Comparison of the long-term follow-up and perioperative outcomes of partial nephrectomy and radical nephrectomy for 4 cm to 7 cm renal cell carcinoma: a systematic review and meta-analysis.
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ABSTRACT: Background
The efficacy of partial nephrectomy (PN) for T1b renal cell carcinoma (RCC) is controversial. The oncological outcomes, the change in postoperative renal function and the perioperative complications are unclear.Methods
We searched PUBMED, EMBASE and the Cochrane Central Register for studies from March 1998 to March 2018 for studies comparing PN to radical nephrectomy (RN) for the treatment of T1b RCC. After data extraction and quality assessment, we used RevMan 5.2 to pool the data. Then, we used Stata 12.0 to perform sensitivity analyses and meta-regression. We used the GRADE profiler to evaluate the evidence according to the GRADE approach.Results
A total of 16 studies involving 33,117 patients were included in our meta-analysis. No significant difference was found in the 5-year overall survival (OS), 10-year OS, 5-year recurrence-free survival (RFS) and 10-year RFS. The 5-year cancer-special survival (CSS) and 10-year CSS were better in RN compared to PN, respectively, at RR = 1.02, P < 0.05 and RR = 1.04, P < 0.05. PN was better than RN in the preservation of renal function (WMD = -9.15, 95% CI: - 10.30 to - 7.99, P < 0.05). The confidence level grading of the evidence was moderate for 5-year OS, 10-year OS, 5-year CSS, 10-year CSS, 5-year RFS, 10-year RFS, tumor recurrence, decline in eGFR, and postoperative complications.Conclusions
PN may provide comparable outcomes in terms of RFS & OS, and better renal function preservation although CSS was worse.
SUBMITTER: Jiang YL
PROVIDER: S-EPMC6554915 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundThere is limited and controversial evidence on the prognosis of partial nephrectomy (PN) versus radical nephrectomy (RN) in patients with T3aN0/xM0 renal cell carcinoma (RCC) upstaged from clinical T1 RCC. In this study, we aimed to assess the prognosis difference following PN versus RN in patients with ≤7 cm T3aN0/xM0 RCC.MethodsFrom the Surveillance, Epidemiology, and End Results database, a total of 3196 patients receiving treatment of PN/RN for ≤7 cm T3aN0/xM0 RCC with only extrarenal fat extension in 2010-2017 were identified. An inverse probability of treatment weighting (IPTW)-adjusted cause-specific Cox model with hazard ratio (HR) and 95% confidence interval (CI) was used for overall survival (OS) and cancer-specific survival (CSS) analyses. Sensitivity analysis was based on the propensity score matching of PN and RN groups and from the dataset of 2010-2013.ResultsA total of 872 patients underwent PN, compared with 2324 undergoing RN. After IPTW adjustment, there was no significant difference in preoperative baseline characteristics between the PN and RN cohorts. Patients who underwent RN had worse OS (HRIPTW-adjusted , 1.46; 95% CI, 1.16-1.84; p = 0.001) and comparable CSS (HRIPTW-adjusted , 1.03; 95% CI, 0.64-1.66; p = 0.890) than those receiving PN in all cohorts and subgroups with T3a RCC of ≤4 cm and perinephric fat extension. Further, in patients with 4-7 cm T3a RCC with perinephric-fat invasion and all sizes of T3a RCC with sinus/perisinus fat extension, PN led to comparable OS and CSS. Sensitivity analyses validated these results.ConclusionPN provides comparable CSS and OS or even better OS than RN for patients with RCC ≤7 cm T3aN0/xM0. Although our study has some limitations, our results indicated that PN might oncologically safe for clinical T1 RCC, even confirmed a pathologically T3a upstaging post-PN.
