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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 -
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 -
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 -
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 -
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 -
Frontiers in Oncology 2023This study aims to perform a pooled analysis to compare the outcomes of robot-assisted partial nephrectomy (RAPN) between complex tumors (hilar, endophytic, or cystic)...
Perioperative, oncologic, and functional outcomes of robot-assisted partial nephrectomy for special types of renal tumors (hilar, endophytic, or cystic): an evidence-based analysis of comparative outcomes.
PURPOSE
This study aims to perform a pooled analysis to compare the outcomes of robot-assisted partial nephrectomy (RAPN) between complex tumors (hilar, endophytic, or cystic) and non-complex tumors (nonhilar, exophytic, or solid) and evaluate the effects of renal tumor complexity on outcomes in patients undergoing RAPN.
METHODS
Four databases were systematically searched, including Science, PubMed, Web of Science, and Cochrane Library, to identify relevant studies published in English up to December 2022. Review Manager 5.4 was used for statistical analyses and calculations. The study was registered with PROSPERO (Registration number: CRD42023394792).
RESULTS
In total, 14 comparative trials, including 3758 patients were enrolled. Compared to non-complex tumors, complex tumors were associated with a significantly longer warm ischemia time (WMD 3.67 min, 95% CI 1.78, 5.57; p = 0.0001), more blood loss (WMD 22.84 mL, 95% CI 2.31, 43.37; p = 0.03), and a higher rate of major complications (OR 2.35, 95% CI 1.50, 3.67; p = 0.0002). However, no statistically significant differences were found between the two groups in operative time, length of stay, transfusion rates, conversion to open nephrectomy and radical nephrectomy rates, estimated glomerular filtration rate (eGFR) decline, intraoperative complication, overall complication, positive surgical margins (PSM), local recurrence, and trifecta achievement.
CONCLUSIONS
RAPN can be a safe and effective procedure for complex tumors (hilar, endophytic, or cystic) and provides comparable functional and oncologic outcomes to non-complex tumors.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=394792, identifier CRD42023394792.
PubMed: 37152053
DOI: 10.3389/fonc.2023.1178592 -
Cancers Nov 2023We aimed to analyze the influence of near-infrared fluorescence (NIRF) using indocyanine green (ICG) with standard robot-assisted partial nephrectomy (RAPN) in patients... (Review)
Review
BACKGROUND
We aimed to analyze the influence of near-infrared fluorescence (NIRF) using indocyanine green (ICG) with standard robot-assisted partial nephrectomy (RAPN) in patients with a kidney tumor (KT).
METHODS
We performed a literature search on 12 September 2023 through PubMed, EMBASE, and Scopus. The analysis included observational studies that examined the perioperative and long-term outcomes of patients with a KT who underwent RAPN with NIRF.
RESULTS
Overall, eight prospective studies, involving 535 patients, were eligible for this meta-analysis, with 212 participants in the ICG group and 323 in the No ICG group. For warm ischemia time, the ICG group showed a lower duration (weighted Mean difference (WMD) = -2.05, 95% confidence interval (CI) = -3.30--0.80, = 0.011). The postoperative eGFR also favored the ICG group (WMD = 7.67, 95% CI = 2.88-12.46, = 0.002). No difference emerged for the other perioperative outcomes between the two groups. In terms of oncological radicality, the positive surgical margins and tumor recurrence rates were similar among the two groups.
CONCLUSIONS
Our meta-analysis showed that NIRF with ICG during RAPN yields a favorable impact on functional outcomes, whereas it exerts no such influence on oncological aspects. Therefore, NIRF should be adopted when preserving nephron function is a paramount concern.
PubMed: 38067266
DOI: 10.3390/cancers15235560 -
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