The Analysis Of Comparison Of Clinical Efficacy Of Surgical Approach In Treatment Of Localized Renal Carcinoma

Objective1、Radical nephrectomy is the gold standard for the treatment of localized renal cell carcinoma. With the development of imaging technology and the enhancement of people’s Awareness of Physical examination, The Early, accidental, asymptomatic small renal cancer detection rate is gradually increased. Because partial nephrectomy reduces unnecessary nephrectomy and saves part of side kidney function, so it become valued Increasingly, At present,it is still controversial in whether people choose partial nephrectomy as the Surgical approach of treating the localized renal cell carcinoma which have normal contralateral kidney function. Therefore, we will Systematically review relevant literature comparing oncological outcomes of partial nephrectomy and radical nephrectomy for localized renal carcinoma. We want to know that whether there were significant differences between partial nephrectomy and radical nephrectomy in the oncological outcomes, inculde of the 5-year overall survivl,5-year cancer specific survival,10-year overall survivl,10-year cancer specific survival,5-year recurrence free survival,10-year recurrence free survival, the incidence of complications, the morbidity of chronic kidney disease, tumor recurrence, tumor metastasis in order to provide evidence for the selection of clinical operation mode.2、To evaluate the clinical efficacy and safety of retroperitoneal laparoscopic radical nephrectomy and open radical nephrectomy in treating localized renal cell carcinomaMethods1、Comparative Oncological Outcomes of Partial and Radical Nephrectomy for Localized Renal Carcinoma:A Systematic Review and Meta-Analysis:(1)Data sources and retrieval strategy:Relevant databases including the Cochrane Library, Medline, Embase, Web of Science, China Biology Medicine disc, China National Knowledge Internet and WANGFANG were searched up to March 2014. The relative clinical controlled trials which evaluated the oncological outcomes of partial nephrectomy and Radical nephrectomy for localized renal carcinoma were analyzed by using the Stata (version 10.0). According to Cochrane Handbook5.0 retrieval strategy to develop search strategies, search strategies were adjusted according to the specific circumstances of the database, use the following search terms:Partial nephrectomy、Nephron-sparing surgery Radical nephrectomy、 Renal cell carcinoma% Renal neoplasm、Renal mass.(2) Inclusion criteria and exclusion criteria:①The type of Study:Randomized controlled trials and/or Quasi-randomized control trials are about the comparing oncological outcomes of partial nephrectomy and radical nephrectomy for localized renal carcinoma. The sample size has clearly defined. The Collection method of data is Reasonable and Logical. Data analysis method is correct. Either open surgery or laparoscopic surgery and whether the use of randomization and blinding. ② Case Type:The patient whose Contralateral renal function are normal have Localized renal cell carcinoma (T1NOMO-T2NOMO) which was unilateral and single. The patient who have solitary kidney or who have bilateral renal cell carcinoma or who have multiple renal cell carcinoma or who have distant metastatic renal cell carcinoma or who have Lymph node metastasis renal cell carcinoma or who was operated with Radical nephrectomy or partial nephrectomy at the second time are excluded. ③The type of outcomes:The postoperative 5-year overall survival, the postoperative 10-year overall survival, the postoperative 5-year cancer specific survival, the postoperative 10-year cancer specific survival, the rate of Complications, the rate of the postoperative tumor recurrence, the rate of the postoperative tumor metastasis chronic kidney disease.(3) Statistical analysis:we will use the software of stata 10 to analyze the postoperative 5-year overall survival, the postoperative 10-year overall survival, the postoperative 5-year cancer specific survival, the postoperative 10-year cancer specific survival, the postoperative 5-year recurrence free survival, the postoperative 10-year recurrence free survival with the method of inverse variance. We will analyze the rate of complications,the rate of the postoperative tumor recurrence,the rate of the postoperative tumor metastasis chronic kidney disease with the method of Mantel Haenszel. We will use the relative Risk and its 95% confidence interval As statistics. There were significant differences between partial nephrectomy and radical nephrectomy when the hypothesis test P values less than 0.05(P≤0.05). We will use the Statistics of and 12 to test the Statistical heterogeneity of all the result which were included. The test level is α=0.1. when P≥0.1 and I2≤50%,we will consider that there are nothing of Statistical heterogeneity between all the results which were included.We will use the fixed effects model to analyze the data from the study. When P< 0.1 and I2> 50%, we will consider that there are apparent