(!.3,>'!%&(6(7'!*'&!>(,+&DF"4!

!

! !

Page 51: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! #D!

!"#$%&'&%&()"*+!!

1. Jemal, A. et al. Cancer statistics, 2008. CA Cancer J Clin 58, 71-96 (2008).

2. Thomas, A. A. & Campbell, S. C. Small renal masses: toward more rational treatment. Cleve Clin J Med 78, 539-547 (2011).

3. Eggener, S. E. et al. Renal tumors in young adults. J Urol 171, 106-110 (2004).

4. G. Joel DeCastro, J. M. M. Epidemiología, estatificación clínica y presentación del carcinoma de células renales. Urolgical clinics of north america 35, 581-592 (2008).

5. Ferlay, J. et al. Estimates of the cancer incidence and mortality in Europe in 2006. Ann Oncol 18, 581-592 (2007).

6. Anglada Curado, F. J. et al. [New epidemiologic patterns and risk factors in renal cancer]. Actas Urol Esp 33, 459-467 (2009).

7. Stafford, H. S. et al. Racial/ethnic and gender disparities in renal cell carcinoma incidence and survival. J Urol 179, 1704-1708 (2008).

8. Pascual, D. & Borque, A. Epidemiology of kidney cancer. Adv Urol 782381 (2008).

9. Kane, C. J., Mallin, K., Ritchey, J., Cooperberg, M. R. & Carroll, P. R. Renal cell cancer stage migration: analysis of the National Cancer Data Base. Cancer 113, 78-83 (2008).

10. Lee, C. T. et al. Surgical management of renal tumors 4 cm. or less in a contemporary cohort. J Urol 163, 730-736 (2000).

11. Woldrich, J. M., Mallin, K., Ritchey, J., Carroll, P. R. & Kane, C. J. Sex differences in renal cell cancer presentation and survival: an analysis of the National Cancer Database, 1993-2004. J Urol 179, 1709-13; discussion 1713 (2008).

12. Tsui, K. H. et al. Prognostic indicators for renal cell carcinoma: a multivariate analysis of 643 patients using the revised 1997 TNM staging criteria. J Urol 163, 1090-5; quiz 1295 (2000).

13. Patard, J. J., Rodriguez, A., Rioux-Leclercq, N., Guille, F. & Lobel, B. Prognostic significance of the mode of detection in renal tumours. BJU Int 90, 358-363 (2002).

14. Hollingsworth, J. M., Miller, D. C., Daignault, S. & Hollenbeck, B. K. Rising incidence of small renal masses: a need to reassess treatment effect. J Natl Cancer Inst 98, 1331-1334 (2006).

15. Welch, H. G., Schwartz, L. M. & Woloshin, S. Are increasing 5-year survival rates evidence of success against cancer? JAMA 283, 2975-2978 (2000).

Page 52: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! #E!

16. Chawla, S. N. et al. The natural history of observed enhancing renal masses: meta-analysis and review of the world literature. J Urol 175, 425-431 (2006).

17. Iriarte Soldevilla, J. I. et al. [Current treatment of small renal masses]. Actas Urol Esp 33, 505-513 (2009).

18. MichaelA.S.Jewett, A. Evolución natural de los tumores renales: fundamento teorico y papel de la vigilancia activa. Urological clinics of north america 35, 627-634 (2008).

19. Bosniak, M. A., Birnbaum, B. A., Krinsky, G. A. & Waisman, J. Small renal parenchymal neoplasms: further observations on growth. Radiology 197, 589-597 (1995).

20. Kouba, E., Smith, A., McRackan, D., Wallen, E. M. & Pruthi, R. S. Watchful waiting for solid renal masses: insight into the natural history and results of delayed intervention. J Urol 177, 466-70; discussion 470 (2007).

21. Jewett, M. A. et al. Active surveillance of small renal masses: progression patterns of early stage kidney cancer. Eur Urol 60, 39-44 (2011).

22. Kunkle, D. A., Crispen, P. L., Chen, D. Y., Greenberg, R. E. & Uzzo, R. G. Enhancing renal masses with zero net growth during active surveillance. J Urol 177, 849-53; discussion 853-4 (2007).

23. Frank, I. et al. Solid renal tumors: an analysis of pathological features related to tumor size. J Urol 170, 2217-2220 (2003).

