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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 -
World Journal of Urology Sep 2022To systematically review the published literature on surgical margins as a risk factor for local recurrence (LR) in patients undergoing partial nephrectomy (PN) for pT1... (Review)
Review
PURPOSE
To systematically review the published literature on surgical margins as a risk factor for local recurrence (LR) in patients undergoing partial nephrectomy (PN) for pT1 renal cell carcinomas (RCC).
EVIDENCE ACQUISITION
A systematic literature search of relevant databases (MEDLINE, Embase and the Cochrane Library) was performed according to the PRISMA criteria up to February 2022. The hypothesis was developed using the PPO method (Patients = patients with pT1 RCC undergoing PN, Prognostic factor = positive surgical margins (PSM) detected on final pathology versus negative surgical margins (NSM) and Outcome = LR diagnosed on follow-up imaging). The primary outcome was the rate of PSM and LR. The risk of bias was assessed by the QUIPS tool.
EVIDENCE SYNTHESIS
After assessing 1525 abstracts and 409 full-text articles, eight studies met the inclusion criteria. The percentage of PSM ranged between 0 and 34.3%. In these patients with PSM, LR varied between 0 and 9.1%, whereas only 0-1.5% of LR were found in the NSM-group. The calculated odds ratio (95% confident intervals) varied between 0.04 [0.00-0.79] and 0.27 [0.01-4.76] and was statistically significant in two studies (0.14 [0.02-0.80] and 0.04 [0.00-0.79]). The quality analysis of the included studies resulted in an overall intermediate to high risk of bias and the level of evidence was overall very low. A meta-analysis was considered unsuitable due to the high heterogeneity between the included studies.
CONCLUSION
PSM after PN in patients with pT1 RCC is associated with a higher risk of LR. However, the evidence has significant limitations and caution should be taken with the interpretation of this data.
Topics: Carcinoma, Renal Cell; Humans; Kidney Neoplasms; Margins of Excision; Neoplasm Recurrence, Local; Nephrectomy; Prognosis; Retrospective Studies; Treatment Outcome
PubMed: 35503118
DOI: 10.1007/s00345-022-04016-0 -
The International Journal of Medical... Feb 2019To compare perioperative outcomes of robotic-assisted partial nephrectomy (RaPN) with open partial nephrectomy (OPN). (Meta-Analysis)
Meta-Analysis
OBJECTIVES
To compare perioperative outcomes of robotic-assisted partial nephrectomy (RaPN) with open partial nephrectomy (OPN).
METHODS
Systematically search through PubMed, Embase, ClinicalKey, Cochrane Library, ProQuest, ScienceDirect, Web of Science, and ClinicalTrials.gov for eligible studies was performed to April 11, 2018. A meta-analysis was conducted for studies comparing RaPN and OPN. Confounding variables were assessed by meta-regression or subgroup analysis.
RESULTS
This study included 34 studies with 60 808 patients. Meta-analysis revealed less blood loss, less transfusion, longer operative time, less postoperative complications, lower readmission rate, shorter length of stay, and less estimated glomerular filtration rate (eGFR) decline in RaPN groups. The superiority of RaPN in blood loss was attenuated with highly complex renal masses. The superiority of RaPN in intraoperative complications was strengthened with renal hilar control. The advantage of RaPN in surgical margin was increased in patient with body mass index (BMI) < 28.
CONCLUSIONS
Compared with OPN, RaPN provided lower morbidities and better renal function preservation.
Topics: Aged; Databases, Factual; Female; Glomerular Filtration Rate; Humans; Intraoperative Complications; Kidney Neoplasms; Male; Margins of Excision; Middle Aged; Minimally Invasive Surgical Procedures; Nephrectomy; Operative Time; Patient Readmission; Regression Analysis; Reproducibility of Results; Robotic Surgical Procedures
PubMed: 30265760
DOI: 10.1002/rcs.1963 -
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 -
Medicine Nov 2018Robot-assisted partial nephrectomy (RPN) and focal therapy (FT) have both been successfully employed in the management of small renal masses. However, despite this being... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Robot-assisted partial nephrectomy (RPN) and focal therapy (FT) have both been successfully employed in the management of small renal masses. However, despite this being the era of minimally invasive surgery, few comparative studies exist on RPN and FT. The aim of our study is to review perioperative, renal functional and oncologic outcomes of FT and RPN in cT1 renal masses.
