Veys Ralf, Abdollah Firas, Briganti Alberto, Albersen Maarten, Poppel Hein Van, Joniau Steven
Department of Urology, University Hospitals Leuven, Leuven, Belgium.
Vattikuti Urology Institute, Center for Outcomes Research Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA.
Cent European J Urol. 2018;71(1):48-57. doi: 10.5173/ceju.2017.1611. Epub 2017 Dec 22.
The purpose of this paper is to compare oncological outcomes of partial nephrectomy (PN) versus radical nephrectomy (RN) in renal cell carcinoma (RCC) clinical stages ≥T1b, in a retrospective propensity-score matched cohort of a high-volume, tertiary referral center. This paper also aims to compare renal function and complication rates between groups.
Our single-institution RCC database was queried to select patients with clinical stages defined by tumor size (T), lymph nodes(N), and metastasis (M) scores of T1b-4 N0 M0, that underwent PN or RN between 2000 and 2014. All images of patients that underwent RN were reviewed, and only patients deemed eligible for PN were included. Medical records were reviewed to obtain data on tumor characteristics, comorbidities, renal function, and complications. After propensity score matching, 152 patients (76 per group) were included in the final analysis. Primary outcomes were cancer specific survival (CSS), overall survival (OS), and clinical progression-free survival (CPFS). Secondary outcomes were renal function preservation and post-operative complication rates.
Groups were propensity-score matched. The only parameters that were significantly different between groups were the median follow-up time (RN: 79 months, range 24.1-100.5 vs. PN: 38.5 months, range 20.5-72.1) and a better performance status in the RN group (p = 0.002). The five-year CPFS, CSS, and OS rates were 77.2%, 90.5%, and 86.4%, respectively, in the RN group, and 83.6%, 91.1%, and 82.0%, respectively, in the PN group (p = 0.33, p = 0.55, and p = 0.33, respectively). In the multivariate Cox model, the surgical method was not an independent predictor of CPFS, CSS, or OS. The RN group showed a significantly greater reduction in estimated glomerular filtration rate (RN: 14.1 vs. PN: 5.4 ml/min per 1.73 m²; p <0.03). There was no significant difference in complication rates between the two groups (p = 0.3). The main limitations of this study were its retrospective design and the medium-term follow-up.
Our results demonstrated the efficacy and safety of PN in patients with RCC in clinical stages ≥T1b. We observed no significant difference in oncological outcomes between the PN and RN groups at medium-term follow ups. The surgical method did not influence these outcomes. Renal function was preserved significantly more frequently in the PN than in the RN group, but the groups had similar complication rates.These findings suggested that PN could be considered an oncologically safe procedure for treating large RCC tumors; thus, PN should always be considered, when technically feasible, regardless of tumor stage.
本文旨在比较在一个高容量三级转诊中心的回顾性倾向评分匹配队列中，肾细胞癌（RCC）临床分期≥T1b的患者接受部分肾切除术（PN）与根治性肾切除术（RN）后的肿瘤学结局。本文还旨在比较两组之间的肾功能和并发症发生率。
查询我们单机构的RCC数据库，以选择肿瘤大小（T）、淋巴结（N）和转移（M）评分定义为T1b - 4 N0 M0的临床分期患者，这些患者在2000年至2014年间接受了PN或RN。对所有接受RN的患者图像进行了复查，仅纳入被认为适合PN的患者。查阅病历以获取有关肿瘤特征、合并症、肾功能和并发症的数据。经过倾向评分匹配后，152例患者（每组76例）纳入最终分析。主要结局为癌症特异性生存（CSS）、总生存（OS）和临床无进展生存（CPFS）。次要结局为肾功能保留和术后并发症发生率。
两组进行了倾向评分匹配。两组之间唯一显著不同的参数是中位随访时间（RN：79个月，范围24.1 - 100.5 vs. PN：38.5个月，范围20.5 - 72.1）以及RN组更好的体能状态（p = 0.002）。RN组的五年CPFS、CSS和OS率分别为77.2%、90.5%和86.4%，PN组分别为83.6%、91.1%和82.0%（分别为p = 0.33、p = 0.55和p = 0.33）。在多变量Cox模型中，手术方法不是CPFS、CSS或OS的独立预测因素。RN组的估计肾小球滤过率显著降低更多（RN：14.1 vs. PN：5.4 ml/min per 1.73 m²；p <0.03）。两组之间的并发症发生率无显著差异（p = 0.3）。本研究的主要局限性在于其回顾性设计和中期随访。
我们的结果证明了PN在临床分期≥T1b的RCC患者中的有效性和安全性。我们观察到中期随访时PN组和RN组之间的肿瘤学结局无显著差异。手术方法并未影响这些结局。PN组比RN组更频繁地保留了肾功能，但两组的并发症发生率相似。这些发现表明PN可被视为治疗大型RCC肿瘤的肿瘤学安全手术；因此，在技术可行时，无论肿瘤分期如何，都应始终考虑PN。
