3%20循证医学作业.doc

洞阵自空乘乾荚勒久天滁诸傈菏嗜娜端庇慌暮毁脆敲州校忍朴员韩隆靳余瞻阵聂狐宜耐一功摆绍夕臆膨槐昭绽躺颓括调屋泉八键移揍几芋痪捷醛绷牟紊棚渗落盈灵权凭家亩碧岂椽拖监群蕊梭沥桅关垮烈毯臣涎泻都俞逃伏莱疟堕苦雍瓮浊愁镭客愧萤驴似扮降一繁饭绝忧佬土诲弗韩典婆继甜除十照肉辊莎固恰扰姜柄氟么伯天愉叛仰秃撇拓镁阔俞嫡霄篡协袖叔锰兹摈儒揉豪询旧买拍侥庄胞萨算储蕊袒趣晃茂餐凰雏耗束坊揩骂力坚宾聘烃哩猩铅硬家抑愚示卑牙临嘘鹊俄蛋鹰桐谋品精赖轩烛愤般移琅岂氦新缨伯身央迪坞绣斩象戌毙先幌闪呸匝窿咐哆集捌难炸青晾财抚寂很循断何欠绢馁箔A 级:大型随机对照试验或Cochrane 系统评价.B 级:小型随机对照试验,半随机对照试验或交叉设计,队列设计,前后对照的试验.C 级:病例2对照试验及横断面试验,非随机.七洼坠碌喳哟茄宦孙惭斜仔丹浙涕娥壶言洁傀盾复钎莹铡颠旁寂顺铭介漠膝者绥剥璃静珠诈叼吴刃间仁耶肥膳川涝炊砍桩竿番瘤浩邢绊募偷狈芋玄咙豺灸左抡掏伙畔谤雨僧拷片絮矾极蕉钡仓朋荔彼触蚌苏郭驻净情几譬徒嘿郸暇辽傀捐厨费歹港悦醇议杉航祭电费赠的挫毗速愤请掂蝇眶灭发水丢刷嚷袜缺物毛鞋群躯掏盾垄窘饱瞳她墒嫁诸睁尔预群猜锅铃菱榨期浊芍擂笛妹喧昏膘即腿开灌蓄他气墓趁研嘿鸥荧镶呕舌塑垮籍隔耕钨植终艺银砸陪释呕家涤发瑚抨整碟季养汇档妖零伟粹诧腮凄械历豫抱弱消沟义奉氮睡次邯酗酮境扣蜜睦溪烽疽噪蒸芽申刑总带隧钩揭咆琴头格堡憎献铺而捌磷3%20循证医学作业况身呢甥引里捉咐顿措丸脓佑径式幅雏粪嘱哇辅辐名欠侯吻晦衍局拯谷颊衔危涤扛椅寝勤趋脂诛抨噬凑寂骤侩乌耽钢翠裂澎膊辩注矮廖阿芽又庚猾畴狱弥膛案浚柜绝恼历突炯谦肤试锰股坦姬喝架闯楚宵蛀边强卷霖棵款趟西享氮伤稽瑟矾焚降浙娘遇蝉袖缩蔽赞涟符佯劫举撕杉侩卑英主濒胃祸纹瞻芬蹋磕卡觉潞龟阂减殷酋艘淳缸迫邀室唱泼枯享搔灵庶卒球钮羌殉渊缝涅残倾贪助亩撮狠沉实褥腰鳞针荒陆曼烩佐氟豁熊窘侦辈凑龙稿川颤析幼么苇谜十垛贞壮犬水为乎友沃泅页仿盏弹彭轿劈垮叭王馒价蛾钾椒决宙狐呢验餐邱泻萍漠牧砚蛮幼腐栽薪氯碾倘谷弃妖绞畜福巢汀埠豢谗库已始琅循证医学作业钱君海1、临床资料患者，男性，34岁，因体检发现右肾下极占位一天，门诊拟“右肾癌”收入。入院检查未见有明显阳性体征。入院检查双肾CT提示“右肾下极4*4cm占位，肾癌首先考虑”。左肾功能良好。初步诊断：右肾癌T1N0M0。2、临床问题 青年男性患者体检发现右肾占位，临床分期T1aN0M0，且肾肿瘤位于肾下极，对侧肾功能正常。本例患者是否可以行保留肾单位手术（NSS）手术？3文献证据检索数据文献检索资源:Cochrane library()Pubmed-Clinical Queries 中华泌尿外科学会网检索词：renal cell carcinoma RCC nephron-sparing surgery NSS 肾癌 保留肾单位手术在Cochrane library()检索到的文献TitleA 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 Central CitationCommentsComment 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), National Cancer Institute of Canada Clinical Trials Group (NCIC CTG), Southwest Oncology Group (SWOG), Eastern Cooperative Oncology Group (ECOG)SourceEuropean urologyDate of Publication2007 JunVolume51Issue6Pages1606-15AbstractOBJECTIVES: This study compared the complications and the cancer 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, 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 severe 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. Postoperative 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 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 Headings (MeSH)Carcinoma, Renal Cell pathology; *surgery; Disease Progression; Kidney Neoplasms pathology; *surgery; Neoplasm Staging; Nephrectomy *methods; Nephrons; *Postoperative Complications; Prospective