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Urologic Oncology Apr 2019We conducted a meta-analysis to evaluate the efficiency and safety of partial nephrectomy (PN) compared with radical nephrectomy (RN) for large (≥7 cm) renal tumors. A... (Meta-Analysis)
Meta-Analysis
We conducted a meta-analysis to evaluate the efficiency and safety of partial nephrectomy (PN) compared with radical nephrectomy (RN) for large (≥7 cm) renal tumors. A comprehensive literature search with no restrictions on language or region was conducted from August up to October in 2018 in the electronic databases of PubMed, EMBASE, the Cochrane Library, and Scopus. Studies meeting the inclusion criteria were subjected to a systematic review and cumulative meta-analysis to assess the oncological, functional, and perioperative outcomes of PN compared with RN for large renal tumors. Sensitivity analyses were performed by repeating the original meta-analyses with exclusion of the lowest-weighted or lowest-scored study. Thirteen retrospective studies including 2906 patients (PN: 1172; RN: 1734) were included in our analyses. The pooled hazard ratio (HR) of overall survival (OS) indicated significant differences between the PN and RN groups (HR: 0.76; p = 0.001), although no significant difference was observed between the two groups in terms of cancer-specific survival (CSS; HR: 0.91; p = 0.51). The pooled eGFR decrease was significantly lower in the PN group than that in the RN group (mean difference (MD): 11.59; p < 0.001). PN was associated with longer operative time and more estimated blood loss (MD: 65.33 min, p < 0.001 and MD: 97.83 ml, p < 0.001, respectively). Pooled odds ratios (ORs) revealed that, compared with RN, PN is associated with a significantly higher risk of low-grade and high-grade (OR: 1.59, p = 0.01 and OR: 7.35, p < 0.001, respectively) surgical complications. No statistical significances were changed in sensitivity analyses on all outcome variables, except for that on the low-grade complication when excluding the lowest-scored study. All results were pooled using the fixed-effects model due to the nil or low heterogeneity. No obvious publication bias was screened about reporting OS. In conclusion, while PN for large (≥7 cm) renal tumors is associated with better OS compared with RN, these methods show a similar CSS. However, the advantages of PN, a more involved procedure than RN, in preserving renal function are accompanied by a higher risk of surgical complications. Large-sample and well-designed randomized controlled trials with extensive follow up are needed to confirm and update our conclusions.
Topics: Female; Humans; Kidney Neoplasms; Male; Nephrectomy; Treatment Outcome
PubMed: 30704957
DOI: 10.1016/j.urolonc.2018.12.015 -
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 -
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 -
Journal of Endourology Aug 2015To compare the clinical efficacy and safety of selective vs hilar clamping during minimally invasive partial nephrectomy (PN). (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To compare the clinical efficacy and safety of selective vs hilar clamping during minimally invasive partial nephrectomy (PN).
METHODS
Studies comparing the effect and safety of selective versus hilar clamping during PN were identified by a systematic search using MEDLINE and EMBASE from January 2000 to November 2014. Quality of the selected studies was assessed according to the Newcastle-Ottawa Scale (NOS).
RESULTS
A total of seven retrospective studies were included. No significant differences were observed between the two groups in age, body mass index, tumor size, pre-estimated glomerular filtration rate (eGFR), operative time, and length of stay. The selective clamping group had greater estimated blood loss (P<0.01) but similar blood transfusion rate (P=0.78) compared with the hilar clamping group. There were no significant differences between the two groups in terms of urinary leaks, overall complication rate, and positive margin rate. Patients who underwent selective clamping had a lower change in eGFR (mean difference [MD]: 13.95; 95% CI 8.85 to 19.05; P<0.01) and a lower percent change in eGFR (MD: 18.51; 95% CI 14.18 to 22.84; P<0.01) at 1 week. Combined results from two studies showed a trend toward a lower percent change in eGFR at 3 months (MD: 5.47; 95% CI -0.28 to 11.22; P=0.06). At 6 months, two studies showed no significant differences in percent change of renal function between the two groups (MD: 16.85; 95% CI -10.47 to 44.16; P=0.23).
CONCLUSIONS
Although selective clamping resulted in greater estimated blood loss, it provided comparable perioperative safety and superior short-term renal function preservation. The advantage of selective clamping in preservation of intermediate-term renal function remains to be evaluated in the future, however. There is a need for properly designed studies to confirm our founding.
