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European UrologyVolume 60, issue 3, pages e19-e28, September 2011
Reply from Authors re: Christian G. Stief. If a Partial Nephrectomy Could Be Done Safely for a Renal Tumor, Would Radical Nephrectomy Be Considered Malpractice? Eur Urol 2011;60:465–6
Published online 9 June 2011, pages 466 - 467
Refers to article:
Routine Adrenalectomy in Patients with Locally Advanced Renal Cell Cancer Does Not Offer Oncologic Benefit and Places a Significant Portion of Patients at Risk for an Asynchronous Metastasis in a Solitary Adrenal Gland
Accepted 7 April 2011
September 2011 (Vol. 60, Issue 3, pages 458 - 464)
Refers to article:
If a Partial Nephrectomy Could Be Done Safely for a Renal Tumor, Would Radical Nephrectomy Be Considered Malpractice?
September 2011 (Vol. 60, Issue 3, pages 465 - 466)
We appreciate the thoughtful editorial by Dr. Stief . Particularly insightful are Dr. Stief's observations about “eminence–based” practice versus evidence-based practice. Unfortunately, eminence-based practice has long been the modus operandi in surgical tradition, and urology is no exception. All “evidence,” however, is not created equal, and we must know the weaknesses of the various study designs to know how much stock we should put in the conclusions. It has been said that “if we torture the data enough, it will eventually tell us what we want to hear”.
It has been >40 yr since Dr. Robson first described radical nephrectomy (RN) in a very few patients . Finally now, as a specialty, we have adequately demonstrated that a less aggressive approach (including partial nephrectomy [PN] and sparing of the ipsilateral adrenal gland) neither compromises cancer control nor increases the risk of cancer-specific death.
But to take the next step and claim that we have proven that these less aggressive approaches to renal tumors are superior cannot be done at this juncture and, quite frankly, may never be done. Despite our institutional preference for sparing the normal kidney, when technically feasible, and the adrenal gland, our specialty has not been able to supply irrefutable evidence that PN is superior to RN. Although multiple single-institution and population-based studies in North America suggest that improved overall survival is associated with PN, all of these studies were retrospective and nonrandomized and therefore subject to confounding that may not be accounted for with statistical models. In fact, recent results of a randomized noninferiority trial comparing PN and RN showed that PN was not superior in terms of overall survival . The trial has several flaws including the change of the primary end point midway through the trial, the inability to complete accrual and the early closing of the trial, the lack of evaluation of renal function after surgery, and the poor quantification of comorbidities through a validated index; however, we cannot wholly discount the results. Even with these flaws, this trial has fewer biases than single-institution or population-based comparisons, and it remains possible that the observed survival benefit noted in these retrospective studies was merely a result of confounding and selection. It signals that we need to continue to study the issue of whether preservation of the normal kidney tissue offers any measurable benefit to the patient. Based on these data, it is not possible to condemn a urologist performing an RN. The biases introduced by an experienced urologist deciding which patients are appropriate for PN may be the exact reason why retrospective series show improved overall and cancer-specific survival.
In conclusion, we still have work to do. If we are to follow evidence-based medicine, we must conclude that we have not answered the question of whether less radical surgery such as PN and sparing of the ipsilateral adrenal gland will improve overall survival. We believe we have presented a strong case against the use of routine ipsilateral adrenalectomy and are unaware of any data that suggest adrenalectomy offers an advantage to a patient when preoperative imaging and intraoperative findings are negative. However, we note that our study has limitations. In the case of PN, we need to continue to study this issue to determine which patients are best served with nephron-sparing surgery. Our philosophy is that the historical stance of removing maximal normal tissue is not supported by the majority of current data. We advocate that, whenever appropriate, urologists should remove minimal amounts of normal tissue unless irrefutable evidence is presented demonstrating that this approach is inferior.
Conflicts of interest
The authors have nothing to disclose.
-  C. Stief. If a partial nephrectomy could be done safely for a renal tumor, would radical nephrectomy be considered malpractice?. Eur Urol. 2011;60:465-466 Abstract, Full-text, PDF, Crossref.
-  H. Motulsky. Intuitive biostatistics: a nonmathematical guide to statistical thinking. (Oxford Press, New York, NY, 2010)
-  C.J. Robson, B.M. Churchill, W. Anderson. The results of radical nephrectomy for renal cell carcinoma. J Urol. 1969;101:297-301
-  H. Van Poppel, L. Da Pozzo, W. Albrecht, et al. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol. 2011;59:543-552 Abstract, Full-text, PDF, Crossref.
Department of Urology, Mayo Clinic, Rochester, MN, USA
© 2011 European Association of Urology, Published by Elsevier B.V.
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