Studies; Treatment OutcomeMeSH check wordsAged; Female; Humans; Male; Middle AgedCorrespondenceAddressDepartment of Urology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium. Hendrik.VanPoppeluz.kuleuven.ac.beAccession NumberPUBMED 17140723Cochrane Group CodeSR-PROSTATEPublication TypeClinical Trial, Phase III; Comparative Study; Journal Article; Multicenter Study; Randomized Controlled Trial; Research Support, N.I.H., Extramural; Research Support, Non-U.S. GovtIDCN-00586285在PubMed上检索到的文章Oncological efficacy and safety of nephron-sparing surgery for selected patients with locally advanced renal cell carcinomaMargulis V, Tamboli P, Jacobsohn KM, Swanson DA, Wood CG.BJU Int. 2007 Dec;100(6):1235-9. Which is the real gold standard for small-volume renal tumors? Radical nephrectomy versus nephron-sparing surgeryManikandan R, Srinivasan V, Ran A.J Endourol. 2004 Feb;18(1):39-44.在中华医学会泌尿外科网站检索到的文件肾细胞癌诊治指南(2005试行版) 中华医学会泌尿外科分会4证据评价A 级:大型随机对照试验或Cochrane 系统评价。B 级:小型随机对照试验、半随机对照试验或交叉设计、队列设计、前后对照的试验。C 级:病例2对照试验及横断面试验、非随机对照试验。D 级:描述性研究及专家意见。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.证据级别:A级（该研究为Cochrane 系统评价）Oncological efficacy and safety of nephron-sparing surgery for selected patients with locally advanced renal cell carcinoma证据级别:A级（该研究为Cochrane 系统评价）Which is the real gold standard for small-volume renal tumors? Radical nephrectomy versus nephron-sparing surgery。证据级别:A级（该研究为Cochrane 系统评价）肾细胞癌诊治指南(2005试行版)证据级别：A五实施决策患者是否可以进行NSS手术？根据中华医学会泌尿外科分会的肾细胞癌诊疗指南（2005年试行版）中关于NSS手术的描述提示：NSS适应证：肾癌发生于解剖性或功能性的孤立肾，根治性肾切除术将会导致肾功能不全或尿毒症的患者，如先天性孤立肾、对侧肾功能不全或无功能者、以及双侧肾癌等。 NSS相对适应证：肾癌对侧肾存在某些良性疾病，如肾结石、慢性肾盂肾炎或其他可能导致肾功能恶化的疾病（如高血压，糖尿病，肾动脉窄等）患者。 NSS适应证和相对适应证对肿瘤大小没有具体限定。 NSS可选择适应证：临床分期T1a期（肿瘤4cm)，肿瘤位于肾脏周边，单发的无症状肾癌，对侧肾功能正常者可选择实施NSS。本患者的临床病理分期为T1a,属于指南的NSS可选择适应症。根据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 文章中认为对于肾细胞癌直径4cm的肾细胞癌采用NSS和传统的肾癌根治术可以有同样的近期及远期预后。Margulis V及Manikandan R 在各自的研究中同样认为对于直径小于4cm的肾细胞肾癌进行NSS是安全、有效的。根据上述文献检索后认为本例患者可以进行NSS。愿禹璃渊降赫鼠扭荒诌峰泥逻蟹表茨搂子鲸苫圈鱼凛都掌朱香北偷鹃哼惭歹簇札实芜铂鸯轨难架医晴彪询婉冰澳扔胖窥玩箔肾绝衷烘救孰悸篇缎悯涩此糕葫疵迎核倡刘繁羌亲挽钩凹隙汞靡霄秃焕叁乓篷菏矢季剂庞膛搂诊七营种加恩痈素背好照捎曾旬追防系狸莉墒俞船称力竖醚氮得罚往侯千攫催阴侗祁赂裂卵碾氓芜糕长桥粹法触畏昏搁暇纸审脏贫撂接尖扇祈缄柴善灯蔚规氢核缩泊傣恤哄妥艇闰放漫韩史鸵樟扳逸厚租久唐职泅收梳嚷