Statistical heterogeneity between all the results which were included.We will use the random effects model to analyze the data from the study. If there are significant clinical heterogeneity, we will use the descriptive analysis. At last, we will use the method of egger linear regression to detect quantitative the study which were included in order to determine the presence of publication bias.2、The clinical data of 248 cases of localized renal cell carcinoma of whom 74 cases underwent retroperitoneal laparoscopic radical nephrectomy (laparoscopy group) and 174 cases underwent open radical nephrectomy(open surgery group) were retrospectively analyzed. The general clinical data and the surgical curative effect indexes were compared between the two groups.Results1、Comparative Oncological Outcomes of Partial and Radical Nephrectomy for Localized Renal Carcinoma:A Systematic Review and Meta-Analysis:(1) The results of the study included from literature searches:According to inclusion criteria and exclusion criteria, there are 33 study which meet the requirements. A total of 33,520 cases, there are 9190 cases about the patient who were operated through partial nephrectomy. There are 24340 cases about the patient who were operated through radical nephrectomy.(2) There are 14 study comparing the postoperative 5-year overall survival between partial and radical nephrectomy for localized renal carcinoma. There are a total of 19796 cases which are included. There are 3924 cases about the patient who were operated through partial nephrectomy. There are 15872 cases about the patient who were operated through radical nephrectomy. Due to I2=45.3%<50%, we consider that there are nothing of Statistical heterogeneity between all the results which were included. We will use the fixed effects model to analyze the data from the study. The results of Meta analysis point out that the merged value of relative risk is 1.037 and its confidence interval of 95% is 1.023 to 1.050. There were no significant differences between partial nephrectomy and radical nephrectomy in Postoperative 5-year overall survival (P>0.05).It points out that partial nephrectomy offered equivalent effectiveness to radical nephrectomy in Postoperative 5-year overall survival.(3) There are 12 study comparing the postoperative 10-year overall survival between partial and radical nephrectomy for localized renal carcinoma. There are a total of 9410 cases which are included. There are 3088 cases about the patient who were operated through partial nephrectomy. There are 6322 cases about the patient who were operated through radical nephrectomy. Due to I2=74.4%>50%, we consider that there are obvious Statistical heterogeneity between all the results which were included. We will use the random effects model to analyze the data from the study. The results of Meta analysis point out that the merged value of relative risk is 1.046 and its confidence interval of 95% is 1.020 to 1.073. There were no significant differences between partial nephrectomy and radical nephrectomy in Postoperative 10-year overall survival (P>0.05).It points out that partial nephrectomy offered equivalent effectiveness to radical nephrectomy in Postoperative 10-year overall survival.(4) There are 14 study comparing the postoperative 5-year cancer specific survival between partial nephrectomy and radical nephrectomy for localized renal carcinoma. There are a total of 19153 cases which are included. There are 4057 cases about the patient who were operated through partial nephrectomy. There are 15096 cases about the patient who were operated through radical nephrectomy. Due to 12=64.7%>50%, we consider that there are nothing of Statistical heterogeneity between all the results which were included. We will use the random effects model to analyze the data from the study. The results of Meta analysis point out that the merged value of relative risk is 1.022 and its confidence interval of 95% is 1.006 to 1.038. There were no significant differences between partial nephrectomy and radical nephrectomy in Postoperative 5-year cancer specific survival (P>0.05).It points out that partial nephrectomy offered equivalent effectiveness to radical nephrectomy in Postoperative 5-year cancer specific survival.(5) There are 11 study comparing the postoperative 10-year cancer specific survival between partial nephrectomy and radical nephrectomy for localized renal carcinoma. There are a total of 9212 cases which are included. There are 2999 cases about the patient who were operated through partial nephrectomy. There are 6213 cases about the patient who were operated through radical nephrectomy. Due to I2=80.4%>50%, we consider that there are obvious Statistical heterogeneity between all the results which were included. We will use the random effects model to analyze the data from the study. The results of Meta analysis point out that the merged value of relative risk is 1.018 and its confidence interval of 95% is 0.992 to 1.043. There were no significant differences between partial nephrectomy and radical nephrectomy in Postoperative 10-year cancer specific survival (P>0.05).It points out that partial nephrectomy offered equivalent effectiveness to radical nephrectomy in Postoperative 10-year cancer specific survival 1.