title: Systematic review of adrenalectomy and lymph node dissection in locally advanced renal cell carcinoma.
abstract: BACKGROUND
  Controversy remains over whether adrenalectomy and lymph node dissection (LND) should be performed concomitantly with radical nephrectomy (RN) for locally advanced renal cell carcinoma (RCC) cT3-T4N0M0.
  
  
  OBJECTIVE
  To systematically review all relevant literature comparing oncologic, perioperative, and quality-of-life (QoL) outcomes for locally advanced RCC managed with RN with or without concomitant adrenalectomy or LND.
  
  
  METHODS
  Relevant databases were searched up to August 2012. Randomised controlled trials (RCTs) and comparative studies were included. Outcome measures were overall survival, QoL, and perioperative adverse effects. Risks of bias (RoB) were assessed using Cochrane RoB tools. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.
  
  
  RESULTS
  A total of 3658 abstracts and 252 full-text articles were screened. Eight studies met the inclusion criteria: six LNDs (one RCT and five nonrandomised studies [NRSs]) and two adrenalectomies (two NRSs). RoB was high across the evidence base, and the quality of evidence from outcomes ranged from moderate to very low. Meta-analyses were not undertaken because of diverse study designs and data heterogeneity. There was no significant difference in survival between the groups, even though 5-yr overall survival appears better for the RN plus LND group compared with the no-LND group in one randomised study. There was no evidence of a difference in adverse events between the RN plus LND and no-LND groups. No studies reported QoL outcomes. There was no evidence of an oncologic difference between the RN with adrenalectomy and RN without adrenalectomy groups. No studies reported adverse events or QoL outcomes.
  
  
  CONCLUSIONS
  There is insufficient evidence to draw any conclusions on oncologic outcomes for patients having concomitant LND or ipsilateral adrenalectomy compared with patients having RN alone for cT3-T4N0M0 RCC. The quality of evidence is generally low and the results potentially biased. Further research in adequately powered trials is needed to answer these questions.
authors: Department of Critical Care, University of Groningen, University Medical Centre Groningen, The Netherlands.
authors: Hendrika J
authors: HJ
authors: Bekema
authors: Steven
authors: S
authors: MacLennan
authors: Mari
authors: M
authors: Imamura
authors: Thomas B L
authors: TB
authors: Lam
authors: Fiona
authors: F
authors: Stewart
authors: Neil
authors: N
authors: Scott
authors: Graeme
authors: G
authors: MacLennan
authors: Sam
authors: S
authors: McClinton
authors: T R Leyshon
authors: TR
authors: Griffiths
authors: Andreas
authors: A
authors: Skolarikos
authors: Sara J
authors: SJ
authors: MacLennan
authors: Richard
authors: R
authors: Sylvester
authors: Börje
authors: B
authors: Ljungberg
authors: James
authors: J
authors: N'Dow
mesh_terms: D000310:Adrenal Gland Neoplasms / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D000315:Adrenalectomy / Q000009:adverse effects / Q000401:mortality; D002292:Carcinoma, Renal Cell / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D007680:Kidney Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008197:Lymph Node Excision / Q000009:adverse effects / Q000401:mortality; D008207:Lymphatic Metastasis; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D009392:Nephrectomy / Q000009:adverse effects / Q000401:mortality; D011788:Quality of Life; D012307:Risk Factors; D016896:Treatment Outcome
keywords: Adrenalectomy; Adverse events; Locally advanced renal cancer; Lymph node dissection; Lymphadenectomy; Oncologic outcomes; Radical nephrectomy; Systematic review