-
European Urology Oncology Dec 2018Management of locally recurrent renal cancer is complex. (Review)
Review
CONTEXT
Management of locally recurrent renal cancer is complex.
OBJECTIVE
In this systematic review we analyse the available literature on the management of local renal cancer recurrence.
EVIDENCE ACQUISITION
A systematic search (PubMed, Web of Science, CINAHL, Clinical Trials, and Scopus) of English literature from 2000 to 2017 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.
EVIDENCE SYNTHESIS
The search identified 1838 articles. Of those, 36 were included in the evidence synthesis. The majority of the studies identified were retrospective and not controlled. Local recurrence after thermal ablation (TA) may be managed with repeat TA. Alternatively, salvage nephrectomy is possible. However, a higher rate of complications should be expected than after primary nephrectomy. Salvage nephrectomy and TA represent treatment options for local recurrence after partial nephrectomy. Local retroperitoneal recurrence after radical nephrectomy is ideally treated with surgical resection, for which minimally invasive approaches might be applicable to select patients. For large recurrences, addition of intraoperative radiation may improve local control. Local tumour destruction appears to be more beneficial than systemic therapy alone for local recurrences.
CONCLUSIONS
Management of local renal cancer relapse varies according to the clinical course and prior treatments. The available data are mainly limited to noncontrolled retrospective series. After nephron-sparing treatment, TA represents an effective treatment with low morbidity. For local recurrence after radical nephrectomy, the low-level evidence available suggests superiority of surgical excision relative to systemic therapy or best supportive care. As a consequence, surgery should be prioritised when feasible and applicable.
PATIENT SUMMARY
In renal cell cancer, the occurrence and management of local recurrence depend on the initial treatment. This cancer is a disease with a highly variable clinical course. After initial organ-sparing treatment, thermal ablation offers good cancer control and low rates of complications. For recurrence after radical nephrectomy, surgical excision seems to provide the best long-term cancer control and it is superior to medical therapy alone.
Topics: Carcinoma, Renal Cell; Humans; Kidney Neoplasms; Neoplasm Recurrence, Local; Nephrectomy; Organ Sparing Treatments; Prognosis; Salvage Therapy
PubMed: 31158097
DOI: 10.1016/j.euo.2018.06.007 -
Urologic Oncology Mar 2023This systematic review and meta-analysis aimed to evaluate the postoperative renal and cardiovascular outcomes of partial nephrectomy (PN) versus radical nephrectomy... (Meta-Analysis)
Meta-Analysis Review
This systematic review and meta-analysis aimed to evaluate the postoperative renal and cardiovascular outcomes of partial nephrectomy (PN) versus radical nephrectomy (RN) for the treatment of renal carcinoma. A systematic literature search was performed on scientific databases including Scopus, Web of Science, MEDLINE, and EMBASE from their inception to September 2021. Studies comparing renal and cardiovascular outcomes between PN and RN in patients with renal cancer were included. The generic inverse variance method with random-effects models was used to determine the pooled hazard ratios and odds ratio for each outcome. Quality Assessment for observational studies was guided by the New-Castle Ottawa Scale. Overall, a total of 31 studies (n=51,866) reported renal outcomes, while 11 studies (n= 101,678) reported cardiovascular outcomes. When compared to PN, RN had a higher rate of new-onset postoperative EGFR <60 mL/min/1.73 m (HR 3.39; CI 2.45 - 4.70; I=93%; P=<0.00001) and EGFR <45 mL/min/1.73 m (HR 4.70; CI 2.26 - 9.79; I=98%; P=<0.0001). No difference was observed in new-onset advanced kidney disease and end-stage renal disease. A 19% reduction in cardiovascular events was observed in the PN group (HR 0.81; CI 0.70 - 0.93, P=0.002). No protective effect of PN was observed in new-onset or worsening hypertension (HR 0.85; CI 0.64 - 1.14, P=0.28) nor myocardial infarction (HR 0.86; CI 0.71 - 1.04, P=0.13). PN was associated with a decreased risk of postoperative early-stage CKD and cardiovascular events compared with RN. However, no benefit of PN over RN was observed in advanced CKD, new-onset or worsening hypertension, myocardial infarction, and cardiovascular mortality.
Topics: Humans; Kidney Neoplasms; Nephrectomy; Carcinoma, Renal Cell; Hypertension; Kidney Failure, Chronic; Myocardial Infarction; ErbB Receptors; Retrospective Studies; Treatment Outcome; Glomerular Filtration Rate
PubMed: 36642639
DOI: 10.1016/j.urolonc.2022.11.024 -
Annals of Surgical Oncology Aug 2017The aim of this study was to assess the outcomes of minimally invasive (laparoscopic and robotic) partial nephrectomy (MIPN) for large renal masses. (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The aim of this study was to assess the outcomes of minimally invasive (laparoscopic and robotic) partial nephrectomy (MIPN) for large renal masses.
