Tobert Conrad M, Riedinger Christopher B, Lane Brian R
Michigan State University College of Human Medicine, Grand Rapids, MI, USA.
World J Urol. 2014 Jun;32(3):573-9. doi: 10.1007/s00345-014-1275-8. Epub 2014 Mar 27.
Partial nephrectomy (PN) has become the gold standard for treating small renal masses amenable to such an approach. Surprisingly, the single randomized controlled trial of PN versus radical nephrectomy (RN) indicated an overall survival benefit for RN over PN. Recent studies have shed light on this discordance, and this review will attempt to discern what is known at present.
Multiple retrospective observational studies have demonstrated superior outcomes with PN compared with RN. Whether the observed survival benefit with PN is the result of renal functional advantages or the result of selection bias and other unmeasured variables is up for discussion. A meta-analysis of 21 studies including the EORTC 30904 found a 19 % reduction in all-cause mortality (p = 0.0001) and 29 % reduction in cancer-specific mortality (p = 0.0002) with PN versus RN. Recent analysis of SEER-Medicare data revealed that patients undergoing RN had similar survival when compared with non-cancer controls, further supporting concerns about selection biases in prior observational series.
Although PN is clearly of benefit for those likely to experience end-stage renal disease with RN, a survival benefit with PN in the elective setting is not proven at present. While experts may still believe PN to improve survival for these patients, the only level I evidence in the field would suggest otherwise, and selection bias is undoubtedly responsible for a significant part of the improved survival observed in retrospective studies. Given recent evidence, any further push to limit the role of RN should be tempered until we know PN is indeed superior.
对于适合该手术方式的小肾肿瘤，部分肾切除术（PN）已成为治疗的金标准。令人惊讶的是，一项关于PN与根治性肾切除术（RN）的单随机对照试验表明，RN的总生存获益优于PN。近期研究已阐明了这种不一致性，本综述将试图厘清目前已知的情况。
多项回顾性观察性研究表明，与RN相比，PN的预后更佳。PN观察到的生存获益是肾功能优势的结果，还是选择偏倚及其他未测量变量的结果，尚有待讨论。一项对包括欧洲癌症研究与治疗组织（EORTC）30904在内的21项研究的荟萃分析发现，与RN相比，PN可使全因死亡率降低19%（p = 0.0001），癌症特异性死亡率降低29%（p = 0.0002）。近期对监测、流行病学和最终结果（SEER）-医疗保险数据的分析显示，与非癌症对照相比，接受RN的患者生存情况相似，这进一步支持了对既往观察系列中选择偏倚的担忧。
尽管PN对那些接受RN可能会发展为终末期肾病的患者显然有益，但目前在择期情况下PN的生存获益尚未得到证实。虽然专家们可能仍认为PN可改善这些患者的生存，但该领域唯一的I级证据却表明并非如此，选择偏倚无疑是回顾性研究中观察到的生存改善的重要原因。鉴于近期的证据，在我们确定PN确实更优之前，任何进一步限制RN作用的举措都应谨慎。