METHODS
Literature published in Medline, EMBASE, and Cochrane Library databases up to April 22, 2018, was systematically searched. We included literature comparing outcomes of FT (radiofrequency ablation, cryoablation, microwave ablation, and irreversible electroporation) and RPN. Studies that reported only on laparoscopic partial nephrectomy or open partial nephrectomy, and review articles, editorials, letters, or cost analyses were excluded. In total, data from 1166 patients were included.
RESULTS
From 858 total articles, 7 nonrandomized, observational studies were included. Compared with RPN, FT was associated with a significantly lower decrease of estimated glomerular filtration rate (weighted mean difference [WMD] -8.06 mL/min/1.73 m; confidence interval [CI] -15.85 to -0.26; P = .04), and lower estimated blood loss (WMD -49.61 mL; CI -60.78 to -38.45; P < .001). However, patients who underwent FT had a significantly increased risk of local recurrence (risk ratio [RR] 9.89; CI 4.24-23.04; P < .001) and distant metastasis (RR 6.42; CI 1.70-24.33; P = .006). However, operative times, lengths of stay, and complication rates were revealed to be similar between FT and RPN.
CONCLUSION
RPN has a substantial advantage in preventing cancer recurrence. However, in the era of minimally invasive surgery, FT has advantages in renal function preservation and less bleeding. Long-term follow-up for survival rates and comparative analysis of microwave ablation and irreversible electroporation are needed to extend FT for patients with significant morbidities and for those who need sufficient renal function preservation with minimal bleeding.
Topics: Ablation Techniques; Electrochemotherapy; Glomerular Filtration Rate; Humans; Kidney; Kidney Neoplasms; Length of Stay; Neoplasm Recurrence, Local; Nephrectomy; Operative Time; Postoperative Complications; Robotic Surgical Procedures; Survival Rate; Treatment Outcome
PubMed: 30407321
DOI: 10.1097/MD.0000000000013102 -
European Urology Sep 2014A standardised system to report outcomes and complications of urologic procedures has recently been proposed by an ad hoc European Association of Urology (EAU)... (Review)
Review
CONTEXT
A standardised system to report outcomes and complications of urologic procedures has recently been proposed by an ad hoc European Association of Urology (EAU) Guidelines panel. To date, no studies have used these criteria to evaluate the quality of reports of outcomes and complications after partial nephrectomy (PN).
OBJECTIVE
To address the quality of reporting of PN complications.
DESIGN, SETTING, AND PARTICIPANTS
A systematic review of papers reporting outcomes of PN was conducted through the electronic search of databases, including Medline, PubMed, Embase, Scopus, and the Cochrane Database of Systematic Reviews.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
Analysis was carried out on structured forms. The quality criteria that the EAU Working Group proposed for reporting complications were recorded for each paper, and adherence to the Martin criteria was assessed.
RESULTS AND LIMITATIONS
Standardised criteria to report and grade complications were used in 71 out of 204 evaluable studies (34.8%). Only six studies (2.9%) fulfilled all criteria that the EAU Guidelines Office ad hoc panel proposed. The mean number did not change significantly by time or by surgical approach used. The most underreported criteria (in <50% of the studies) were who collected the data (18.6%), whether he or she were involved in the treatment (13.7%), duration of follow-up (47.1%), mortality data and causes of death (33.8%), definition of procedure-specific complications (39.2), separate reporting of intra- and postoperative complications (45.1%), complication severity or grade (32.4%), risk factors analysis (44.1%), readmission rates (12.7%), and percentage of patients lost to follow-up (6.9%). The mean number fulfilled was 6.5 ± 2.9 (mean plus or minus standard deviation) and did not change significantly by time or by surgical approach used.
CONCLUSIONS
The only way to improve the quality of the surgical scientific literature and to allow sound comparisons among different approaches, especially with the lack of randomised trials, is the use of more rigorous methodology than the one recently proposed to report outcomes and complications.
PATIENT SUMMARY
A rigorous methodology is mandatory when surgeons report about complications after surgery. Otherwise, the rate of adverse events is underestimated.
