Review Article
Renal functional and cardiovascular outcomes of partial nephrectomy versus radical nephrectomy for renal tumors: a systematic review and meta-analysis

https://doi.org/10.1016/j.urolonc.2022.11.024Get rights and content

Highlights

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    Evidence has shown controversial results between radical and partial nephrectomy.

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    Partial nephrectomy shows a decrease risk of early-stage chronic kidney disease.

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    Partial nephrectomy demonstrated a protective effect on cardiovascular events.

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    Benefit of partial nephrectomy is not maintained in advanced chronic kidney disease.

Abstract

This systematic review and meta-analysis aimed to evaluate the postoperative renal and cardiovascular outcomes of partial nephrectomy (PN) versus radical nephrectomy (RN) for the treatment of renal carcinoma. A systematic literature search was performed on scientific databases including Scopus, Web of Science, MEDLINE, and EMBASE from their inception to September 2021. Studies comparing renal and cardiovascular outcomes between PN and RN in patients with renal cancer were included. The generic inverse variance method with random-effects models was used to determine the pooled hazard ratios and odds ratio for each outcome. Quality Assessment for observational studies was guided by the New-Castle Ottawa Scale. Overall, a total of 31 studies (n=51,866) reported renal outcomes, while 11 studies (n= 101,678) reported cardiovascular outcomes. When compared to PN, RN had a higher rate of new-onset postoperative EGFR <60 mL/min/1.73 m2 (HR 3.39; CI 2.45 - 4.70; I2=93%; P=<0.00001) and EGFR <45 mL/min/1.73 m2 (HR 4.70; CI 2.26 - 9.79; I2=98%; P=<0.0001). No difference was observed in new-onset advanced kidney disease and end-stage renal disease. A 19% reduction in cardiovascular events was observed in the PN group (HR 0.81; CI 0.70 - 0.93, P=0.002). No protective effect of PN was observed in new-onset or worsening hypertension (HR 0.85; CI 0.64 - 1.14, P=0.28) nor myocardial infarction (HR 0.86; CI 0.71 - 1.04, P=0.13). PN was associated with a decreased risk of postoperative early-stage CKD and cardiovascular events compared with RN. However, no benefit of PN over RN was observed in advanced CKD, new-onset or worsening hypertension, myocardial infarction, and cardiovascular mortality.

Introduction

Renal cell carcinoma (RCC) accounts for 90% of all kidney malignancies and is often small and localized at presentation [1]. It represents approximately 3% of all cancers, with an annual incidence increase of 2% [2]. Partial nephrectomy (PN) and radical nephrectomy (RN) are curative in most patients with localized disease. Traditionally, RN has been the gold standard treatment for kidney cancer and the most common approach for small renal masses. However, PN now corresponds for about 60% of all nephrectomies performed in specialized centers as RN has been associated with an increased risk of chronic kidney disease (CKD) and the possibility of overtreating small renal masses [3,4].

Several studies have explored the cardiovascular and renal function outcomes after PN or RN for localized RCC. Results of previous studies indicate that PN improves overall survival and renal function preservation and reduces the risk of CKD and cardiovascular-related events [5], [6], [7]. Based on these observations, recent guidelines recommend performing PN whenever technically feasible, independently of the size of the tumor [8]. Nonetheless, these conclusions result primarily from retrospective studies with a limited number of patients and their inherited bias. Data became controversial after the results of the European Organization for the Research and Treatment of Cancer randomized trial (EORTC 30904) were published. In this study, PN failed to demonstrate protection against advanced CKD, end-stage renal disease (ESRD), and presented a higher rate of cardiovascular mortality [9]. However, its conclusions remain questionable due to its methodological bias and significant loss of follow-up.

Due to these controversial data, Wang et al. conducted a meta-analysis with the aim of clarifying this issue. In this study, PN demonstrated a reduction in the postoperative risk of new-onset CKD. However, PN did not show a protective effect on cardiovascular outcomes [10]. Therefore, we conducted an updated systematic review and meta-analysis integrating new evidence of renal and cardiovascular outcomes of PN and RN for the treatment of RCC.

Section snippets

Inclusion and exclusion criterion

Eligible studies were included if they compared renal function and cardiovascular adverse events in adults with RCC that underwent either partial or radical nephrectomy with at least three months of follow-up and reported an adjusted effect estimate (hazard ratio or odds ratio). Exclusion criterions included patients with metastatic renal disease, bilateral kidney tumors, or a solitary kidney. Only articles written in English were included. No limitations on a time frame were considered. Only

Data retrieval & quality assessment

The search results are shown in the PRISMA flow chart [Fig. 1]. Our electronic search identified a total of (n=4,304) studies for title and abstract screening. A substantial level of agreement between reviewers (k=0.71) was obtained. From these, 242 publications were identified as eligible for full-text screening (k=0.86). A total of 64 studies were included in the qualitative analysis. Thirty-nine studies met the inclusion criteria for quantitative analyses. Thirty-one studies described

Discussion

Indications for PN have broadened over the last years due to various retrospective studies showing the superiority of PN compared with RN for the treatment of RCC. The present meta-analysis reports up-to-date evidence on renal and cardiovascular outcomes after RN versus PN to appraise its specific benefits and conciliate conflicting data. Compared to PN, RN was associated with a 3-fold and 4-fold increase in the risk of developing new-onset kidney disease with EGFR <60 mL/min/1.73m2 and <45

Conclusion

The present systematic review of literature and meta-analysis shows that PN lowers the risk of new-onset postoperative CKD with EGFR <60 mL/min/1.73 m2 and EGFR <45 mL/min/1.73 m2 after surgical treatment for localized renal tumors. However, the preservation of renal parenchyma by PN did not protect against advanced CKD or ESRD. With respect to cardiovascular outcomes, PN proved to have an independent protective effect on composite cardiovascular events but failed to establish the same effect

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