循證醫(yī)學作業(yè)

1、循證醫(yī)學作業(yè)錢君海1、臨床資料患者，男性， 34 歲，因體檢發(fā)現右腎下極占位一天，門診擬“右腎癌”收入。入院檢查未見有明顯陽性體征。入院檢查雙腎ct提示“右腎下極 4*4cm占位，腎癌首先考慮”。左腎功能良好。初步診斷 : 右腎癌 t1n0m0 。2、臨床問題青年男性患者體檢發(fā)現右腎占位，臨床分期t1an0m0 ，且腎腫瘤位于腎下極，對側腎功手術, 能正常。本例患者是否可以行保留腎單位手術(nss) 3( 文獻證據檢索數據文獻檢索資源 : cochrane library() pubmed-clinical queries 中華泌尿外科學會網檢索詞 : rena

2、l cell carcinoma rcc nephron-sparing surgery nss 腎癌 保留腎單位手術在 cochrane library()檢索到的文獻title a prospective randomized eortc intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. links export

3、central citation comments comment in: eur urol. 2007 jun;51(6):1475-6. pmid: 17287074. author(s) van poppel h, da pozzo l, albrecht w, matveev v, bono a, borkowski a, marechal jm, klotz l, skinner e, keane t, claessens i, sylvester r, european organization for research and treatment of cancer (eortc

4、), national cancer institute of canada clinical trials group (ncic ctg), southwest oncology group (swog), eastern cooperative oncology group (ecog) source european urology date of publication2007 jun volume 51 issue 6 pages 1606-15 abstract objectives: this study compared the complications and the c

5、ancer control of elective nephron-sparing surgery (nss) and radical nephrectomy (rn) in patients with a small (or=5 cm), solitary, low-stage n0 m0 tumour suspicious for renal cell carcinoma (rcc) and a normal contralateral kidney. methods: 541 patients were randomised in a prospective, multicentre,

6、phase 3 trial to undergo nss (n=268) or rn (n=273) together with a limited lymph node dissection. results: this publication reports only on the complications reported for both surgical methods. the rate of perioperative blood loss0.5l was slightly higher after rn (96.0% vs. 87.2%) and the rate of se

7、vere haemorrhage was slightly higher after nss (3.1% vs. 1.2%). ten patients (4.4%), all of whom were treated with nss, developed urinary fistulas. pleural damage (11.5% for nss vs. 9.3% for rn) and spleen damage (0.4% for nss and 0.4% for rn) were observed with similar rates in both groups. postope

8、rative computed tomography scanning abnormalities were seen in 5.8% of nss and 2.0% of rn patients. reoperation for complications was necessary in 4.4% of nss and 2.4% of rn patients. conclusions: nss for small, easily resectable, incidentally discovered rcc in the presence of a normal contralateral

9、 kidney can be performed safely with slightly higher complication rates than after rn. the oncologic results are eagerly awaited to confirm that nss is an acceptable approach for small asymptomatic rcc. medical subject carcinoma, renal cell pathology; *surgery; disease progression; headings (mesh)ki

10、dney neoplasms pathology; *surgery ; neoplasm staging; nephrectomy *methods; nephrons; *postoperative complications; prospective studies; treatment outcome mesh check words aged; female; humans; male; middle aged correspondence addressdepartment of urology, university hospital gasthuisberg, katho li

11、eke universiteit leuven, leuven, belgium. hendrik.vanpoppeluz.kuleuven.ac.be accession number pubmed 17140723 cochrane group code sr-prostate publication type clinical trial, phase iii; comparative study; journal article; multicenter study; randomized controlled trial; research support, n.i.h., extr

12、amural; research support, non-u.s. govt id cn-00586285 在 pubmed 上檢索到的文章oncological efficacy and safety of nephron-sparing surgery for selected patients with locally advanced renal cell carcinoma margulis v, tamboli p, jacobsohn km, swanson da, wood cg. bju int. 2007 dec;100(6):1235-9. which is the r

13、eal gold standard for small-volume renal tumors? radical nephrectomy versus nephron-sparing surgery manikandan r, srinivasan v, ran a. j endourol. 2004 feb;18(1):39-44. 在中華醫(yī)學會泌尿外科網站檢索到的文件腎細胞癌診治指南 (2005 試行版 ) 中華醫(yī)學會泌尿外科分會4( 證據評價a 級: 大型隨機對照試驗或cochrane 系統(tǒng)評價。 b 級: 小型隨機對照試驗、半隨機對照試驗或交叉設計、隊列設計、前后對照的試驗。c 級:

14、病例 2 對照試驗及橫斷面試驗、非隨機對照試驗。d 級: 描述性研究及專家意見。a prospective randomized eortc intergroup phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. 證據級別 :a 級(該研究為 cochrane 系統(tǒng)評價 ) oncological efficacy and safety of nephron-sparin

15、g surgery for selected patients with locally advanced renal cell carcinoma 證據級別 :a 級(該研究為 cochrane 系統(tǒng)評價 ) which is the real gold standard for small-volume renal tumors? radical nephrectomy versus nephron-sparing surgery。證據級別 :a 級(該研究為 cochrane 系統(tǒng)評價 ) 腎細胞癌診治指南 (2005 試行版 ) 證據級別 :a 五(實施決策患者是否可以進行nss手術,

16、 根據中華醫(yī)學會泌尿外科分會的腎細胞癌診療指南(2005 年試行版 ) 中關于 nss手術的描述提示 :nss適應證 : 腎癌發(fā)生于解剖性或功能性的孤立腎，根治性腎切除術將會導致腎功能不全或尿毒癥的患者，如先天性孤立腎、對側腎功能不全或無功能者、以及雙側腎癌等。nss相對適應證 : 腎癌對側腎存在某些良性疾病，如腎結石、慢性腎盂腎炎或其他可能導致腎功能惡化的疾病( 如高血壓，糖尿病，腎動脈窄等) 患者。nss適應證和相對適應證對腫瘤大小沒有具體限定。nss可選擇適應證 : 臨床分期 t期( 腫瘤?4cm)，腫瘤位于腎臟周邊，單發(fā)的無癥狀 1a 腎癌，對側腎功能正常者可選擇實施nss 。本患者的臨床病理分期為t1a,屬于指南的 nss 可選擇適應癥。根據 a prospective randomized eortc intergroup phase 3 study comp