MATERIALS AND METHODS
A systematic literature review was performed up to September 2016 using multiple search engines to identify studies comparing MIPN for tumors larger than 4 cm (>cT1a) with MIPN for tumors smaller than 4 cm (cT1a). The preferred reporting items for systematic reviews and meta-analyses (PRISMA) criteria were used for article selection. Baseline demographics and surgical, functional, and oncological parameters were extracted from the included studies whenever available. An overall analysis including all studies was performed, then sensitivity analyses were performed for studies on laparoscopic partial nephrectomy (PN) only, and, finally, for studies on robotic PN only.
RESULTS
Overall, 13 case-control studies comparing the outcomes of PN in tumors <4 cm (n = 4441) with those of PN for tumors >4 cm (n = 1024) were included. Warm ischemia time was shorter for the <4 cm group [weighted mean difference (WMD) 3.75 min; 95% confidence interval (CI) -6.4 to -0.7; p = 0.01] and the odds of perioperative complications was lower [odds ratio (OR) 0.62; 95% CI 0.5-0.8; p < 0.001]. There were no significant differences in terms of postoperative estimated glomerular filtration rate (WMD 4.2 ml/min; 95% CI 0.45-8.97; p = 0.08), as well as onset of postoperative chronic kidney disease (risk ratio 0.71; 95% CI 0.48-1.04; p = 0.08). In addition, no difference was found in the likelihood of positive surgical margins (OR 0.74; 95% CI 0.43-1.28; p = 0.29).
CONCLUSIONS
MIPN represents a viable treatment option for renal masses larger than 4 cm (higher than cT1a) as it offers good functional outcomes, without increased risk of positive surgical margins. An increased rate of complications should be taken into account when approaching these tumors.
Topics: Humans; Kidney Neoplasms; Laparoscopy; Nephrectomy; Postoperative Complications; Robotic Surgical Procedures; Treatment Outcome
PubMed: 28303428
DOI: 10.1245/s10434-017-5831-5 -
European Journal of Surgical Oncology :... Sep 2019ablative techniques have been increasing as an alternative to surgical approaches, especially in patients who are unfit for surgery. This study was performed to compare... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
ablative techniques have been increasing as an alternative to surgical approaches, especially in patients who are unfit for surgery. This study was performed to compare oncologic and functional outcomes after partial nephrectomy (PN) and ablation for treating clinical T1a renal masses.
METHODS
An electronic search was completed on the basis of PubMed, Embase and Cochrane Central Register of Controlled Trials. Studies comparing partial nephrectomy versus ablative therapies in patients with small renal masses were enrolled.
RESULTS
Twenty articles incorporating 5,011 patients were eligible for the present meta-analysis. Perioperative complications were fewer in the ablation group than in the PN group (OR = 0.76; 95%CI, 0.60-0.97; P = 0.025), but ablation group was associated with increased risk of local recurrence (OR = 1.88; 95%CI, 1.29-2.72; P = 0.001) and lower OS (HR = 1.53; 95% CI, 1.16-2.00; P = 0.002). CSS and DFS were comparable in two groups. Decline of renal function at 6-month follow up was lower in ablation than PN (WMD = 3.32; 95% CI, 0.04-6.60; P = 0.047). Beside, ablation had a trend towards lower reduction of renal function of long-term follow up (WMD = 3.06; 95% CI, -2.13-8.25; P = 0.247).
CONCLUSION
Compared to PN, ablation may have a significantly lower OS and higher local recurrence rates in selected patients, while CSS and DFS were comparable between the two treatments. On the other hand, ablation had a significantly decreased risk of perioperative complication and the potential advantage of long-term renal function preservation. More large randomized controlled trials are needed further to enhance the evidence of ablation in patients with small renal tumors. We believe that ablation is an attractive addition to the urologist's treatment options for small renal masses.
Topics: Ablation Techniques; Humans; Kidney Neoplasms; Neoplasm Grading; Nephrectomy
PubMed: 31171480
DOI: 10.1016/j.ejso.2019.05.010 -
Frontiers in Oncology 2021The choice of surgical method for clinically diagnosed T2 or higher stage kidney cancer remains controversial. Here, we systematically reviewed and collected published...