24. Bach, A. M. & Zhang, J. Contemporary radiologic imaging of renal cortical tumors. Urol Clin North Am 35, 593-604; vi (2008).

25. Warshauer, D. M. et al. Detection of renal masses: sensitivities and specificities of excretory urography/linear tomography, US, and CT. Radiology 169, 363-365 (1988).

26. Jamis-Dow, C. A. et al. Small (< or = 3-cm) renal masses: detection with CT versus US and pathologic correlation. Radiology 198, 785-788 (1996).

27. Leveridge, M. J., Bostrom, P. J., Koulouris, G., Finelli, A. & Lawrentschuk, N. Imaging renal cell carcinoma with ultrasonography, CT and MRI. Nat Rev Urol 7, 311-325 (2010).

28. Bosniak, M. A. The current radiological approach to renal cysts. Radiology 158, 1-10 (1986).

29. Birnbaum, B. A., Maki, D. D., Chakraborty, D. P., Jacobs, J. E. & Babb, J. S. Renal cyst pseudoenhancement: evaluation with an anthropomorphic body CT phantom. Radiology 225, 83-90 (2002).

30. Israel, G. M. & Bosniak, M. A. How I do it: evaluating renal masses. Radiology 236, 441-450 (2005).

31. Israel, G. M. & Bosniak, M. A. Pitfalls in renal mass evaluation and how to avoid them. Radiographics 28, 1325-1338 (2008).

Page 53: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! #F!

32. Daniel, W. W. J., Hartman, G. W., Witten, D. M., Farrow, G. M. & Kelalis, P. P. Calcified renal masses. A review of ten years experience at the Mayo Clinic. Radiology 103, 503-508 (1972).

33. Israel, G. M. & Bosniak, M. A. Calcification in cystic renal masses: is it important in diagnosis? Radiology 226, 47-52 (2003).

34. Sherman, J. L. et al. Angiomyolipoma: computed tomographic-pathologic correlation of 17 cases. AJR Am J Roentgenol 137, 1221-1226 (1981).

35. Bosniak, M. A. Angiomyolipoma (hamartoma) of the kidney: a preoperative diagnosis is possible in virtually every case. Urol Radiol 3, 135-142 (1981).

36. D'Angelo, P. C., Gash, J. R., Horn, A. W. & Klein, F. A. Fat in renal cell carcinoma that lacks associated calcifications. AJR Am J Roentgenol 178, 931-932 (2002).

37. Choudhary, S., Rajesh, A., Mayer, N. J., Mulcahy, K. A. & Haroon, A. Renal oncocytoma: CT features cannot reliably distinguish oncocytoma from other renal neoplasms. Clin Radiol 64, 517-522 (2009).

38. Prasad, S. R., Surabhi, V. R., Menias, C. O., Raut, A. A. & Chintapalli, K. N. Benign renal neoplasms in adults: cross-sectional imaging findings. AJR Am J Roentgenol 190, 158-164 (2008).

39. Kim, J. K., Park, S. Y., Shon, J. H. & Cho, K. S. Angiomyolipoma with minimal fat: differentiation from renal cell carcinoma at biphasic helical CT. Radiology 230, 677-684 (2004).

40. Sheir, K. Z., El-Azab, M., Mosbah, A., El-Baz, M. & Shaaban, A. A. Differentiation of renal cell carcinoma subtypes by multislice computerized tomography. J Urol 174, 451-5; discussion 455 (2005).

41. Zhang, J. et al. Solid renal cortical tumors: differentiation with CT. Radiology 244, 494-504 (2007).

42. Bosniak, M. A. Problems in the radiologic diagnosis of renal parenchymal tumors. Urol Clin North Am 20, 217-230 (1993).

43. Warren, K. S. & McFarlane, J. The Bosniak classification of renal cystic masses. BJU Int 95, 939-942 (2005).

44. Bosniak, M. A. & Rofsky, N. M. Problems in the detection and characterization of small renal masses. Radiology 200, 286-287 (1996).

45. Scialpi, M. et al. Small renal masses: assessment of lesion characterization and vascularity on dynamic contrast-enhanced MR imaging with fat suppression. AJR Am J Roentgenol 175, 751-757 (2000).

