EURURO Vol. 72 No. 3

E61 476

Letter to the Editor
Reply to Lorenzo Marconi, Steven [3_TD$DIFF]MacLennan,
Thomas B.L. Lam[1_TD$DIFF], [4_TD$DIFF]et [5_TD$DIFF]al’s Letter to the Editor
re: [6_TD$DIFF]Maria [7_TD$DIFF]Carmen Mir, [8_TD$DIFF]Ithaar [9_TD$DIFF]Derweesh, [10_TD$DIFF]
Francesco [11_TD$DIFF]Porpiglia, [12_TD$DIFF]Homayoun [13_TD$DIFF]Zargar, [14_TD$DIFF]
Alexandre [15_TD$DIFF]Mottrie, [16_TD$DIFF]Riccardo [17_TD$DIFF]Autorino.
Partial Nephrectomy Versus Radical Nephrectomy for
Clinical T1b and T2 Renal Tumors: A Systematic Review
and Meta-analysis of Comparative Studies.
Eur Urol 2017;71:606–17
We read with great interest the letter by Marconi et al
regarding our recent systematic review and meta-analysis
. Indeed, the authors highlight the recognized methodo-
logical and philosophical points that need to be raised and
commented on in the discussion and interpretation of our
findings and synthesis, and those of systematic reviews and
meta-analyses of the surgical literature in general.
Our colleagues raise the concern regarding the well-
hewn limitation of meta-analyses with respect to inclusion
of heterogeneous data from observational or retrospective
analyses and the potential of flawed conclusions. They
further provide a detailed description of the shortcomings
of retrospective analysis and the potential cumulative effect
of selection bias. Their philosophical quibbles notwith-
standing, we respectfully disagree with their conclusions
regarding the validity of our methodology and analysis, and
the synthesis of the analysis that we proposed.
We applaud the European Association of Urology’s
guideline methodology and frequent and evidence-based
updates . Indeed, a systematic review, even of literature
flawed with limitations, may be best informed by a rigorous
meta-analysis to reduce bias in the narrative interpretation
. Use of observational studies in meta-analyses is an
accepted methodology , and our analysis reflects the
current state of the literature in the management of
localized renal cell carcinoma. To that end, in our narrative,
we have already acknowledged the limitations expounded
upon by our colleagues. Our methods are similar to the
elegant work of the systematic review and meta-analysis on
the management of localized renal cell carcinoma con-
ducted by the Agency for Healthcare Research and Quality
(USA), which informed the recently promulgated American
Urological Association guidelines
Importantly, our findings and limitations are reflective of
the current state of the literature with respect to manage-
ment of localized renal masses, and reflect observational
and mostly retrospective data. Our conclusions are mea-
sured and reflective of an emerging paradigm shift in the
management of localized renal malignancy, which is not
constrained by simple tumor size cutoffs when considering
application of nephron-sparing surgery, and which seeks to
address the tradeoff between functional benefit form
nephron-sparing surgery and increased risk of procedure-
specific complications inherent with partial nephrectomy in
the setting of pre-existing patient morbidity and life
expectancy . Such an approach recognizes emerging
data that suggest oncological similarity between partial and
radical nephrectomy in the setting of larger masses (cT1b+)
and renal functional benefit in select circumstances, which
nonetheless must be tempered with the knowledge of the
existing limitations of the literature
Ultimately, we share Marconi et al’s call for a random-
ized controlled trial to assess oncological efficacy and
functional effect of radical and partial nephrectomy in
clinical T1b and T2a mass. Indeed, the primary author of this
response was one of the main authors of a recently
presented clinical trial proposal (Campbell, Derweesh,
and Messing) that encompassed the aims that Marconi
et al call for Indeed, we strongly believe that the time is
nigh for us to proceed with this goal, and urge our North
American and European colleagues to collaborate on
bringing such a proposal to fruition.
Conflicts of interest: The authors have nothing to disclose.
References
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ava ilable at
journal homepage:
DOIs of original articles: , .
0302-2838/Published by Elsevier B.V. on behalf of European Association of Urology.