OBJECTIVE
The choice of surgical method for clinically diagnosed T2 or higher stage kidney cancer remains controversial. Here, we systematically reviewed and collected published comparative studies on renal function, oncologic outcomes, and perioperative results of partial nephrectomy (PN) versus radical nephrectomy (RN) for larger renal tumors (T2 and above), and performed a meta-analysis.
EVIDENCE ACQUISITION
Following searches of PubMed, Web of Science, and Embase, the original studies on PN vs. RN in the treatment of T2 renal cancer were screened through strict inclusion and exclusion criteria. RevMan 5.4 was used for data analysis of the perioperative results, renal function, and oncologic outcomes of the two surgical methods for T2 renal tumor therapy. The weighted mean difference was used as the combined effect size for continuous variables, while the odds ratio (OR) or risk ratio (RR) was used as the combined effect size for binary variables. Both variables used a 95% confidence interval (CI) to estimate statistical accuracy. In cases with low heterogeneity, the fixed-effects model was used to pool the estimated value; otherwise, the random-effects model was used when significant heterogeneity was detected.
RESULTS
Fifteen retrospective studies including 5,056 patients who underwent nephrectomy (PN: 1975, RN: 3081) were included. The decline in estimated GFR (eGFR) after PN was lower than RN [(MD: -11.74 ml/min/1.73 m; 95% CI: -13.15, -10.32; p < 0.00001)]. The postoperative complication rate of PN was higher than that of PN (OR: 2.09; 95% CI: 1.56, 2.80; p < 0.00001)], and the postoperative overall survival (OS) of PN was higher than that of RN (HR: 0.77; 95% CI: 0.65, 0.90; p = 0.002), and tumor recurrence (RR, 0.69; 95% CI: 0.53, 0.90; p = 0.007). No obvious publication bias was found in the funnel chart of the OS rates of the two groups of patients.
CONCLUSIONS
PN is beneficial for patients with T2 renal tumors in terms of OS and renal function protection. However, it is also associated with a higher risk of surgical complications.
PubMed: 34178668
DOI: 10.3389/fonc.2021.680842 -
Urologia May 2019The debate on the pros and cons of robot-assisted partial nephrectomy performed with (on-clamp) or without (off-clamp) renal artery clamping is ongoing. The aim of this... (Comparative Study)
Comparative Study Meta-Analysis
BACKGROUND
The debate on the pros and cons of robot-assisted partial nephrectomy performed with (on-clamp) or without (off-clamp) renal artery clamping is ongoing. The aim of this meta-analysis is to summarize the available evidence on the comparative studies assessing the outcomes of these two approaches.
MATERIAL AND METHODS
A systematic review of the literature on PubMed, ScienceDirect, and Embase was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (PRISMA). Only comparative and case-control studies were submitted to full-text assessment and meta-analysis. RevMan 5.3 software was used.
RESULTS
From the initial retrieval of 1937 studies, 15 fulfilling inclusion criteria were selected and provided 2075 patients for analysis (702 off-clamp, 1373 on-clamp). Baseline tumor's features showed a significant difference in size (weighted mean difference: -0.58 cm; 95% confidence interval: [-1.06, -0.10]; p = 0.02) and R.E.N.A.L. score (weighted mean difference: -0.53; 95% confidence interval: [-0.81, -0.25]; p = 0.0002), but not in the exophytic property, the location, and the PADUA score. Pooled analysis revealed shorter operative time (p = 0.02) and higher estimated blood loss (p = 0.0002) for the off-clamp group. Overall complication and transfusion rates were similar, while higher major complication rate was observed in the on-clamp approach (5.6% vs 1.9%, p = 0.03). No differences in oncological outcomes were found. Finally, functional outcomes (assessed by estimated glomerular filtration rate at early postoperative, 3 month, 6 month, and last available follow-up) were not statistically different.
CONCLUSION
This meta-analysis shows that off-clamp robot-assisted partial nephrectomy is reserved to smaller renal masses. Under such conditions, no differences with the on-clamp approach emerged.
Topics: Case-Control Studies; Constriction; Humans; Nephrectomy; Renal Artery; Robotic Surgical Procedures; Surgical Instruments
PubMed: 31179885
DOI: 10.1177/0391560319847847 -
European Urology Oct 2015On-clamp partial nephrectomy (PN) has been considered the standard approach to minimize intraoperative bleeding and thus achieve adequate control of tumor margins. The... (Review)
Review
CONTEXT
On-clamp partial nephrectomy (PN) has been considered the standard approach to minimize intraoperative bleeding and thus achieve adequate control of tumor margins. The potential negative impact of ischemia on renal function (RF) led to the development of techniques to minimize or avoid renal ischemia, such as off-clamp PN and minimally ischemic PN techniques.