46. Pretorius, E. S., Wickstrom, M. L. & Siegelman, E. S. MR imaging of renal neoplasms. Magn Reson Imaging Clin N Am 8, 813-836 (2000).

47. Semelka, R. C., Shoenut, J. P., Kroeker, M. A., MacMahon, R. G. & Greenberg, H. M. Renal lesions: controlled comparison between CT and 1.5-T MR imaging with

Page 54: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! #"!

nonenhanced and gadolinium-enhanced fat-suppressed spin-echo and breath-hold FLASH techniques. Radiology 182, 425-430 (1992).

48. Sadowski, E. A. et al. Nephrogenic systemic fibrosis: risk factors and incidence estimation. Radiology 243, 148-157 (2007).

49. Guzzo, T. J., Pierorazio, P. M., Schaeffer, E. M., Fishman, E. K. & Allaf, M. E. The accuracy of multidetector computerized tomography for evaluating tumor thrombus in patients with renal cell carcinoma. J Urol 181, 486-90; discussion 491 (2009).

50. Zhang, J. et al. Renal masses: characterization with diffusion-weighted MR imaging--a preliminary experience. Radiology 247, 458-464 (2008).

51. Raj, G. V. et al. Predicting the histology of renal masses using preoperative Doppler ultrasonography. J Urol 177, 53-58 (2007).

52. Kumada, T. et al. Assessment of tumor hemodynamics in small hepatocellular carcinoma: comparison of Doppler ultrasonography, angiography-assisted computed tomography, and pathological findings. Liver Int 24, 425-431 (2004).

53. Nicolau Molina, C. et al. [Usefulness of contrast-enhanced ultrasonography in daily clinical practice: a multicenter study in Spain]. Radiologia 52, 144-152 (2010).

54. Jakobsen, J. A., Oyen, R., Thomsen, H. S. & Morcos, S. K. Safety of ultrasound contrast agents. Eur Radiol 15, 941-945 (2005).

55. Claudon, M. et al. Guidelines and good clinical practice recommendations for contrast enhanced ultrasound (CEUS) - update 2008. Ultraschall Med 29, 28-44 (2008).

56. Filippone, A. et al. Color Doppler flow imaging of renal disease. Value of a new intravenous contrast agent: SH U 508 A (Levovist). Radiol Med 87, 50-58 (1994).

57. Kim, A. Y., Kim, S. H., Kim, Y. J. & Lee, I. H. Contrast-enhanced power Doppler sonography for the differentiation of cystic renal lesions: preliminary study. J Ultrasound Med 18, 581-588 (1999).

58. Correas, J. M., Claudon, M., Tranquart, F. & Helenon, O. [Contrast-enhanced ultrasonography: renal applications]. J Radiol 84, 2041-2054 (2003).

59. Tamai, H. et al. Contrast-enhanced ultrasonography in the diagnosis of solid renal tumors. J Ultrasound Med 24, 1635-1640 (2005).

60. Fan, L., Lianfang, D., Jinfang, X., Yijin, S. & Ying, W. Diagnostic efficacy of contrast-enhanced ultrasonography in solid renal parenchymal lesions with maximum diameters of 5 cm. J Ultrasound Med 27, 875-885 (2008).

61. Ignee, A. et al. The value of contrast enhanced ultrasound (CEUS) in the characterisation of patients with renal masses. Clin Hemorheol Microcirc 46, 275-290 (2010).

Page 55: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! ##!

62. Ignee, A., Straub, B., Schuessler, G. & Dietrich, C. F. Contrast enhanced ultrasound of renal masses. World J Radiol 2, 15-31 (2010).

63. Smaldone, M. C. et al. Small renal masses progressing to metastases under active surveillance: A systematic review and pooled analysis. Cancer (2011).

64. Huang, W. C., Elkin, E. B., Levey, A. S., Jang, T. L. & Russo, P. Partial nephrectomy versus radical nephrectomy in patients with small renal tumors--is there a difference in mortality and cardiovascular outcomes? J Urol 181, 55-61; discussion 61-2 (2009).

65. Campbell, S. C. et al. Guideline for management of the clinical T1 renal mass. J Urol 182, 1271-1279 (2009).

66. Leibovich, B. C. et al. Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy. J Urol 171, 1066-1070 (2004).

67. Dash, A. et al. Comparison of outcomes in elective partial vs radical nephrectomy for clear cell renal cell carcinoma of 4-7 cm. BJU Int 97, 939-945 (2006).

