Which Is the Real Gold Standard for Small-Volume Renal Tumors? Radical Nephrectomy versus Nephron-Sparing Surgery

Manikandan, Ramaswamy; Srinivasan, V.; Rané, Abhay

doi:10.1089/089277904322836659

Cited by 36 publications

(14 citation statements)

References 53 publications

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“…A comparison between this systematic review with two other reviews [58,59] can be accessed in the full report [13]. Other reviews were either not systematically performed [60] or were based on noncomparative case series [61,62]; these will not be considered any further.…”

Section: How This Systematic Review Compares With Other Recent Systemmentioning

confidence: 99%

Systematic Review of Oncological Outcomes Following Surgical Management of Localised Renal Cancer

MacLennan

Imamura

Lapitan³

et al. 2012

European Urology

300

174

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Context: Renal cell carcinoma (RCC) accounts for 2-3% of adult malignancies. There remain uncertainties over the oncological outcomes for the surgical management of localised RCC. Objective: To systematically review relevant literature comparing oncological outcomes of surgical management of localised RCC (T1-2N0M0). Evidence Acquisition: Relevant databases including MEDLINE, Embase and the Cochrane Library were searched up to October 2010, and an updated scoping search was performed up to January 2012. Randomised or quasi-randomised controlled trials (RCTs), prospective observational studies with controls, retrospective matched-pair studies, and comparative studies from well defined registries/databases were included. The main outcomes were overall survival, cancer-specific survival, recurrence and metastases. The Cochrane risk of bias (RoB) tool was used to assess RCTs and an extended version was used to assess Non Randomised Studies (NRS). The quality of evidence was assessed using GRADE. Evidence Synthesis: 4580 abstracts and 389 full text articles were assessed. 34 studies met the inclusion criteria (6 RCTs and 28 NRSs). Meta-analyses were planned but were deemed inappropriate due to data heterogeneity. There were high risks of bias and low quality evidence across the evidence base. Open radical nephrectomy and open partial nephrectomy showed similar cancer-specific and overall survival, but when both open and laparoscopic approaches are considered together the evidence showed improved survival for partial nephrectomy for tumours ≤4cm.Overall, the evidence suggests either equivalent or better survival with partial nephrectomy. Laparoscopic radical nephrectomy offered equivalent survival to open radical nephrectomy, and all laparoscopic approaches achieved equivalent survival. Open and laparoscopic partial nephrectomy achieved equivalent survival. The issue of ipsilateral adrenalectomy or complete lymph node dissection with radical nephrectomy or partial nephrectomy remains unresolved. Conclusions: The evidence base suggests localised RCC are best managed by nephron sparing surgery where technically feasible. However, the current evidence base has significant limitations due to studies of low methodological quality marked by high risks of bias.

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Section: How This Systematic Review Compares With Other Recent Systemmentioning

confidence: 99%

Systematic Review of Oncological Outcomes Following Surgical Management of Localised Renal Cancer

MacLennan

Imamura

Lapitan³

et al. 2012

European Urology

300

174

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“…This probability was 48% higher relative to that associated with NSS (0.0037 [0.37%]) (20). RF ablation strongly dominated NSS below an annual post-RF ablation local recurrence probability of 0.0040 (0.4%), affording a greater qualityadjusted life expectancy at a lower cost (Fig 3).…”

Section: Sensitivity Analysis Resultsmentioning

confidence: 92%

“…For NSS, the yearly local recurrence probability (0.37%) was derived from a meta-analysis by using an exponential assumption to convert reported mean follow-up time and recurrence rate estimates to a probability (20). Specifically, we used the standard assumption of an exponential relationship between an event probability (p) and hazard rate (r) over a specified time period (t), which can be expressed as p ϭ 1Ϫe…”

Section: Model Data and Data Sourcesmentioning

confidence: 99%

“…The probability of direct progression to metastatic disease following tumor treatment also was elicited from the meta-analysis (20) and was assumed to be the same for both. The probability of progression from local recurrence to metastatic RCC was calibrated, given reported cancer-specific mortality estimates associated with local recurrence (37) and metastatic RCC (38).…”

Section: Model Data and Data Sourcesmentioning

confidence: 99%

“…This higher risk may or may not be associated with a survival difference. When NSS is compared with radical nephrectomy for small RCC, an analogous comparison, the minimally higher local recurrence rate after NSS does not confer decreased survival (18)(19)(20).…”

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confidence: 99%

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Radiofrequency Ablation versus Nephron-sparing Surgery for Small Unilateral Renal Cell Carcinoma: Cost-effectiveness Analysis

Pandharipande

Gervais²,

Müeller³

et al. 2008

Radiology

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Purpose:To evaluate the relative cost-effectiveness of percutaneous radiofrequency (RF) ablation versus nephron-sparing surgery (NSS) in patients with small (Յ4-cm) renal cell carcinoma (RCC), given a commonly accepted level of societal willingness to pay. Materials and Methods:A decision-analytic Markov model was developed to estimate life expectancy and lifetime costs for 65-year-old patients with a small RCC treated with RF ablation or NSS. The model incorporated RCC presence, treatment effectiveness and costs, and short-and long-term outcomes. An incremental cost-effectiveness analysis was performed to identify treatment preference under an assumed $75 000 per quality-adjusted life-year (QALY) societal willingnessto-pay threshold level, within proposed ranges for guiding implementation of new health care interventions. The effect of changes in key parameters on strategy preference was addressed in sensitivity analysis. Results:By using base-case assumptions, NSS yielded a minimally greater average quality-adjusted life expectancy than did RF ablation (2.5 days) but was more expensive. NSS had an incremental cost-effectiveness ratio of $1 152 529 per QALY relative to RF ablation, greatly exceeding $75 000 per QALY. Therefore, RF ablation was considered preferred and remained so if the annual probability of post-RF ablation local recurrence was up to 48% higher relative to that post-NSS. NSS preference required an estimated NSS cost reduction of $7500 or RF ablation cost increase of $6229. Results were robust to changes in most model parameters, but treatment preference was dependent on the relative probabilities of local recurrence after RF ablation and NSS, the short-term costs of both, and quality of life after NSS. Conclusion:RF ablation was preferred over NSS for small RCC treatment at a societal willingness-to-pay threshold level of $75 000 per QALY. This result was robust to changes in most model parameters, but somewhat dependent on the relative probabilities of post-RF ablation and post-NSS local recurrence, NSS and RF ablation short-term costs, and post-NSS quality of life, factors which merit further primary investigation.

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Estrogen Receptor α Polymorphisms and the Risk of Myocardial Infarction

2004

JAMA

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Which Is the Real Gold Standard for Small-Volume Renal Tumors? Radical Nephrectomy versus Nephron-Sparing Surgery

Abstract: Nephron-sparing surgery seems to be as effective as RN in patients with renal cell tumours up to 4 cm, although only a large randomized controlled trial with long follow-up periods would provide a definite answer.

Cited by 36 publications

References 53 publications

Systematic Review of Oncological Outcomes Following Surgical Management of Localised Renal Cancer

Systematic Review of Oncological Outcomes Following Surgical Management of Localised Renal Cancer

Radiofrequency Ablation versus Nephron-sparing Surgery for Small Unilateral Renal Cell Carcinoma: Cost-effectiveness Analysis

Estrogen Receptor α Polymorphisms and the Risk of Myocardial Infarction

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