Topics: Blood Loss, Surgical; Constriction; Glomerular Filtration Rate; Humans; Kidney Neoplasms; Minimally Invasive Surgical Procedures; Nephrectomy; Operative Time; Retrospective Studies
PubMed: 25746718
DOI: 10.1089/end.2014.0878 -
Investigative and Clinical Urology Sep 2020This study aimed to determine the effectiveness and safety of partial nephrectomy (PN) without ischemia compared with PN with warm ischemia for reducing the... (Comparative Study)
Comparative Study Meta-Analysis
PURPOSE
This study aimed to determine the effectiveness and safety of partial nephrectomy (PN) without ischemia compared with PN with warm ischemia for reducing the deterioration in renal function in patients with cT1 renal tumors.
MATERIALS AND METHODS
We conducted a systematic review that included patients over 18 years of age who underwent PN with or without warm ischemia for cT1 renal tumors. The primary outcome was impaired renal function. A search strategy was performed in MEDLINE, EMBASE, LILACS, CENTRAL, the article reference lists, and the unpublished literature to reach saturation of the information. We assessed the risk of bias with the methodological index for nonrandomized studies (MINORS) tool, and we performed a meta-analysis according to the type of variable.
RESULTS
We found a total of 5,682 articles, of which 14 met the inclusion criteria. Seven studies evaluated renal function, identifying a difference in means (MD) of 3.50 (95% confidence interval [CI], 1.16 to 5.83), favoring no ischemia. We did not find any significant differences regarding intraoperative bleeding or operative time (MD, 55 mL; 95% CI, -33.16 to 144.08; and MD, 1.87; 95% CI, -20.47 to 24.21; respectively).
CONCLUSIONS
In this study, PN without ischemia showed a decrease in deterioration of the estimated glomerular filtration rate compared with warm ischemia.
Topics: Humans; Kidney Neoplasms; Neoplasm Staging; Nephrectomy; Treatment Outcome; Warm Ischemia
PubMed: 32869563
DOI: 10.4111/icu.20190313 -
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 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 -
European Urology Focus May 2021Predictors of upstaging from cT1 to pT3a renal masses are poorly inquired, and this remains an area of controversial findings. (Meta-Analysis)
Meta-Analysis Review
CONTEXT
Predictors of upstaging from cT1 to pT3a renal masses are poorly inquired, and this remains an area of controversial findings.
OBJECTIVE
To evaluate predictors and outcomes of upstaging from cT1 to pT3a in patients undergoing surgical removal of a renal tumor.
EVIDENCE ACQUISITION
A systematic literature search was performed to identify relevant articles using three electronic engines (PubMed, Embase, and Web of Science). Only studies looking at upstaging to pT3a in patients undergoing either partial nephrectomy (PN) or radical nephrectomy (RN) for cT1 renal tumor were included. Study selection was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement.
EVIDENCE SYNTHESIS
Thirteen studies, including 21869 patients (cT1/pT3a: 1256 [5.7%]; cT1/pT1: 20613 [93.3%]), were identified. Patients in the upstaged group were older (weighted mean difference [WMD]: 3.89; p < 0.00001) and mostly male (odds ratio [OR]: 1.23; p = 0.04). Renal tumors were larger (WMD: 0.98; p < 0.00001), more complex (OR: 2.38; p < 0.0001), and with a higher rate of cT1b masses (OR: 3.36; p < 0.00001). The cT1/pT3a group had a higher rate of other renal cell carcinoma histological subtypes (OR: 1.59; p = 0.04), as well as higher odds of Fuhrman grade ≥3 (OR: 2.57; p < 0.00001) and positive surgical margins (OR: 1.85; p = 0.007). Five-year recurrence-free survival (RFS) was worse in the upstaged group (OR: 0.31; p = 0.02). Age (OR: 1.03; p < 0.00001), tumor size (OR: 1.51; p < 0.00001), and RENAL score (OR: 2.80; p = 0.0004) were predictors of upstaging. Upstaging was associated with overall survival (hazard ratio [HR]: 1.94; p = 0.05), cancer-specific survival (HR: 2.24; p = 0.007), and RFS (HR: 2.17; p < 0.00001).
CONCLUSIONS
Upstaging to pT3a in case of surgical removal of a cT1 renal tumor is an uncommon event, which however can translate into worse oncological outcomes. Both patient (older age) and tumor (larger size and higher complexity) characteristics are associated with a higher risk of upstaging. There is very limited evidence regarding whether RN would be better than PN in these cases. There remains an unmet need for tools to better characterize renal masses in the preoperative setting.
