Tang Kun, Yao Weimin, Li Heng, Guo Xiaolin, Guan Wei, Ma Xin, Zhang Xu, Zeng Guohua, He Wei, Xu Hua, Ye Zhangqun
1 Department of Urology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology , Wuhan, China .
J Laparoendosc Adv Surg Tech A. 2014 Jun;24(6):403-10. doi: 10.1089/lap.2013.0550.
For small renal masses (SRMs), open partial nephrectomy represents the therapeutic standard of care, and laparoscopic partial nephrectomy (LPN) has provided encouraging outcomes. Laparoscopic renal cryoablation (LRC) could be regarded as an alternative to surgical excision in selected patients, if perioperative complication rates and oncologic results are comparable. However, the short- and long-term outcomes of LRC versus LPN have not been adequately assessed. This study evaluated the safety and efficacy of LRC compared with LPN in the treatment of SRMs.
A systematic search of the Medline, Scopus, and CNKI databases and the Cochrane Library was performed up to October 1, 2013. Outcomes of interest assessing the two techniques included demographic and clinical baseline characteristics, surgical and oncological variables, renal function, and complications.
Nine eligible trials (555 cases and 642 controls) assessing LRC versus LPN were identified, including two prospective and seven retrospective studies. Patients undergoing LRC were significantly older (weighted mean difference [WMD], 6.48 years; 95% confidence interval [CI], 3.12-9.83; P<.001) and had a higher solitary kidney rate (odds ratio [OR]=3.76; 95% CI, 2.05-6.92; P<.001). Although LRC was associated with shorter operative time (WMD, -54.28 minutes; 95% CI, -83.79 to -24.78; P<.001), less blood loss (WMD, -111.75 mL; 95% CI, -147.96 to -75.53; P<.001), lower risk of conversion (OR=0.17; 95% CI, 0.05-0.60; P=.005), and fewer overall complications (OR=0.53; 95% CI, 0.29-0.98; P=.04), especially the rate of intraoperative complications (OR=0.20; 95% CI, 0.07-0.58; P=.003) and major complications (OR=0.45; 95% CI, 0.25-0.81; P=.008), patients having LPN might still benefit from a significantly lower local recurrence rate (OR=13.03; 95% CI, 4.20-40.39; P<.001) and lower distant metastasis rate (OR=9.05; 95% CI, 2.31-35.51; P=.002).
Compared with LPN, LRC was associated with reliable perioperative safety, comparable renal function, and fewer complications; however, LRC may still result in a higher risk of tumor progression. Therefore, our meta-analysis suggested that LRC was associated with worse oncological outcomes than LPN but that LRC may be indicated in selected patients with significant comorbidity. Because of the inherent limitations of the included studies, further large sample, prospective, multicenter, and long-term follow-up studies are awaited to corroborate these findings.
对于小肾肿块（SRMs），开放性部分肾切除术是治疗的标准方法，而腹腔镜部分肾切除术（LPN）也取得了令人鼓舞的结果。如果围手术期并发症发生率和肿瘤学结果相当，腹腔镜肾冷冻消融术（LRC）可被视为特定患者手术切除的替代方法。然而，LRC与LPN的短期和长期结果尚未得到充分评估。本研究评估了LRC与LPN治疗SRMs的安全性和有效性。
截至2013年10月1日，对Medline、Scopus、中国知网数据库和考克兰图书馆进行了系统检索。评估这两种技术的感兴趣的结果包括人口统计学和临床基线特征、手术和肿瘤学变量、肾功能及并发症。
共确定了9项评估LRC与LPN的符合条件的试验（555例病例和642例对照），包括2项前瞻性研究和7项回顾性研究。接受LRC的患者年龄显著更大（加权平均差[WMD]，6.48岁；95%置信区间[CI]，3.12 - 9.83；P <.001），且孤立肾发生率更高（比值比[OR]=3.76；95% CI，2.05 - 6.92；P <.001）。虽然LRC与较短的手术时间相关（WMD，-54.28分钟；95% CI，-83.79至-24.78；P <.001）、更少的失血量（WMD，-111.75 mL；95% CI，-147.96至-75.53；P <.001）、更低的中转风险（OR=0.17；95% CI，0.05 - 0.60；P =.005）以及更少的总体并发症（OR=0.53；95% CI，0.29 - 0.98；P =.04），尤其是术中并发症发生率（OR=0.20；95% CI，0.07 - 0.58；P =.003）和主要并发症发生率（OR=0.45；95% CI，0.25 - 0.81；P =.008），但接受LPN的患者可能仍从显著更低的局部复发率（OR=13.03；95% CI，4.20 - 40.39；P <.001）和更低远转移率（OR=9.05；95% CI，2.31 - 35.51；P =.002）中获益。
与LPN相比，LRC具有可靠的围手术期安全性、相当的肾功能及更少的并发症；然而，LRC可能仍导致更高的肿瘤进展风险。因此，我们的荟萃分析表明，LRC与比LPN更差的肿瘤学结果相关，但LRC可能适用于有严重合并症的特定患者。由于纳入研究的固有局限性，期待进一步的大样本、前瞻性、多中心和长期随访研究来证实这些发现。