68. Gill, I. S. et al. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. J Urol 178, 41-46 (2007).

69. Crepel, M. et al. A population-based comparison of cancer-control rates between radical and partial nephrectomy for T1A renal cell carcinoma. Urology 76, 883-888 (2010).

70. Lau, W. K., Blute, M. L., Weaver, A. L., Torres, V. E. & Zincke, H. Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc 75, 1236-1242 (2000).

71. McKiernan, J., Simmons, R., Katz, J. & Russo, P. Natural history of chronic renal insufficiency after partial and radical nephrectomy. Urology 59, 816-820 (2002).

72. Huang, W. C. et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol 7, 735-740 (2006).

73. Kates, M., Badalato, G., Pitman, M. & McKiernan, J. Persistent overuse of radical nephrectomy in the elderly. Urology 78, 555-559 (2011).

74. Miller, D. C., Hollingsworth, J. M., Hafez, K. S., Daignault, S. & Hollenbeck, B. K. Partial nephrectomy for small renal masses: an emerging quality of care concern? J Urol 175, 853-7; discussion 858 (2006).

75. Lane, B. R. & Gill, I. S. 7-year oncological outcomes after laparoscopic and open partial nephrectomy. J Urol 183, 473-479 (2010).

76. Ljungberg, B. et al. EAU guidelines on renal cell carcinoma: the 2010 update. Eur Urol 58, 398-406 (2010).

Page 56: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! #W!

77. Gill, I. S., Aron, M., Gervais, D. A. & Jewett, M. A. Clinical practice. Small renal mass. N Engl J Med 362, 624-634 (2010).

78. Van Poppel, H. et al. A prospective randomized EORTC intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 51, 1606-1615 (2007).

79. Hafron, J. & Kaouk, J. H. Ablative techniques for the management of kidney cancer. Nat Clin Pract Urol 4, 261-269 (2007).

80. Zlotta, A. R. et al. Radiofrequency interstitial tumor ablation (RITA) is a possible new modality for treatment of renal cancer: ex vivo and in vivo experience. J Endourol 11, 251-258 (1997).

81. Estebanez Zarranz, J. et al. [Radiofrequency ablation of renal cell carcinoma]. Actas Urol Esp 33, 514-521 (2009).

82. Volpe, A. et al. Contemporary management of small renal masses. Eur Urol 60, 501-515 (2011).

83. Hsu, T. H., Fidler, M. E. & Gill, I. S. Radiofrequency ablation of the kidney: acute and chronic histology in porcine model. Urology 56, 872-875 (2000).

84. Matlaga, B. R., Zagoria, R. J., Woodruff, R. D., Torti, F. M. & Hall, M. C. Phase II trial of radio frequency ablation of renal cancer: evaluation of the kill zone. J Urol 168, 2401-2405 (2002).

85. Ogan, K. et al. Percutaneous radiofrequency ablation of renal tumors: technique, limitations, and morbidity. Urology 60, 954-958 (2002).

86. Arima, K. et al. Percutaneous radiofrequency ablation with transarterial embolization is useful for treatment of stage 1 renal cell carcinoma with surgical risk: results at 2-year mean follow up. Int J Urol 14, 585-90; discussion 590 (2007).

87. Gervais, D. A., McGovern, F. J., Arellano, R. S., McDougal, W. S. & Mueller, P. R. Radiofrequency ablation of renal cell carcinoma: part 1, Indications, results, and role in patient management over a 6-year period and ablation of 100 tumors. AJR Am J Roentgenol 185, 64-71 (2005).

88. Goldberg, S. N. et al. Percutaneous radiofrequency tissue ablation: does perfusion-mediated tissue cooling limit coagulation necrosis? J Vasc Interv Radiol 9, 101-111 (1998).

89. Zagoria, R. J. Imaging of small renal masses: a medical success story. AJR Am J Roentgenol 175, 945-955 (2000).

90. Venkatesan, A. M., Wood, B. J. & Gervais, D. A. Percutaneous ablation in the kidney. Radiology 261, 375-391 (2011).

91. McDougal, W. S. Radiofrequency ablation of renal cell carcinoma. BJU Int 99, 1271-1272 (2007).

Page 57: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! #Z!