Topics: Guidelines as Topic; Humans; Nephrectomy; Outcome Assessment, Health Care; Quality Indicators, Health Care; Research Design
PubMed: 24576502
DOI: 10.1016/j.eururo.2014.02.004 -
Urologia Internationalis 2015To analyze current evidence comparing the safety and outcomes of regional and global ischemia for partial nephrectomy (PN). (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To analyze current evidence comparing the safety and outcomes of regional and global ischemia for partial nephrectomy (PN).
MATERIALS AND METHODS
A systematic search of the PubMed and Web of Science databases was conducted in May 2014 to identify studies comparing the safety and outcomes of regional and global ischemia for PN. A systematic review and meta-analysis was also performed.
RESULTS
Six retrospective observational studies were selected for the analysis, including 363 patients who underwent PN (162 regional ischemia and 201 global ischemia cases). Operation times were not statistically different [weighted mean difference (WMD) = 20.35 min, 95% CI: -0.28-40.97, p = 0.05], but estimated blood loss was significantly higher in the regional ischemia group (WMD = 52.04 ml, 95% CI: 14.30-89.78, p = 0.007) than in the global ischemia group. Complication rates [odds ratio (OR) = 1.16; 95% CI: 0.63-2.15, p = 0.63] and blood transfusion rates (OR = 1.85; 95% CI: 0.86-4.01, p = 0.12) of the two groups were not significantly different. The regional ischemia group showed better postoperative renal function (WMD = 4.23 ml/min, 95% CI: 2.61-5.85, p < 0.00001) than the global ischemia group, and all cases in the regional ischemia group showed negative margins.
CONCLUSIONS
Regional ischemia is as safe to perform as global ischemia, and the former leads to better postoperative renal functions than the latter. These findings support the application of regional ischemia for PN.
Topics: Blood Loss, Surgical; Blood Transfusion; Bloodless Medical and Surgical Procedures; Chi-Square Distribution; Humans; Nephrectomy; Odds Ratio; Operative Time; Reperfusion Injury; Risk Factors; Time Factors; Treatment Outcome; Warm Ischemia
PubMed: 25427979
DOI: 10.1159/000367997 -
Urologic Oncology Jul 2022To assess the differential clinical outcomes of patients treated with partial nephrectomy (PN) vs. those treated with ablation therapy (AT) such as radiofrequency... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To assess the differential clinical outcomes of patients treated with partial nephrectomy (PN) vs. those treated with ablation therapy (AT) such as radiofrequency ablation, cryoablation and microwave ablation for cT1b compared to cT1a renal tumors.
MATERIALS AND METHODS
Multiple databases were searched for articles published before August 2021. Studies were deemed eligible if they compared clinical outcomes in patients who underwent PN with those who underwent AT for cT1a and/or cT1b renal tumors.
RESULTS
Overall, 27 studies comprising 13,996 patients were eligible for this meta-analysis. In both cT1a and cT1b renal tumors, there was no significant difference in the percent decline of estimated glomerular filtration rates or in the overall/severe complication rates between PN and AT. Compared to AT, PN was associated with a lower risk of local recurrence in both patients with cT1a and cT1b tumors (cT1a: pooled risk ratio [RR]; 0.43, 95% confidence intervals [CI]; 0.28-0.66, cT1b: pooled RR; 0.41, 95%CI; 0.23-0.75). Subgroup analyses regarding the technical approach revealed no statistical difference in local recurrence rates between percutaneous AT and PN in patients with cT1a tumors (pooled RR; 0.61, 95%CI; 0.32-1.15). In cT1b, however, PN was associated with a lower risk of local recurrence (pooled RR; 0.45, 95%CI; 0.23-0.88). There was no difference in distant metastasis or cancer mortality rates between PN and AT in patients with cT1a, or cT1b tumors.
CONCLUSIONS
AT has a substantially relevant disadvantage with regards to local recurrence compared to PN, particularly in cT1b renal tumors. Despite the limitations inherent to the nature of retrospective and unmatched primary cohorts, percutaneous AT could be used as a reasonable alternative treatment for well-selected patients with cT1a renal tumors.
Topics: Carcinoma, Renal Cell; Humans; Kidney Neoplasms; Neoplasm Staging; Nephrectomy; Retrospective Studies; Treatment Outcome
PubMed: 35562311
DOI: 10.1016/j.urolonc.2022.04.002 -
Minerva Urologica E Nefrologica = the... Oct 2019This manuscript is a review of current studies and conducts a meta-analysis on the topic of partial nephrectomy (PN) and radical nephrectomy (RN) in larger renal tumors... (Comparative Study)
Comparative Study Meta-Analysis
INTRODUCTION
This manuscript is a review of current studies and conducts a meta-analysis on the topic of partial nephrectomy (PN) and radical nephrectomy (RN) in larger renal tumors (cT2 and greater).