(6) There are 7 study comparing the postoperative 5-year recurrence free survival between partial and radical nephrectomy for localized renal carcinoma. There are a total of 2308 cases which are included. There are 557 cases about the patient who were operated through partial nephrectomy. There are 1731 cases about the patient who were operated through radical nephrectomy. Due to I2=67.0%>50%, we consider that there are obvious Statistical heterogeneity between all the results which were included. We will use the random effects model to analyze the data from the study. The results of Meta analysis point out that the merged value of relative risk is 1.047 and its confidence interval of 95% is 0.990 to 1.107. There were no significant differences between partial nephrectomy and radical nephrectomy in Postoperative 5-year recurrence free survival (P>0.05).It points out that partial nephrectomy offered equivalent effectiveness to radical nephrectomy in Postoperative 5-year recurrence free survival.(7) There are 5 study comparing the postoperative 10-year recurrence free survival between partial and radical nephrectomy for localized renal carcinoma. There are a total of 1824 cases which are included. There are 677 cases about the patient who were operated through partial nephrectomy. There are 1147 cases about the patient who were operated through radical nephrectomy. Due to 12=73.6%>50%, we consider that there are obvious Statistical heterogeneity between all the results which were included. We will use the random effects model to analyze the data from the study. The results of Meta analysis point out that the merged value of relative risk is 1.041 and its confidence interval of 95% is 0.975 to 1.112. There were no significant differences between partial nephrectomy and radical nephrectomy in Postoperative 10-year recurrence free survival (P>0.05).It points out that partial nephrectomy offered equivalent effectiveness to radical nephrectomy in Postoperative 10-year recurrence free survival.(8) There are 5 study comparing the incidence of postoperative tumor recurrence between partial nephrectomy and radical nephrectomy for localized renal carcinoma. There are a total of 2564 cases which are included. There are 734 cases about the patient who were operated through partial nephrectomy. There are 1830 cases about the patient who were operated through radical nephrectomy. Due to 12=19.9%<50%, we consider that there are nothing of Statistical heterogeneity between all the results which were included. We will use the fixed effects model to analyze the data from the study. The results of Meta analysis point out that the merged value of relative risk is 1.375 and its confidence interval of 95% is 0.920 to 2.057. There were no significant differences between partial nephrectomy and radical nephrectomy in the incidence of Postoperative tumor recurrence (P>0.05).It points out that partial nephrectomy offered equivalent effectiveness to radical nephrectomy in the incidence of Postoperative tumor recurrence.(9) There are 7 study comparing the incidence of postoperative tumor metastasis between partial nephrectomy and radical nephrectomy for localized renal carcinoma. There are a total of 6719 cases which are included. There are 2146 cases about the patient who were operated through partial nephrectomy. There are 4573 cases about the patient who were operated through radical nephrectomy. Due to I2=66.8%>50%, we consider that there are nothing of Statistical heterogeneity between all the results which were included. We will use the random effects model to analyze the data from the study. The results of Meta analysis point out that the merged value of relative risk is 0.520 and its confidence interval of 95% is 0.260 to 1.039. There were no significant differences between partial nephrectomy and radical nephrectomy in the incidence of Postoperative tumor metastasis (P>0.05).It points out that partial nephrectomy offered equivalent effectiveness to radical nephrectomy in the incidence of Postoperative tumor metastasis.(10) There are 8 study comparing the incidence of complications between partial and radical nephrectomy for localized renal carcinoma. There are a total of 3201 cases which are included. There are 1320 cases about the patient who were operated through partial nephrectomy. There are 1881 cases about the patient who were operated through radical nephrectomy. Due to I2=62.3%>50%, we consider that there are nothing of Statistical heterogeneity between all the results which were included. We will use the random effects model to analyze the data from the study. The results of Meta analysis point out that the merged value of relative risk is 1.397 and its confidence interval of 95% is 1.078 to 1.811. There were significant differences between partial nephrectomy and radical nephrectomy in The incidence of complications (P<0.05).It points out that radical nephrectomy has an advantage than partial nephrectomy in the incidence of complications.