Glickman Urological and Kidney Institute, Cleveland Clinic , Cleveland , Ohio.
Division of Urology, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University , Bangkok , Thailand.
J Urol. 2019 Jun;201(6):1088-1096. doi: 10.1097/JU.0000000000000060.
Retrospective studies suggest that partial nephrectomy provides improved survival compared to radical nephrectomy even when performed electively. However, selection bias may contribute. We evaluated factors associated with nonrenal cancer related mortality after partial and radical nephrectomy in patients with a preoperative glomerular filtration rate of 60 ml/minute/1.73 m or greater.
We retrospectively evaluated the records of 3,133 patients with a preoperative glomerular filtration rate of 60 ml/minute/1.73 m or greater who underwent partial or radical nephrectomy. Nonrenal cancer related mortality was analyzed by the Kaplan-Meier test based on procedure and functional parameters, including the new baseline glomerular filtration rate. We used the Cox proportional hazards model to assess factors associated with nonrenal cancer related mortality among patients with a new baseline rate of 45 ml/minute/1.73 m or greater.
Overall median age was 59 years and the median preoperative glomerular filtration rate was 85 ml/minute/1.73 m. The new baseline glomerular filtration rate was 80 and 63 ml/minute/1.73 m and 10-year nonrenal cancer related mortality was 11.3% and 17.7% after partial and radical nephrectomy, respectively (each p <0.001). Median followup was 9.3 years. Nonrenal cancer related mortality was similar in all patients with a new baseline glomerular filtration rate of 45 ml/minute/1.73 m or greater (p = 0.26). However, it increased 50% or more in the 290 patients with a new baseline below this level (p = 0.001). In patients with a new baseline greater than 45 ml/minute/1.73 m 10-year nonrenal cancer related mortality was still substantially improved after partial nephrectomy (10.6% vs 16.3%, p <0.001). In this population age, gender and partial vs radical nephrectomy were associated with nonrenal cancer related mortality on multivariable analysis (all p ≤0.001). In contrast, the increased new baseline glomerular filtration rate, as seen for partial nephrectomy, was not associated with reduced nonrenal cancer related mortality.
In patients with a glomerular filtration rate of 60 ml/minute/1.73 m or greater who undergo partial or radical nephrectomy our data suggest that treatment should achieve a new baseline of 45 ml/minute/1.73 m or greater if feasible. Partial nephrectomy should be prioritized if needed to accomplish this. In patients with a new baseline rate of 45 ml/minute/1.73 m or greater partial nephrectomy was associated with improved survival. However, the functional dividend, namely the increased new baseline rate, failed to correlate, suggesting that selection bias may also impact outcomes.
回顾性研究表明，与根治性肾切除术相比，即使是选择性部分肾切除术也能提供更好的生存。然而，选择偏倚可能是一个因素。我们评估了肾小球滤过率（GFR）为 60ml/min/1.73m 或更高的患者中，接受部分或根治性肾切除术与非肾相关癌症死亡率之间相关的因素。
我们回顾性评估了 3133 名 GFR 为 60ml/min/1.73m 或更高的患者的记录，这些患者接受了部分或根治性肾切除术。根据手术和功能参数（包括新的基线 GFR），使用 Kaplan-Meier 检验分析非肾相关癌症死亡率。我们使用 Cox 比例风险模型评估新基线率为 45ml/min/1.73m 或更高的患者中非肾相关癌症死亡率相关的因素。
总体中位年龄为 59 岁，术前中位 GFR 为 85ml/min/1.73m。新的基线 GFR 为 80 和 63ml/min/1.73m，10 年非肾相关癌症死亡率分别为 11.3%和 17.7%，接受部分和根治性肾切除术（均 P<0.001）。中位随访时间为 9.3 年。在新基线 GFR 为 45ml/min/1.73m 或更高的所有患者中，非肾相关癌症死亡率相似（P=0.26）。然而，在新基线低于此水平的 290 名患者中，死亡率增加了 50%或更多（P=0.001）。在新基线大于 45ml/min/1.73m 的患者中，部分肾切除术仍能显著降低 10 年非肾相关癌症死亡率（10.6%比 16.3%，P<0.001）。在这一人群中，年龄、性别、部分肾切除术与根治性肾切除术与多变量分析中的非肾相关癌症死亡率相关（均 P≤0.001）。相反，如部分肾切除术所见，新的基线 GFR 升高与非肾相关癌症死亡率降低无关。
在 GFR 为 60ml/min/1.73m 或更高的患者中，接受部分或根治性肾切除术，我们的数据表明，如果可行，治疗应达到新的基线 45ml/min/1.73m 或更高。如果需要达到这一目标，应优先选择部分肾切除术。在新基线率为 45ml/min/1.73m 或更高的患者中，部分肾切除术与生存率提高相关。然而，功能优势，即新的基线率的增加，未能相关，这表明选择偏倚也可能影响结果。