EVIDENCE ACQUISITION
A systematic research of PubMed, Ovid, Scopus (up to January 2019), and reference lists was performed to identify eligible comparative studies. All studies comparing PN with RN for cT2 or greater renal tumors were included. The quality of the included trials was assessed and the data were extracted independently by two reviewers. Statistical analyses were performed using the Cochrane Collaboration's Review Manager (RevMan) 5.3 software.
EVIDENCE SYNTHESIS
Overall, 11 retrospective cohort studies including 19,281 patients (PN 1,146; RN 18,135) were included in the analysis. The tumor size was likely smaller in PN compared with RN (WMD -0.85 cm; P=0.05). Lower estimated blood loss (EBL) was found for RN (WMD 100.44 mL; P<0.001). The length of hospital stay was longer for PN (WMD 1.07 days; P=0.002). There was a higher likelihood of postoperative complications for PN (RR 1.96; P<0.001). PN was associated with better postoperative renal function (eGFR; WMD 7.31 mL/min/1.73 m2; P<0.001), and lower decline in eGFR (WMD -9.00 mL/min/1.73 m2; P<0.001). The positive margins were more common in PN (RR 4.19; P=0.003). The PN group might be non-inferior to RN for tumor recurrence (RR 0.57; P<0.001), tumor-specific mortality (RR 0.58; P=0.007), and all-cause mortality (RR 0.78; P=0.004).
CONCLUSIONS
PN shows a feasible, safe and viable treatment option for larger renal tumors because it provides better preservation of kidney function and non-inferior survival. However, PN in patients with stage T2 or greater renal masses should be more selective, because of higher complications.
Topics: Humans; Kidney Neoplasms; Margins of Excision; Nephrectomy; Postoperative Complications
PubMed: 31287256
DOI: 10.23736/S0393-2249.19.03470-2 -
Minerva Urologica E Nefrologica = the... Apr 2019Robot-assisted partial nephrectomy (RAPN) is increasingly used for the surgical management of renal masses. Aim of this study was to analyze the available literature... (Comparative Study)
Comparative Study
INTRODUCTION
Robot-assisted partial nephrectomy (RAPN) is increasingly used for the surgical management of renal masses. Aim of this study was to analyze the available literature regarding the outcomes of RAPN compared to those of open partial nephrectomy (OPN).
EVIDENCE ACQUISITION
A literature search was performed up to October 2018 using PubMed, MEDLINE and Embase. Article selection followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) principles and Population, Intervention, Comparator, Outcomes (PICO) methodology was used. Population (P) was patients with renal masses who underwent RAPN (I). RAPN was compared with OPN (C). Outcomes of interest were perioperative, oncological and functional outcomes of both surgical procedures (O). Inclusion criteria were: randomized controlled studies andobservational cohort studies comparing RAPN versus OPN, which reported at least one outcome of interest.
EVIDENCE SYNTHESIS
Twenty-two manuscripts met our inclusion criteria and were included in the systematic review. RAPN was superior to OPN in terms of complication rate in 11 studies while similar results were observed in 9 studies. Positive surgical margins were similar in 13 studies while RAPN had lower surgical margins in 6 studies. Operative and warm ischemia times were longer in OPN in 13 and 10 studies, respectively. Seventeen and 19 studies showed that estimated blood loss and length of hospital stay were higher in RAPN. Estimated glomerular filtration rate decline and chronic kidney disease upstaging decline were similar in the majority of studies.
CONCLUSIONS
Current evidence demonstrate that RAPN is a reasonable alternative to OPN with regard to oncological and early functional outcomes with a straightforward advantage of improved perioperative morbidity, as expected by minimally invasive techniques. Nevertheless, there is still a great need for well-designed randomized studies with an extended follow-up.
Topics: Humans; Kidney Neoplasms; Nephrectomy; Robotic Surgical Procedures; Treatment Outcome
PubMed: 30895768
DOI: 10.23736/S0393-2249.19.03391-5