Review – Kidney CancerSystematic Review of Oncological Outcomes Following Surgical Management of Localised Renal Cancer
Introduction
Renal cell carcinoma (RCC) accounts for approximately 2–3% of all adult malignancies. More than 50% of all RCCs diagnosed are a localised stage (ie, T1–T2N0M0 or stage I–II) [1]. Open radical nephrectomy has been the standard curative intervention for localised RCC for the past five decades [2]. There were controversies over whether radical nephrectomy should be performed in conjunction with ipsilateral adrenalectomy, as originally described by Robson, or if the adrenal should be preserved [3], [4], [5], [6] and whether ipsilateral extended retroperitoneal lymphadenectomy or limited hilar lymphadenectomy should be performed [7], [8].
With the advent of minimally invasive surgery, laparoscopic radical nephrectomy has become an acceptable alternative to open surgery for localised RCCs [6], [7]. Another recent controversy is the use of nephron-sparing surgery (NSS; partial nephrectomy). NSS has been the accepted mode of treatment when radical nephrectomy would render the patient anephric or at high risk for subsequent renal replacement therapy [9]. This organ-preserving approach has recently emerged as a viable alternative for small renal tumours (<4 cm or T1a) in patients with a normal contralateral kidney, with encouraging short-term and long-term oncological outcomes [10], [11]. The era of increasing use of NSSs has also witnessed the development of minimally invasive nephron-sparing interventions such as cryoablation, radiofrequency ablation (RFA), and high-intensity focussed ultrasound (HIFU) for the treatment of localised renal cancer [10], [11].
Although various guidelines exist in relation to the various interventions for localised RCC [6], [12], it is important to recognise that such guidelines were based on reviews that were not undertaken systematically and often used methodology that was not transparent, reproducible, or robust. A systematic review of current evidence is urgently needed to establish whether the outcomes of competing treatment options are comparable. Methodological rigour is needed in assessing risks of bias and quality of evidence in a standardised and transparent way to highlight weaknesses in the evidence base and to make recommendations for future research.
The objective of this systematic review was to compare the oncological outcomes for all interventions relevant to the management of localised RCC. This paper reports the oncological outcomes, and a separate article reports the surgical and quality-of-life outcomes from this systematic review. There is also a full report published online with extra methodological information and data for oncological and surgical outcomes [13].
Section snippets
Search strategy
The databases searched were Medline (1950 to October 2010) and Embase (1980 to October 2010), Cochrane Library, all sections (Issue 4, 2010), Web of Science, with Conference Proceedings (1970 to October 2010), and American Society of Clinical Oncology meeting abstracts (up to October 2010). The searches were not limited by language. Auto-alerts in Medline were also run during the course of the review. Reference lists of relevant articles were also checked [13]. Two reviewers screened all
Risk of bias and quality assessment of the included studies
The study selection process is outlined in the Preferred Reporting Items for Systematic Reviews (PRISMA) diagram (Fig. 1). There were 44 studies that met inclusion criteria, and 34 of them reported oncological outcomes (6 RCTs and 28 NRSs). The Cochrane risk of bias assessment can be viewed in Appendix 1. The additional NRS risk of bias assessment adjustment scores (outlined earlier) are displayed in Table 1, which reports baseline characteristics (all study designs) and adjustment scores (NRSs
Conclusions
Patient and tumour characteristics permitting, the current oncological outcomes evidence base suggests that localised RCCs are best managed by NSS rather than by radical nephrectomy irrespective of surgical approach. Where open surgery is deemed necessary, open NSS oncological outcomes are at least as good as open radical nephrectomy and should be the preferred option when technically feasible. The evidence around minimally invasive ablative technologies is weak due to low methodological
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