Pignot Géraldine, Bigot Pierre, Bernhard Jean-Christophe, Bouliere Fabien, Bessede Thomas, Bensalah Karim, Salomon Laurent, Mottet Nicolas, Bellec Laurent, Soulié Michel, Ferrière Jean-Marie, Pfister Christian, Drai Julien, Colombel Marc, Villers Arnauld, Rigaud Jerome, Bouchot Olivier, Montorsi Francesco, Bertini Roberto, Belldegrun Arie S, Pantuck Allan J, Patard Jean-Jacques
Department of Urology, Bicetre Hospital, Paris XI University, Le Kremlin Bicêtre, France.
Department of Urology, Angers University Hospital, Angers, France.
Urol Oncol. 2014 Oct;32(7):1024-30. doi: 10.1016/j.urolonc.2014.03.012. Epub 2014 Jul 2.
To analyze to what extent partial nephrectomy (PN) is superior to radical nephrectomy (RN) in preserving renal function outcome in relation to tumor size indication.
Clinical data from 973 patients operated at 9 academic institutions were retrospectively analyzed. Glomerular filtration rate (GFR) before and after surgery was calculated with the abbreviated Modification of the Diet in Renal Disease equation. For a fair comparison between the 2 techniques, all imperative indications for PN were excluded. A shift to a less favorable GFR group following surgery was considered clinically significant.
Median age at diagnosis was 60 years (19-91). Tumor size was smaller than 4 cm in 665 (68.3%) cases and larger than 4 cm in 308 (31.7%) cases. PN and RN were performed in 663 (68.1%) and 310 (31.9%) patients, respectively. In univariate analysis, patients undergoing PN had a smaller risk for developing significant GFR change following surgery than those undergoing RN did. This was true for tumors≤4 cm (P = 0.0001) and for tumors>4 cm (P = 0.0001). In multivariate analysis, the following criteria were independent predictive factors for developing significant postoperative GFR loss: the use of RN (P = 0.0001), preoperative GFR<60 ml/min (P = 0.0001), tumor size≥4 cm (P = 0.0001), and older age at diagnosis (P = 0.0001).
The renal function benefit carried out by elective PN over RN persists even when expanding nephron-sparing surgery indications beyond the traditional 4-cm cutoff.
分析在肿瘤大小指征方面，部分肾切除术（PN）在保留肾功能结局上优于根治性肾切除术（RN）的程度。
回顾性分析来自9家学术机构的973例接受手术患者的临床资料。采用简化的肾脏疾病饮食改良方程计算手术前后的肾小球滤过率（GFR）。为了对这两种技术进行公平比较，排除了所有PN的必要指征。术后向较差GFR组的转变被认为具有临床意义。
诊断时的中位年龄为60岁（19 - 91岁）。665例（68.3%）患者的肿瘤大小小于4 cm，308例（31.7%）患者的肿瘤大小大于4 cm。分别有663例（68.1%）和310例（31.9%）患者接受了PN和RN。在单因素分析中，接受PN的患者术后发生显著GFR变化的风险低于接受RN的患者。对于肿瘤≤4 cm（P = 0.0001）和肿瘤>4 cm（P = 0.0001）的情况均如此。在多因素分析中，以下标准是术后发生显著GFR损失的独立预测因素：使用RN（P = 0.0001）、术前GFR<60 ml/min（P = 0.0001）、肿瘤大小≥4 cm（P = 0.0001）以及诊断时年龄较大（P = 0.0001）。
即使将保肾手术指征扩大到传统的4 cm临界值以上，选择性PN相对于RN在肾功能方面的益处仍然存在。
