Article

Excise, Ablate, or Observe: The Small Renal Mass Dilemma—A Meta-Analysis and Review

Temple University, Filadelfia, Pennsylvania, United States
The Journal of urology (Impact Factor: 3.75). 05/2008; 179(4):1227-33; discussion 1233-4. DOI: 10.1016/j.juro.2007.11.047
Source: PubMed

ABSTRACT The incidence of renal cell carcinoma is increasing due to the incidental detection of small renal masses. Resection, predominantly by nephron sparing surgery, remains the standard of care due to its durable oncological outcomes. Active surveillance and ablative technologies have emerged as alternatives to surgery in select patients. We performed a meta-analysis of published data evaluating nephron sparing surgery, cryoablation, radio frequency ablation and observation for small renal masses to define the current data.
A MEDLINE search was performed for clinically localized sporadic renal masses. Patient age, tumor size, duration of followup, available pathological data and oncological outcomes were evaluated.
A total of 99 studies representing 6,471 lesions were analyzed. Significant differences in mean patient age (p <0.001), tumor size (p <0.001) and followup duration (p <0.001) were detected among treatment modalities. The incidence of unknown/indeterminate pathological findings was significantly different among cryoablation, radio frequency ablation and observation (p = 0.003), and a significant difference in the rates of malignancy among lesions with known pathological results was detected (p = 0.001). Compared to nephron sparing surgery significantly increased local progression rates were calculated for cryoablation (RR = 7.45) and radio frequency ablation (RR = 18.23). However, no statistical differences were detected in the incidence of metastatic progression regardless of whether lesions were excised, ablated or observed.
Nephron sparing surgery, ablation and surveillance are viable strategies for small renal masses based on short-term and intermediate term oncological outcomes. However, a significant selection bias exists in the application of these techniques. While long-term data have demonstrated durable outcomes for nephron sparing surgery, extended oncological efficacy is lacking for ablation and surveillance strategies. The extent to which treatment alters the natural history of small renal masses is not yet established.

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    ABSTRACT: A growing body of retrospective literature is emerging regarding active surveillance (AS) for patients with small renal masses (SRMs). There are limited prospective data evaluating the effectiveness of AS compared to primary intervention (PI). To determine the characteristics and clinical outcomes of patients who chose AS for management of their SRM. From 2009 to 2014, the multi-institutional Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) registry prospectively enrolled 497 patients with solid renal masses ≤4.0cm who chose PI or AS. AS versus PI. The registry was designed and powered as a noninferiority study based on historic recurrence rates for PI. Analyses were performed in an intention-to-treat manner. Primary outcomes were overall survival (OS) and cancer-specific survival (CSS). Of the 497 patients enrolled, 274 (55%) chose PI and 223 (45%) chose AS, of whom 21 (9%) crossed over to delayed intervention. AS patients were older, had worse Eastern Cooperative Oncology Group scores, total comorbidities, and cardiovascular comorbidities, had smaller tumors, and more often had multiple and bilateral lesions. OS for PI and AS was 98% and 96% at 2 yr, and 92% and 75% at 5 yr, respectively (log rank, p=0.06). At 5 yr, CSS was 99% and 100% for PI and AS, respectively (p=0.3). AS was not predictive of OS or CSS in regression modeling with relatively short follow-up. In a well-selected cohort with up to 5 yr of prospective follow-up, AS was not inferior to PI. The current report is among the first prospective analyses of patients electing for active surveillance of a small renal mass. Discussion of active surveillance should become part of the standard discussion for management of small renal masses. Copyright © 2015. Published by Elsevier B.V.
    European Urology 02/2015; DOI:10.1016/j.eururo.2015.02.001 · 12.48 Impact Factor
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    • "L'incidence des tumeurs du rein n'a cessé de croître ces vingt dernières années dans les pays occidentaux, principalement du fait de la généralisation des examens d'imagerie abdominale [1]. La néphrectomie partielle par voie ouverte (NPO) est devenue la technique de référence pour les tumeurs T1 inférieures ou égales à 7 cm. "
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    ABSTRACT: To compare perioperative outcomes of robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) in a single French institution. Between February 2008 and April 2012, 98 patients underwent RAPN (n=54) or NPL (n=44) for a kidney tumor. Demographic data, perioperative and pathological outcomes were compared using Student's test and χ2 for continuous and categorical variables, respectively. Both groups were comparable for age, BMI, American Society of Anesthesiologists classification (ASA) and preoperative renal function (MDRD clearance). Tumor complexity was increased in the RAPN group (55.5 % vs. 29.5 % RENAL score≥2, P=0.05). There was no significant difference in terms of operative time (191 vs. 202min, P=0.2), tumor size (35 vs. 30mm, P=0.1) or positive margins (2 vs. 5, P=0.14). However, there was a significant decrease in warm ischemia time (18 vs. 25.6min, P=0.004) and hospital stay (5.1 vs. 6.9 days, P=0.003) for RAPN. Estimated blood loss was greater in the RAPN group (490 vs. 280mL, P=0.003), but the numbers of transfusions were similar (5 vs. 4 patients, P=0.96). Urinary tract was more frequently entered in the RAPN group (28 vs. 12, P=0.009). The complication rate was similar in both groups (28 % vs. 32 %, P=0.66). RAPN is feasible and reproducible. As in previous publications, our study confirms a potential benefit of RAPN concerning warm ischemia.
    Progrès en Urologie 03/2013; 23(3):176-83. · 0.77 Impact Factor
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    • "L'incidence des tumeurs du rein n'a cessé de croître ces vingt dernières années dans les pays occidentaux, principalement du fait de la généralisation des examens d'imagerie abdominale [1]. La néphrectomie partielle par voie ouverte (NPO) est devenue la technique de référence pour les tumeurs T1 inférieures ou égales à 7 cm. "
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    ABSTRACT: Objective To compare perioperative outcomes of robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) in a single French institution. Patients Between February 2008 and April 2012, 98 patients underwent RAPN (n = 54) or NPL (n = 44) for a kidney tumor. Demographic data, perioperative and pathological outcomes were compared using Student's test and χ2 for continuous and categorical variables, respectively. Results Both groups were comparable for age, BMI, American Society of Anesthesiologists classification (ASA) and preoperative renal function (MDRD clearance). Tumor complexity was increased in the RAPN group (55.5 % vs. 29.5 % RENAL score ≥ 2, P = 0.05). There was no significant difference in terms of operative time (191 vs. 202 min, P = 0.2), tumor size (35 vs. 30 mm, P = 0.1) or positive margins (2 vs. 5, P = 0.14). However, there was a significant decrease in warm ischemia time (18 vs. 25.6 min, P = 0.004) and hospital stay (5.1 vs. 6.9 days, P = 0.003) for RAPN. Estimated blood loss was greater in the RAPN group (490 vs. 280 mL, P = 0.003), but the numbers of transfusions were similar (5 vs. 4 patients, P = 0.96). Urinary tract was more frequently entered in the RAPN group (28 vs. 12, P = 0.009). The complication rate was similar in both groups (28 % vs. 32 %, P = 0.66). Conclusion RAPN is feasible and reproducible. As in previous publications, our study confirms a potential benefit of RAPN concerning warm ischemia.
    Progrès en Urologie 03/2013; 23(3):176–183. DOI:10.1016/j.purol.2012.09.017 · 0.77 Impact Factor
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