PATIENTS SUMMARY
About 6% of surgically treated localized renal tumors can be found to be locally advanced on final pathology after surgery. This "upstaging" can translate into worse oncological outcomes. There are patient and tumor characteristics that are associated with an increased the risk of upstaging.
Topics: Carcinoma, Renal Cell; Female; Humans; Kidney Neoplasms; Male; Margins of Excision; Neoplasm Staging; Nephrectomy
PubMed: 32571744
DOI: 10.1016/j.euf.2020.05.013 -
Urologia Internationalis 2014To compare peri- and postoperative variables, surgical complications, oncological outcomes and renal outcomes of off-clamp partial nephrectomy (PN) and on-clamp PN. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To compare peri- and postoperative variables, surgical complications, oncological outcomes and renal outcomes of off-clamp partial nephrectomy (PN) and on-clamp PN.
METHODS
A systematic search of the electronic databases, including MEDLINE, Embase and Cochrane Library, was performed. The pooled estimates of tumour size, operative time, estimated blood loss, length of stay, overall complications, transfusion rates, urinary leaks, positive surgical margins and eGFR were calculated.
RESULTS
14 studies were included. There was no significant difference between off-clamp PN and on-clamp PN in terms of tumour size, operative time, estimated blood loss, length of stay, overall complications, transfusion rates, urinary leaks, and positive surgical margins. However, a non-statistically significant trend towards increased blood loss (p = 0.12) and transfusion rates (p = 0.07) in those undergoing off-clamp PN was noted. Off-clamp PN was associated with a significantly lower reduction in eGFR than on-clamp PN (standardised weighted mean difference 0.27, 95% CI 0.14, 0.40, p < 0.0001).
CONCLUSIONS
Off-clamp PN may be associated with improved long-term renal outcomes when compared to on-clamp PN with no difference in in peri- and postoperative variables, surgical complications and oncological outcomes. However, the meta-analysis was limited by the design of the underlying studies, and hence further work is necessary.
Topics: Chi-Square Distribution; Constriction; Glomerular Filtration Rate; Humans; Kidney Neoplasms; Length of Stay; Nephrectomy; Odds Ratio; Postoperative Complications; Risk Factors; Time Factors; Treatment Outcome
PubMed: 24992994
DOI: 10.1159/000362799 -
Asian Journal of Urology Jan 2021To conduct a meta-analysis assessing the perioperative, functional and oncological outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) for T1b tumours. The... (Review)
Review
Comparison of the oncological, perioperative and functional outcomes of partial nephrectomy versus radical nephrectomy for clinical T1b renal cell carcinoma: A systematic review and meta-analysis of retrospective studies.
OBJECTIVE
To conduct a meta-analysis assessing the perioperative, functional and oncological outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) for T1b tumours. The primary endpoints were the oncological outcomes. The secondary endpoints were the perioperative and functional outcomes.
METHODS
A systematic literature review was performed by searching multiple databases through February 2019 to identify eligible comparative studies according to the Preferred Reporting Items for Systematic Review and Meta-analysis statement. Identified reports were assessed according to the Newcastle-Ottawa Scale for nonrandomized controlled trials.
RESULTS
Overall, 13 retrospective cohort studies were included in the analysis. Patients undergoing PN were younger (weighted mean difference [WMD] -3.49 years, 95% confidence interval [CI] -5.16 to -1.82; <0.0001) and had smaller masses (WMD -0.45 cm, 95% CI -0.59 to -0.31; <0.0001). There were no differences in the oncological outcome, which was demonstrated by progression-free survival (hazard ratio [HR] 0.70; =0.22), cancer-specific mortality (HR 0.91; =0.57) and all-cause mortality (HR 1.01; =0.96). The two procedures were similar in estimated blood loss (WMD -16.47 mL; =0.53) and postoperative complications (risk ratio [RR] 1.32; =0.10), and PN provided better renal function preservation and was related to a lower likelihood of chronic kidney disease onset (RR 0.38; =0.006).
CONCLUSION
PN is an effective treatment for T1b tumours because it offers similar surgical morbidity, equivalent cancer control, and better renal preservation compared to RN.
PubMed: 33569278
DOI: 10.1016/j.ajur.2019.11.004