92. Weizer, A. Z. et al. Complications after percutaneous radiofrequency ablation of renal tumors. Urology 66, 1176-1180 (2005).

93. Baker, M., Anderson, J. K., Jaffer, O., Trimmer, C. & Cadeddu, J. A. Pain after percutaneous radiofrequency ablation of renal tumors. J Endourol 21, 606-609 (2007).

94. Gill, I. S. et al. Laparoscopic and percutaneous radiofrequency ablation of the kidney: acute and chronic porcine study. Urology 56, 197-200 (2000).

95. Maybody, M. & Solomon, S. B. Image-guided percutaneous cryoablation of renal tumors. Tech Vasc Interv Radiol 10, 140-148 (2007).

96. Lyrdal, D., Andersson, M., Hellstrom, M., Sternal, J. & Lundstam, S. Ultrasound-guided percutaneous radiofrequency ablation of small renal tumors: Clinical results and radiological evolution during follow-up. Acta Radiol 51, 808-818 (2010).

97. Veltri, A. et al. Percutaneous RF thermal ablation of renal tumors: is US guidance really less favorable than other imaging guidance techniques? Cardiovasc Intervent Radiol 32, 76-85 (2009).

98. McGahan, J. P. et al. Pretreatment imaging can be used to select imaging guidance, ultrasound alone versus CT plus ultrasound, for percutaneous renal radiofrequency ablation. AJR Am J Roentgenol 197, 1244-1250 (2011).

99. Boss, A., Clasen, S., Kuczyk, M., Schick, F. & Pereira, P. L. Image-guided radiofrequency ablation of renal cell carcinoma. Eur Radiol 17, 725-733 (2007).

100. Crowley, J. D. et al. Laparoscopic and computed tomography-guided percutaneous radiofrequency ablation of renal tissue: acute and chronic effects in an animal model. Urology 57, 976-980 (2001).

101. Ferakis, N., Bouropoulos, C., Granitsas, T., Mylona, S. & Poulias, I. Long-term results after computed-tomography-guided percutaneous radiofrequency ablation for small renal tumors. J Endourol 24, 1909-1913 (2010).

102. Boss, A. et al. Magnetic resonance-guided percutaneous radiofrequency ablation of renal cell carcinomas: a pilot clinical study. Invest Radiol 40, 583-590 (2005).

103. Zhao, X. et al. Improved outcome of percutaneous radiofrequency ablation in renal cell carcinoma: a retrospective study of intraoperative contrast-enhanced ultrasonography in 73 patients. Abdom Imaging (2011).

104. Levey, A. S. et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 139, 137-147 (2003).

105. Otero, A., de Francisco, A., Gayoso, P. & Garcia, F. Prevalence of chronic renal disease in Spain: results of the EPIRCE study. Nefrologia 30, 78-86 (2010).

106. Sarnak, M. J. et al. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical

Page 58: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! #[!

Cardiology, and Epidemiology and Prevention. Hypertension 42, 1050-1065 (2003).

107. Go, A. S., Chertow, G. M., Fan, D., McCulloch, C. E. & Hsu, C. Y. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 351, 1296-1305 (2004).

108. Weight, C. J. et al. Nephrectomy induced chronic renal insufficiency is associated with increased risk of cardiovascular death and death from any cause in patients with localized cT1b renal masses. J Urol 183, 1317-1323 (2010).

109. Van Poppel, H. et al. Treatment of localised renal cell carcinoma. Eur Urol 60, 662-672 (2011).

110. Lucas, S. M. et al. Renal function outcomes in patients treated for renal masses smaller than 4 cm by ablative and extirpative techniques. J Urol 179, 75-9; discussion 79-80 (2008).

111. Altunrende, F. et al. Image guided percutaneous probe ablation for renal tumors in 65 solitary kidneys: functional and oncological outcomes. J Urol 186, 35-41 (2011).

112. Dominguez-Escrig, J. L., Sahadevan, K. & Johnson, P. Cryoablation for small renal masses. Adv Urol 479495 (2008).

113. Klahr, S. The modification of diet in renal disease study. N Engl J Med 320, 864-866 (1989).

114. Roos, F. C., Hampel, C. & Thuroff, J. W. Renal cancer surgery in the elderly. Curr Opin Urol 19, 459-464 (2009).

115. Raman, J. D. et al. Renal functional outcomes for tumours in a solitary kidney managed by ablative or extirpative techniques. BJU Int 105, 496-500 (2010).