OBJECTIVE
To review current evidence on the indications and techniques for and outcomes of minimally ischemic and off-clamp PN.
EVIDENCE ACQUISITION
A systematic review of English-language publications on PN without a main renal artery clamp from January 2005 to July 2014 was performed using the Medline, Embase, and Web of Science databases.
EVIDENCE SYNTHESIS
The searches retrieved 52 papers. Off-clamp PN has been more commonly applied to small and peripheral renal tumors, while minimally ischemic PN is best suited for hilar and medially located renal tumors. These approaches are associated with increased intraoperative blood loss and perioperative transfusion rates compared to on-clamp PN. Minimally ischemic and off-clamp PN have potential functional benefits when longer ischemia time is anticipated, particularly for patients with lower baseline RF. Limitations include the lack of prospective randomized trials comparing minimally ischemic and off-clamp to on-clamp techniques, and the small sample size and short follow-up of most published series. The impact of different resection and renorrhaphy techniques on postoperative RF and its assessment via renal scintigraphy requires further investigations.
CONCLUSIONS
Minimally ischemic and off-clamp PN are established procedures that may be particularly applicable for patients with decreased baseline RF. However, these techniques are technically demanding, with potential for increased blood loss, and require considerable experience with PN surgery. The role of ischemia in patients with a contralateral healthy kidney and consequently an indication for elective minimally ischemic or off-clamp PN remains a debatable issue.
PATIENT SUMMARY
In this review we analyzed available evidence on minimally ischemic and off-clamp partial nephrectomy. These techniques, although technically demanding, may be particularly applicable for patients with decreased baseline renal function.
Topics: Blood Loss, Surgical; Constriction; Embolization, Therapeutic; Humans; Ischemia; Kidney Neoplasms; Nephrectomy; Postoperative Complications; Renal Artery; Renal Circulation; Risk Factors; Treatment Outcome
PubMed: 25922273
DOI: 10.1016/j.eururo.2015.04.020 -
Asian Journal of Urology Oct 2023Robot-assisted partial nephrectomy (RAPN) has become widely used for treatment of renal cell carcinoma and it is expanding in the field of complex renal masses. The aim... (Review)
Review
A systematic review of robot-assisted partial nephrectomy outcomes for advanced indications: Large tumors (cT2-T3), solitary kidney, completely endophytic, hilar, recurrent, and multiple renal tumors.
OBJECTIVE
Robot-assisted partial nephrectomy (RAPN) has become widely used for treatment of renal cell carcinoma and it is expanding in the field of complex renal masses. The aim of this systematic review was to analyze outcomes of RAPN for completely endophytic renal masses, large tumors (cT2-T3), renal cell carcinoma in solitary kidney, recurrent tumors, completely endophytic and hilar masses, and simultaneous and multiple tumors.
METHODS
A comprehensive search in the PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials databases was performed in December 2022 for English language papers. The primary endpoint was to evaluate the role of RAPN in the setting of each category of complex renal masses considered. The secondary endpoint was to evaluate the surgical and functional outcomes.
RESULTS
After screening 1250 records, 43 full-text manuscripts were selected, comprising over 8500 patients. Twelve and thirteen studies reported data for endophytic and hilar renal masses, respectively. Five and three studies reported outcomes for cT2-T3 and solitary kidney patients, respectively. Four studies focused on redo-RAPN for recurrent tumors. Two studies investigated simultaneous bilateral renal masses and five reports focused on multiple tumor excision in ipsilateral kidney.
CONCLUSION
Over the past decade, evidence supporting the use of RAPN for the most challenging nephron-sparing surgery indications has continuously grown. Although limitations remain including study design and lack of detailed long-term functional and oncological outcomes, the adoption of RAPN for the included advanced indications is associated with favorable surgical outcomes with good preservation of renal function without compromising the oncological result. Certainly, a higher likelihood of complication might be expected when facing extremely challenging cases. However, none of these indications should be considered an exclusion criterion for performing RAPN. Ultimately, a risk-adapted approach should be employed.
PubMed: 38024426
DOI: 10.1016/j.ajur.2023.06.001 -
European Urology Open Science Dec 2023The superiority of off-clamp robot-assisted partial nephrectomy (RAPN) over the on-clamp technique has recently been questioned by randomized controlled trials comparing... (Review)
Review
Off-clamp Versus On-clamp Robot-assisted Partial Nephrectomy: A Systematic Review and Quantitative Synthesis by the European Association of Urology Young Academic Urologists Renal Cancer Study Group.