| S-EPMC8683550 | biostudies-literature
Project description:This study aimed to compare the cancer-specific survival (CSS) and overall survival (OS) of nephrectomized patients with non-metastatic renal cell carcinoma (nmRCC) and local recurrence without distant metastasis (LR group), those with metastasis without local recurrence (MET group), and those with both local recurrence and metastasis (BOTH group). This retrospective multicenter study included 464 curatively nephrectomized patients with nmRCC and disease recurrence between 2000 and 2012; the follow-up period was until 2017. After adjusting for significant clinicopathological factors using Cox proportional hazard models, CSS and OS were compared between the MET (n = 50, 10.7%), BOTH (n = 95, 20.5%), and LR (n = 319, 68.8%) groups. The CSS and OS rates were 34.7 and 6.5% after a median follow-up of 43.9 months, respectively. After adjusting for significant prognostic factors of OS and CSS, the MET group had hazard ratios (HRs) of 0.51 and 0.57 for OS and CSS (p = 0.039 and 0.103), respectively, whereas the BOTH group had HRs of 0.51 and 0.60 for OS and CSS (p < 0.05), respectively; LR was taken as a reference. The 2-year OS and CSS rates from the date of nephrectomy and disease recurrence were 86.9% and 88.9% and 63.5% and 67.8%, respectively, for the LR group; 89.5% and 89.5% and 48.06% and 52.43%, respectively, for the MET group; and 96.8% and 96.8% and 86.6% and 82.6%, respectively, for the BOTH group. Only the LR and BOTH groups had significant differences in the 2-year OS and CSS rates (p < 0.05). In conclusion, our study showed that the LR group had worse survival prognoses than any other group in nephrectomized patients with nmRCC.
| S-EPMC8273547 | biostudies-literature
Project description:BackgroundPartial nephrectomy and radical nephrectomy are the relevant surgical therapy options for localised renal cell carcinoma. However, debate regarding the effects of these surgical approaches continues and it is important to identify and summarise high-quality studies to make surgical treatment recommendations.ObjectivesTo assess the effects of partial nephrectomy compared with radical nephrectomy for clinically localised renal cell carcinoma.Search methodsWe searched CENTRAL, MEDLINE, PubMed, Embase, Web of Science, BIOSIS, LILACS, Scopus, two trial registries and abstracts from three major conferences to 24 February 2017, together with reference lists; and contacted selected experts in the field.Selection criteriaWe included a randomised controlled trial comparing partial and radical nephrectomy for participants with small renal masses.Data collection and analysisOne review author screened all of the titles and abstracts; only citations that were clearly irrelevant were excluded at this stage. Next, two review authors independently assessed full-text reports, identified relevant studies, evaluated the eligibility of the studies for inclusion, assessed trial quality and extracted data. The update of the literature search was performed by two independent review authors. We used Review Manager 5 for data synthesis and data analyses.Main resultsWe identified one randomised controlled trial including 541 participants that compared partial nephrectomy to radical nephrectomy. The median follow-up was 9.3 years.Based on low quality evidence, we found that time-to-death of any cause was decreased using partial nephrectomy (HR 1.50, 95% CI 1.03 to 2.18). This corresponds to 79 more deaths (5 more to 173 more) per 1000. Also based on low quality evidence, we found no difference in serious adverse events (RR 2.04, 95% CI 0.19 to 22.34). Findings are consistent with 4 more surgery-related deaths (3 fewer to 78 more) per 1000.Based on low quality evidence, we found no difference in time-to-recurrence (HR 1.37, 95% CI 0.58 to 3.24). This corresponds to 12 more recurrences (14 fewer to 70 more) per 1000. Due to the nature of reporting, we were unable to analyse overall rates for immediate and long-term adverse events. We found no evidence on haemodialysis or quality of life.Reasons for downgrading related to study limitations (lack of blinding, cross-over), imprecision and indirectness (a substantial proportion of patients were ultimately found not to have a malignant tumour). Based on the finding of a single trial, we were unable to conduct any subgroup or sensitivity analyses.Authors' conclusionsPartial nephrectomy may be associated with a decreased time-to-death of any cause. With regards to surgery-related mortality, cancer-specific survival and time-to-recurrence, partial nephrectomy appears to result in little to no difference.
