UC San Diego Medical Center, Division of Urology VA San Diego Medical Center Moores UCSD Cancer Center, San Diego, CA 92103, USA.
BJU Int. 2012 Dec;110(11):1808-13. doi: 10.1111/j.1464-410X.2012.11071.x. Epub 2012 Apr 3.
Study Type--Cohort study Level of Evidence 2b. What's known on the subject? and What does the study add? Laparoscopic radical nephrectomy for renal cancer provides equivalent long-term cancer control with shorter hospital stays, less postoperative pain, and faster resumption of normal activities, but it has diffused slowly into clinical practice, perhaps as a result of perceptions about safety. Patient safety outcomes for laparoscopic and open radical nephrectomy using validated measures remain incompletely characterized. This is the first study to investigate peri-operative outcomes of radical nephrectomy using validated patient safety measures. We found a 32% decreased probability of adverse patient safety events occurring in laparoscopic compared with open radical nephrectomy. The safety benefits of laparoscopy were attained only after 10% of cases were completed laparoscopically--a proportion some have proposed as the 'tipping point' for the adoption of surgical innovations. This observation could have implications for patient safety in the setting of diffusion of new surgical techniques.
• To compare peri-operative adverse patient safety events occurring in laparoscopic radical nephrectomy (LRN) with those occurring in open radical nephrectomy (ORN).
• We used the US Nationwide Inpatient Sample to identify patients undergoing kidney surgery for renal tumours from 1998 to 2008. • We used patient safety indicators (PSIs), which are validated measures of preventable adverse outcomes, and multivariate regression to analyse associations of surgery type with patient safety.
• Open radical nephrectomy accounted for 235,098 (89%) cases while 28,609 (11%) cases were LRN. • Compared with ORN, LRN patients were more likely to be male (P= 0.048), have lower Charlson comorbidity scores (P < 0.001), and to undergo surgery at urban (P < 0.001) and teaching (P < 0.001) hospitals. • PSIs occurred in 18,714 (8%) of ORN and 1434 (5%) of LRN cases (P < 0.001). • On multivariate analysis, LRN was associated with a 32% decreased probability of any PSI (adjusted odds ratio 0.68, 95% confidence interval: 0.6 to 0.77, P < 0.001). Stratification by year showed that this difference was initially manifested in 2003, when the proportion of LRN cases first exceeded 10%.
• We found that LRN was associated with substantially superior peri-operative patient safety outcomes compared with ORN, but only after the national prevalence of LRN exceeded 10%. • Further study is needed to explain these patterns and promote the safe diffusion of novel surgical therapies into broad practice.
比较腹腔镜根治性肾切除术（LRN）与开放性根治性肾切除术（ORN）中围手术期不良患者安全事件的发生情况。
我们使用美国全国住院患者样本，从 1998 年到 2008 年，确定接受肾脏肿瘤手术的患者。我们使用患者安全指标（PSIs），这是预防不良结果的验证措施，并使用多变量回归分析手术类型与患者安全的关联。
ORN 占 235098（89%）例，LRN 占 28609（11%）例。与 ORN 相比，LRN 患者更可能是男性（P=0.048），Charlson 合并症评分较低（P<0.001），并在城市（P<0.001）和教学（P<0.001）医院接受手术。在 ORN 中有 18714 例（8%）和 LRN 中有 1434 例（5%）发生 PSI（P<0.001）。多变量分析显示，LRN 发生任何 PSI 的概率降低了 32%（调整后的优势比 0.68，95%置信区间：0.6 至 0.77，P<0.001）。按年份分层显示，这种差异最初在 2003 年表现出来，当时 LRN 病例的比例首次超过 10%。
我们发现，与 ORN 相比，LRN 与围手术期患者安全结果显著改善相关，但仅在 LRN 的全国流行率超过 10%之后。需要进一步研究来解释这些模式，并促进新的手术疗法安全地广泛应用于实践。
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