CONTEXT
The superiority of off-clamp robot-assisted partial nephrectomy (RAPN) over the on-clamp technique has recently been questioned by randomized controlled trials comparing the two techniques.
OBJECTIVE
To systematically review the recent literature and perform a quantitative synthesis of data on the comparison of off-clamp versus off-clamp hilar control during RAPN.
EVIDENCE ACQUISITION
A systematic search was performed in the PubMed, Embase, Web of Science, and Scopus databases for studies comparing off-clamp versus on-clamp RAPN in terms of perioperative and functional outcomes. The study protocol was registered in the PROSPERO database (CRD42023413160). Only prospective randomized controlled trials and retrospective matched observational studies were included. The primary outcome of the study was the percentage decrease in the estimated glomerular filtration rate (eGFR).
EVIDENCE SYNTHESIS
A total of 11 studies were included involving a total of 2483 patients (944 patients in the off-clamp and 1539 patients in the on-clamp group). There was no difference between the two groups in the percentage decline in eGFR (mean difference [MD] 0.04%, 95% confidence interval [CI] -3.7% to 3.86%; = 0.98). There were so significant differences between the groups for length of hospital stay ( = 0.56), complications ( = 0.08), conversion to open or radical surgery ( = 0.18), estimated blood loss ( = 0.06), or need for blood transfusion ( = 0.07). The operative time was shorter in the off-clamp group (MD-21.89 min, 95% CI -42.5 to -1.27; = 0.04) but after sensitivity analysis the difference was no longer statistically significant ( = 0.15). The positive surgical margin rate was significantly lower in the off-clamp group (odds ratio 0.6, 95% CI 0.39-0.91; = 0.02).
CONCLUSIONS
Our review revealed no clinically relevant differences in perioperative and functional outcomes between off-clamp and on-clamp RAPN.
PATIENT SUMMARY
In this review, we compared the two methods of controlling the kidney blood vessels during robot-assisted surgery to remove part of the kidney. We noted that there was no difference between the two groups for outcomes such as complications and the decrease in kidney function after surgery.
PubMed: 38028236
DOI: 10.1016/j.euros.2023.10.001 -
Frontiers in Surgery 2023Studies have shown that remote ischemic conditioning (RIC) can effectively attenuate ischemic-reperfusion injury in the heart and brain, but the effect on... (Review)
Review
OBJECTIVE
Studies have shown that remote ischemic conditioning (RIC) can effectively attenuate ischemic-reperfusion injury in the heart and brain, but the effect on ischemic-reperfusion injury in patients with kidney transplantation or partial nephrectomy remains controversial. The main objective of this systematic review and meta-analysis was to investigate whether RIC provides renal protection after renal ischemia-reperfusion injury in patients undergoing kidney transplantation or partial nephrectomy.
METHODS
A computer-based search was conducted to retrieve relevant publications from the PubMed database, Embase database, Cochrane Library and Web of Science database. We then conducted a systematic review and meta-analysis of randomized controlled trials that met our study inclusion criteria.
RESULTS
Eleven eligible studies included a total of 1,145 patients with kidney transplantation or partial nephrectomy for systematic review and meta-analysis, among whom 576 patients were randomly assigned to the RIC group and the remaining 569 to the control group. The 3-month estimated glomerular filtration rate (eGFR) was improved in the RIC group, which was statistically significant between the two groups on kidney transplantation [< 0.001; mean difference (MD) = 2.74, confidence interval (CI): 1.41 to 4.06; = 14%], and the 1- and 2-day postoperative Scr levels in the RIC group decreased, which was statistically significant between the two groups on kidney transplantation (1-day postoperative: < 0.001; MD = 0.10, CI: 0.05 to 0.15, = 0; 2-day postoperative: = 0.006; MD = 0.41, CI: 0.12 to 0.70, = 0), but at other times, there was no significant difference between the two groups in Scr levels. The incidence of delayed graft function (DGF) decreased, but there was no significant difference (= 0.60; 95% CI: 0.67 to 1.26). There was no significant difference between the two groups in terms of cross-clamp time, cold ischemia time, warm ischemic time, acute rejection (AR), graft loss or length of hospital stay.
CONCLUSION
Our meta-analysis showed that the effect of remote ischemia conditioning on reducing serum creatinine (Scr) and improving estimate glomerular filtration rate (eGFR) seemed to be very weak, and we did not observe a significant protective effect of RIC on renal ischemic-reperfusion. Due to small sample sizes, more studies using stricter inclusion criteria are needed to elucidate the nephroprotective effect of RIC in renal surgery in the future.
PubMed: 37091267
DOI: 10.3389/fsurg.2023.1024650