| S-EPMC6481491 | biostudies-literature
Project description:BackgroundAim of this study was to evaluate and compare perioperative outcomes of transperitoneal (TP) and retroperitoneal (TR) approaches in a multi-institutional cohort of minimally invasive partial nephrectomy (MI-PN).Material and methodsAll consecutive patients undergone MI-PN for clinical T1 renal tumors at 26 Italian centers (RECORd2 project) between 01/2013 and 12/2016 were evaluated, collecting the pre-, intra-, and postoperative data. The patients were then stratified according to the surgical approach, TP or RP. A 1:1 propensity score (PS) matching was performed to obtain homogeneous cohorts, considering the age, gender, baseline eGFR, surgical indication, clinical diameter, and PADUA score.Results1669 patients treated with MI-PN were included in the study, 1256 and 413 undergoing TP and RP, respectively. After 1:1 PS matching according to the surgical access, 413 patients were selected from TP group to be compared with the 413 RP patients. Concerning intraoperative variables, no differences were found between the two groups in terms of surgical approach (lap/robot), extirpative technique (enucleation vs standard PN), hilar clamping, and ischemia time. Conversely, the TP group recorded a shorter median operative time in comparison with the RP group (115 vs 150 min), with a higher occurrence of intraoperative overall, 21 (5.0%) vs 9 (2.1%); p = 0.03, and surgical complications, 18 (4.3%) vs 7 (1.7%); p = 0.04. Concerning postoperative variables, the two groups resulted comparable in terms of complications, positive surgical margins and renal function, even if the RP group recorded a shorter median drainage duration and hospital length of stay (3 vs 2 for both variables), p < 0.0001.ConclusionsThe results of this study suggest that both TP and RP are feasible approaches when performing MI-PN, irrespectively from tumor location or surgical complexity. Notwithstanding longer operative times, RP seems to have a slighter intraoperative complication rate with earlier postoperative recovery when compared with TP.
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Project description:ObjectiveTo determine if there is a difference in proceeding to CKD between patients who had undergone radical nephrectomy (RN) and simple nephrectomy (SN) for different indications by comparing the short- and long-term renal function.Materials and methodsWe retrospectively analyzed the records of all patients who underwent nephrectomy (either for malign or benign indications) in our clinic between January 2007 and September 2017. The patients were divided into 2 groups according the type of surgery: 1) Radical nephrectomy Group, 2) Simple Nephrectomy Group. Renal function was evaluated with Glomerular Filtration Rate (GFR) calculated using the MDRD formula.ResultsA total of 276 patients were included in the study. There were 202 patients in RN Group and 74 patients in SN Group. The mean age of the patients in RN Group and SN Group were age 59,2 ± 11,5 and 49,9 ± 15,1 years, respectively (p = 0.001). GFR levels of patients in RN Group versus SN Group were as follows: Preoperative period: 84.9 vs. 81 mL/min/1.73 m2; postoperative 1st day: 60.5 vs. 84.4 mL/min/1.73 m2, postoperative 1st month 58.9 vs. 76 mL/min/1.73 m2, postoperative 1st year: 59.5 vs. 74.1 mL/min/1.73 m2; at last control 60.3 and 76.1 mL/min/1.73 m2. While preoperative GFR was found to be similar in two groups (p = 0.26), postoperative GFR values were found to be significantly lower in Group RN (p < 0.001). In comparison of the decrease in GFR in two groups at last follow-up, significantly higher decrease was observed in RN Group, 29% vs. 6%, (p < 0.05).ConclusionThe decrease in GFR exists more common and intensive after RN compared to SN. In long-term, compensation mechanisms that develop after sudden nephron loss like radical nephrectomy deteriorates kidney function more than gradual nephron loss as in benign etiologies which indicates simple nephrectomy.