116. Young, E. E., Castle, S. M., Gorbatiy, V. & Leveillee, R. J. Comparison of safety, renal function outcomes and efficacy of laparoscopic and percutaneous radio frequency ablation of renal masses. J Urol 187, 1177-1182 (2012).

117. Turna, B. et al. Minimally invasive nephron sparing management for renal tumors in solitary kidneys. J Urol 182, 2150-2157 (2009).

118. Takaki, H. et al. Midterm results of radiofrequency ablation versus nephrectomy for T1a renal cell carcinoma. Jpn J Radiol 28, 460-468 (2010).

119. Faddegon, S. & Cadeddu, J. A. Does renal mass ablation provide adequate long-term oncologic control? Urol Clin North Am 39, 181-90, vi (2012).

120. McDougal, W. S., Gervais, D. A., McGovern, F. J. & Mueller, P. R. Long-term followup of patients with renal cell carcinoma treated with radio frequency ablation with curative intent. J Urol 174, 61-63 (2005).

121. Zagoria, R. J. et al. Oncologic efficacy of CT-guided percutaneous radiofrequency ablation of renal cell carcinomas. AJR Am J Roentgenol 189, 429-436 (2007).

Page 59: Manejo de las Lesiones Renales Menores de 4 Centímetros ... · Manejo de las Lesiones Renales Menores de 4 Centímetros ... ... 2012). !

! #S!

122. Tracy, C. R., Raman, J. D., Donnally, C., Trimmer, C. K. & Cadeddu, J. A. Durable oncologic outcomes after radiofrequency ablation: experience from treating 243 small renal masses over 7.5 years. Cancer 116, 3135-3142 (2010).

123. Breen, D. J. et al. Management of renal tumors by image-guided radiofrequency ablation: experience in 105 tumors. Cardiovasc Intervent Radiol 30, 936-942 (2007).

124. Gervais, D. A., Arellano, R. S., McGovern, F. J., McDougal, W. S. & Mueller, P. R. Radiofrequency ablation of renal cell carcinoma: part 2, Lessons learned with ablation of 100 tumors. AJR Am J Roentgenol 185, 72-80 (2005).

125. Kutikov, A. & Uzzo, R. G. The R.E.N.A.L. nephrometry score: a comprehensive standardized system for quantitating renal tumor size, location and depth. J Urol 182, 844-853 (2009).

126. Ficarra, V. et al. Preoperative aspects and dimensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing surgery. Eur Urol 56, 786-793 (2009).

127. Canter, D. et al. Utility of the R.E.N.A.L. nephrometry scoring system in objectifying treatment decision-making of the enhancing renal mass. Urology 78, 1089-1094 (2011).

128. Simhan, J. et al. Objective measures of renal mass anatomic complexity predict rates of major complications following partial nephrectomy. Eur Urol 60, 724-730 (2011).

129. Reyes, J. et al. Thermal ablation of the small renal mass: Case selection using the R.E.N.A.L-Nephrometry Score. Urol Oncol (2012).

130. Stern, J. M. et al. Intermediate comparison of partial nephrectomy and radiofrequency ablation for clinical T1a renal tumours. BJU Int 100, 287-290 (2007).

131. Olweny, E. O. et al. Radiofrequency ablation versus partial nephrectomy in patients with solitary clinical T1a renal cell carcinoma: comparable oncologic outcomes at a minimum of 5 years of follow-up. Eur Urol 61, 1156-1161 (2012).

132. Kunkle, D. A., Egleston, B. L. & Uzzo, R. G. Excise, ablate or observe: the small renal mass dilemma--a meta-analysis and review. J Urol 179, 1227-33; discussion 1233-4 (2008).

133. Johnson, D. B., Duchene, D. A., Taylor, G. D., Pearle, M. S. & Cadeddu, J. A. Contrast-enhanced ultrasound evaluation of radiofrequency ablation of the kidney: reliable imaging of the thermolesion. J Endourol 19, 248-252 (2005).

134. Gorin, M. A. & Allaf, M. E. Kidney cancer: Radiofrequency ablation of small renal masses--more work required. Nat Rev Urol 9, 297-298 (2012).

!