Elsevier

European Urology

Volume 62, Issue 6, December 2012, Pages 1097-1117
European Urology

Review – Kidney Cancer
Systematic Review of Perioperative and Quality-of-life Outcomes Following Surgical Management of Localised Renal Cancer

https://doi.org/10.1016/j.eururo.2012.07.028Get rights and content

Abstract

Context

For the treatment of localised renal cell carcinoma (RCC), uncertainties remain over the perioperative and quality-of-life (QoL) outcomes for the many different surgical techniques and approaches of nephrectomy. Controversy also remains on whether newer minimally invasive nephron-sparing interventions offer better QoL and perioperative outcomes, and whether adrenalectomy and lymphadenectomy should be performed simultaneously with nephrectomy. These non-oncological outcomes are important because they may have a considerable impact on localised RCC treatment decision making.

Objective

To review systematically all the relevant published literature comparing perioperative and QoL outcomes of surgical management of localised RCC (T1–2N0M0).

Evidence acquisition

Relevant databases including Medline, Embase, and the Cochrane Library were searched up to January 2012. Randomised controlled trials (RCTs) or quasi-randomised controlled trials, prospective observational studies with controls, retrospective matched-pair studies, and comparative studies from well-defined registries/databases were included. The outcome measures were QoL, analgesic requirement, length of hospital stay, time to normal activity level, surgical morbidity and complications, ischaemia time, renal function, blood loss, length of operation, need for blood transfusion, and perioperative mortality. The Cochrane risk of bias tool was used to assess RCTs, and an extended version was used to assess nonrandomised studies (NRSs). The quality of evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluation.

Evidence synthesis

A total of 4580 abstracts and 380 full-text articles were assessed, and 29 studies met the inclusion criteria (7 RCTs and 22 NRSs). There were high risks of bias and low-quality evidence for studies meeting the inclusion criteria. There is good evidence indicating that partial nephrectomy results in better preservation of renal function and better QoL outcomes than radical nephrectomy regardless of technique or approach. Regarding radical nephrectomy, the laparoscopic approach has better perioperative outcomes than the open approach, and there is no evidence of a difference between the transperitoneal and retroperitoneal approaches. Alternatives to standard laparoscopic radical nephrectomy (LRN) such as hand-assisted, robot-assisted, or single-port techniques appear to have similar perioperative outcomes. There is no good evidence to suggest that minimally invasive procedures such as cryotherapy or radiofrequency ablation have superior perioperative or QoL outcomes to nephrectomy. Regarding concomitant lymphadenectomy during nephrectomy, there were low event rates for complications, and no definitive difference was observed. There was no evidence to base statements about concomitant ipsilateral adrenalectomy during nephrectomy.

Conclusions

Partial nephrectomy results in significantly better preservation of renal function over radical nephrectomy. For tumours where partial nephrectomy is not technically feasible, there is no evidence that alternative procedures or techniques are better than LRN in terms of perioperative or QoL outcomes. In making treatment decisions, perioperative and QoL outcomes should be considered in conjunction with oncological outcomes. Overall, there was a paucity of data regarding QoL outcomes, and when reported, both QoL and perioperative outcomes were inconsistently defined, measured, or reported. The current evidence base has major limitations due to studies of low methodological quality marked by high risks of bias.

Introduction

Nephron-sparing surgery (ie, partial nephrectomy) and other minimally invasive interventions such as cryoablation, radiofrequency ablation (RFA), and high-intensity focussed ultrasound (HIFU) are alternative options to radical nephrectomy in the management of localised (T1–2N0M0) renal cell carcinoma (RCC) [1], [2], [3], [4], [5], [6], [7]. Although the decision to undertake these procedures is usually oncologically driven, there is a definite need for a better understanding of non-oncological outcomes associated with these competing interventions because they influence treatment decision making. Various guidelines presently exist in relation to the various interventions for localised RCC [1], [5]. However, it is important to recognise that many current urology guidelines recommendations are not based on systematic reviews of the evidence [8]. Consequently, a systematic review of current evidence is urgently needed to establish whether the non-oncological outcomes of all these competing interventions are comparable. Such a review should be performed with methodological rigour in assessing risks of bias and quality of evidence in a standardised and transparent way to highlight potential weaknesses in the evidence base and highlight areas for future research.

The objective of this systematic review was to compare the perioperative and quality-of-life (QoL) outcomes for all interventions relevant to the management of localised RCC. The oncological outcomes of the review are copublished in a separate article [9]. There is also a full report published online [10] with extra methodological information and data for oncological and surgical (non-oncological) outcomes.

Section snippets

Search strategy

The search was conducted in accordance with the principles outlined in the Cochrane Handbook of Systematic Reviews [11]. The databases searched were Medline (1950–October 2010) and Embase (1980–October 2010), Cochrane Library, all sections (issue 4, 2010), Web of Science with conference proceedings (1970–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 and Embase were also run

Risk of bias and quality assessment of the included studies

The study selection process is outlined in the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) diagram (Fig. 1). There were 39 studies that met the inclusion criteria, 28 (72%) of which reported surgical outcomes, of which only 7 (25%) were RCTs. The Cochrane RoB assessment can be viewed in the appendix. The additional nonrandomised risk of bias assessment adjustment scores (outlined earlier) are displayed in Table 1, which reports baseline characteristics (all study

Conclusions

In terms of perioperative and QoL outcomes, partial nephrectomy results in significantly better preservation of renal function over radical nephrectomy regardless of choice of approach or technique. For tumours where partial nephrectomy is not technically feasible (eg, tumours >4 cm), there is no evidence that alternative procedures or techniques are better than LRN, which is the standard of care for these localised tumours. For LRN, the choice of approach (eg, transperitoneal or

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