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Project description:To compare outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) in patients 65 years and older.Our institutional renal mass registry was queried for patients 65 and older with solitary cT1-T2 renal mass resected by PN or RN. Clinicopathologic features and perioperative outcomes were compared between groups. Renal function outcomes measured by change in estimated glomerular filtration rate (eGFR) and freedom from eGFR< 45?mL/min/1.73?m2 were analyzed. Multivariate Cox proportional hazard models for overall survival and cancer-specific survival were analyzed.Overall, 787 patients met inclusion criteria. Of these, 437 (55.5%) underwent PN and 350 (44.5%) underwent RN. Median follow-up was 36 months. Patients in the PN cohort were younger (median age 70.3 years vs 71.9 years, P?<?.001), had lower American Society of Anesthesiologists scores (2.6 vs 2.8, P?=?.001), smaller tumors (tumor diameter 2.8 cm vs 5.0?cm, P?<?.001), and lower proportion of renal cell carcinoma (76.7% vs 87.4%, P?<?.001). Perioperative outcomes were similar between PN and RN groups as were complications (37.8% vs 38.9%). Estimated change in eGFR was less in PN vs RN (6.4 vs 19.7, P?<?.001) at last follow-up. Overall survival and cancer-specific survival were equivalent between modalities.Because the renal functional benefit of PN is realized over many years and the procedure has a higher historical complication rate than RN, some suspected elderly patients might benefit more from RN over PN. However, these data suggest that elderly patients are not harmed and may potentially benefit from PN. Age alone should not be a contraindication to nephron-sparing surgery.
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Project description:BackgroundWith the establishment of minimally invasive surgery in society, the robot has been increasingly widely used in the urologic field, including in partial nephrectomy. This study aimed to comprehensively summarize the currently available evidence on the feasibility and safety of robotic partial nephrectomy for renal tumors of >4 cm.Method and findingsAn electronic database search of PubMed, Scopus, Web of Science, and the Cochrane Library was performed. This systematic review and meta-analysis was based on all relevant studies that assessed robotic partial nephrectomy for renal tumors of >4 cm. Five studies were included. The meta-analysis involved 3 studies from 11 institutions including 154 patients, while the narrative review involved the remaining 2 studies from 5 institutions including 64 patients. In the meta-analysis, the mean ischemic time, operation time, and console time was 28, 319, and 189 minutes, respectively. The estimated blood loss and length of stay was 317 ml and 3.8 days, respectively. The rates of conversion, positive margins, intraoperative complications, postoperative complications, hilar clamping, and collecting system repair were 7.0%, 3.5%, 7.0%, 9.8%, 93.9%, and 47.5%, respectively. The narrative review showed results similar to those of the meta-analysis.ConclusionsRobotic partial nephrectomy is feasible and safe for renal tumors of >4 cm with an acceptable warm ischemic time, positive margin rate, conversion rate, complication rate, operation time, estimated blood loss, and length of stay.
| S-EPMC3792962 | biostudies-literature
Project description:The comparative effectiveness of partial nephrectomy versus radical nephrectomy to preserve kidney function has not been well established. We determined the risk of clinically significant (stage 4 and higher) CKD after radical or partial nephrectomy among veterans treated for kidney cancer in the Veterans Health Administration (2001-2013). Among patients with preoperative eGFR≥30 ml/min per 1.73 m2, the incidence of CKD stage 4 or higher after radical (n=9759) or partial nephrectomy (n=4370) was 7.9% overall. The median time to stage 4 or higher CKD after surgery was 5 months, after which few patients progressed. In propensity score-matched cohorts, partial nephrectomy associated with a significantly lower relative risk of incident CKD stage 4 or higher (hazard ratio, 0.34; 95% confidence interval [95% CI], 0.26 to 0.43, versus radical nephrectomy). In a parallel analysis of patients with normal or near-normal preoperative kidney function (eGFR≥60 ml/min per 1.73 m2), partial nephrectomy was also associated with a significantly lower relative risk of incident CKD stage 3b or higher (hazard ratio, 0.15; 95% CI, 0.11 to 0.19, versus radical nephrectomy) in propensity score-matched cohorts. Competing risk regression models produced consistent results. Finally, patients treated with a partial nephrectomy had reduced risk of mortality (hazard ratio, 0.55; 95% CI, 0.49 to 0.62). In conclusion, compared with radical nephrectomy, partial nephrectomy was associated with a marked reduction in the incidence of clinically significant CKD and with enhanced survival. Postoperative decline in kidney function occurred mainly in the first year after surgery and appeared stable over time.