(11) There are 7 study comparing the morbidity of chronic kidney disease between partial and radical nephrectomy for localized renal carcinoma. There are a total of 3180 cases which are included. There are 1327 cases about the patient who were operated through partial nephrectomy. There are 1853cases about the patient who were operated through radical nephrectomy. Due to I2=88.8%>50%, we consider that there are nothing of Statistical heterogeneity between all the results which were included. We will use the random effects model to analyze the data from the study. The results of Meta analysis point out that the merged value of relative risk is 0.416 and its confidence interval of 95% is 0.295 to 0.587. There were significant differences between partial nephrectomy and radical nephrectomy in the morbidity of chronic kidney disease (P<0.05).It points out that partial nephrectomy has an advantage than radical nephrectomy in the morbidity of chronic kidney disease.(12) Detect ion of publication bias:we use the method of egger linear regression to detect quantitative the study which were included. The result shows that 95% CI of Intercept in linear regression equation contains 0 and the hypothesis testing is P>0.05 on our meta analysis. It proof that meta analysis of the various outcome measures funnel plot is symmetric. It point out that there is no significant publication bias.2^ There were no difference between the two groups in age, sex constituent ratio, BMI, max dimeter of tumor, tumor location, tumor stage and pathologic diagnosis(P>0.05).But the surgical curative effect indexes, such as operation time, incision length, blood loss, recovery time of bowel function, start eating time after surgery, postoperative drainage tubes removed time, postoperative Ambulation time, postoperative hospital stay, complication incidence rate, the laparoscopy group was significantly different from the open group(p<0.05). There were no difference between the two groups in follow-up survival rate (P>0.05).Conclusions1、Our meta analysis proof that partial nephrectomy offered equivalent effectiveness to radical nephrectomy in Postoperative 5-year overall survival and Postoperative 10-year overall survival, Postoperative 5-year cancer specific survival and Postoperative 10-year cancer specific survival,5-year recurrence free survival and 10-year recurrence free survival. There were no significant differences between partial nephrectomy and radical nephrectomy in the incidence of Postoperative tumor metastasis and incidence of postoperative tumor metastasis. It shows that partial nephrectomy has never increase the risk of tumor recurrence and metastasis because of not removing an entire kidney. Though radical nephrectomy is superior to prevent the complications than partial nephrectomy, partial nephrectomy could maximally preserve the function of remaining kidney and confer a lower risk of chronic kidney disease. Complications may be reduced with the surgeon operating techniques and new technologies increasingly skilled in medical applications. Partial nephrectomy has an advantage than radical nephrectomy in the morbidity of chronic kidney disease. In chronic kidney disease, the incidence and mortality of cardiovascular disease were significantly higher than in the general population of the same age. This means reducing the risk of chronic kidney disease can indirectly improve patient survival. However, there are only 4 randomized controlled trial in our meta analysis, the other 29 study all are retrospective cohort study. There is a certain degree of bias and confounding factors that is existing in our meta analysis. The quality of evidence is relatively low. It influences the authenticity and reliability of the combined effect. In a word, partial nephrectomy is an effective and reliable treatment for localized renal cell carcinoma, partial nephrectomy reduces unnecessary nephrectomy and saves part of side kidney function and avoids the defects of over-treatment. partial nephrectomy reduce the risk of postoperative patients with chronic kidney disease. However, whether people choose the partial nephrectomy is according to the Tumor size, the tumor location, condition of patients and doctors experience. At last, we are looking forward to appearing more high quality randomized controlled trials standardization so that we can more Systematically and comprehensively and rigorously review relevant literature comparing oncological outcomes of partial nephrectomy and radical nephrectomy for localized renal carcinoma.2、Compared with open radical nephrectomy, retroperitoneal laparoscopic radical nephrectomy has the advantages of shorter operation times, minimal invasion, lower blood loss, shorter postoperative hospital stay, rapid recovery, fewer complications and has a significant effect and a higher safety.