| S-EPMC5748903 | biostudies-literature
Project description:Background:Despite randomized data demonstrating better overall survival favoring radical nephrectomy, partial nephrectomy continues to be the treatment of choice for low-stage renal cell carcinoma. Methods:We utilized the National Cancer Database to identify patients younger than 50 years diagnosed with low-stage renal cell carcinoma (cT1) treated with radical nephrectomy or partial nephrectomy (2004-2007). Inverse probability of treatment weighting adjustment was performed for all preoperative factors to account for confounding factors. Kaplan-Meier curves and Cox proportional hazards regression analyses were used to compare overall survival of patients in the two treatment arms. Sensitivity analysis was performed to explore the interaction of type of surgery and clinical stage on overall survival. Results:Among the 3009 patients (median age = 44 years [interquartile range (IQR) = 40-47 years]), 2454 patients (81.6%) were treated with radical nephrectomy and 555 patients (18.4%) with partial nephrectomy. The median follow-up was 108.6 months (IQR = 80.2-124.3 months) during which 297 patients (12.1%) in the radical nephrectomy arm and 58 patients (10.5%) in the partial nephrectomy arm died. Following inverse probability of treatment weighting adjustment, there was no difference in overall survival between patients treated with partial nephrectomy and radical nephrectomy (hazard ratio = 0.83, 95% confidence interval = 0.63 to 1.10, P = .196). There were no statistically significant interactions between type of surgery and clinical stage on treatment outcome. Conclusions:There was no difference in long-term overall survival between radical and partial nephrectomy in young and healthy patients. This patient cohort may have sufficient renal reserve over their lifetime, and preserving nephrons by partial nephrectomy may be unnecessary.
| S-EPMC6649692 | biostudies-other
Project description:ObjectivesWe aimed to report the latest and largest pooled analysis and evidence update to compare the perioperative, renal functional, and oncological outcomes between off-clamp and on-clamp robot-assisted partial nephrectomy (RAPN) for renal tumors.Patients and methodsWe performed a systematic literature search using PubMed, Embase, and Web of Science up to August 2021 for studies that compared the efficacy and/or safety between off-clamp and on-clamp RAPN for renal tumors. Outcomes measured were operating time, estimated blood loss (EBL), conversion rate, length of stay (LOS), complication rate, transfusion rate, long-term % decrease in estimated glomerular filtration rate (eGFR), positive surgical margin rate, and recurrence rate.ResultsA total of 21 eligible articles involving 4,493 patients (1,274 off-clamp versus 3,219 on-clamp) were included for the evidence synthesis. Baseline characteristics of the two groups were similar in all outcomes except that lower R.E.N.A.L. score and smaller tumor size were observed in the off-clamp group. Pooled analysis showed shorter operative time, higher EBL, and lower complication rate in the off-clamp group. No significant difference was observed in the conversion rate, LOS, and transfusion rate. The recurrence rates were similar in the two groups, while a lower positive surgical margin rate was observed in the off-clamp group. Finally, the off-clamp group had a superior postoperative renal functional outcome.ConclusionsGiven the presence of heterogeneity and potential bias, urologists should select the clamp strategy based on their experience and patient-specific factors.
| S-EPMC8490928 | biostudies-literature