Center for Laparoscopic and Robotic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA.
J Urol. 2013 Apr;189(4):1236-42. doi: 10.1016/j.juro.2012.10.021. Epub 2012 Oct 16.
We report a comparative analysis of a large series of laparoscopic and robotic partial nephrectomies performed by a high volume single surgeon at a tertiary care institution.
We retrospectively reviewed the medical charts of 500 patients treated with minimally invasive partial nephrectomy by a single surgeon between March 2002 and February 2012. Demographic and perioperative data were collected and statistically analyzed. R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in mm, anterior/posterior and location relative to polar lines) nephrometry score was used to score tumors. Those scored as moderate and high complexity were designated as complex. Trifecta was defined as a combination of warm ischemia time less than 25 minutes, negative surgical margins and no perioperative complications.
Two groups were identified, including 261 patients with robotic and 231 with laparoscopic partial nephrectomy. Demographics were similar in the groups. The robotic group was significantly more morbid (Charlson comorbidity index 3.75 vs 1.26), included more complex tumors (R.E.N.A.L. score 5.98 vs 7.2), and had lower operative (169.9 vs 191.7 minutes) and warm ischemia (17.9 vs 25.2 minutes) time, intraoperative (2.6% vs 5.6%, each p <0.001) and postoperative (24.53% vs 32.03%, p = 0.004) complications, and positive margin rate (2.9% vs 5.6%, p <0.001). Thus, a higher overall trifecta rate was observed for robotic partial nephrectomy (58.7% vs 31.6%, p <0.001). The laparoscopic group had longer followup (3.43 vs 1.51 years, p <0.001) and no significant difference in postoperative changes in renal function. Main study limitations were the retrospective nature, arbitrary definition of trifecta and shorter followup in the RPN group.
Our large comparative analysis shows that robotic partial nephrectomy offers a wider range of indications, better operative outcomes and lower perioperative morbidity than laparoscopic partial nephrectomy. Overall, the quest for trifecta seems to be better accomplished by robotic partial nephrectomy, which is likely to become the new standard for minimally invasive partial nephrectomy.
我们报告了一位高容量的单一外科医生在一家三级护理机构进行的大量腹腔镜和机器人辅助部分肾切除术的比较分析。
我们回顾性地分析了 2002 年 3 月至 2012 年 2 月期间由一位外科医生采用微创部分肾切除术治疗的 500 例患者的病历。收集并统计分析了人口统计学和围手术期数据。使用 R.E.N.A.L.（半径、外生性/内生性特征、肿瘤与收集系统或窦之间的距离（mm）、前后和相对于极线的位置）肾单位评分对肿瘤进行评分。评分中等和高复杂度的肿瘤被指定为复杂肿瘤。三联征定义为热缺血时间小于 25 分钟、阴性手术切缘和无围手术期并发症的组合。
确定了两组，包括 261 例机器人辅助部分肾切除术和 231 例腹腔镜辅助部分肾切除术。两组患者的人口统计学特征相似。机器人组的发病率明显更高（Charlson 合并症指数 3.75 对 1.26），包括更多复杂的肿瘤（R.E.N.A.L.评分 5.98 对 7.2），手术时间（169.9 对 191.7 分钟）和热缺血时间（17.9 对 25.2 分钟）更短，术中（2.6%对 5.6%，均 P <0.001）和术后（24.53%对 32.03%，P = 0.004）并发症和阳性切缘率（2.9%对 5.6%，P <0.001）更低。因此，机器人辅助部分肾切除术的总体三联征发生率更高（58.7%对 31.6%，P <0.001）。腹腔镜组的随访时间更长（3.43 对 1.51 年，P <0.001），术后肾功能变化无显著差异。主要研究局限性为回顾性、三联征的任意定义以及 RPN 组的随访时间较短。
我们的大型比较分析表明，与腹腔镜辅助部分肾切除术相比，机器人辅助部分肾切除术提供了更广泛的适应证、更好的手术结果和更低的围手术期发病率。总的来说，通过机器人辅助部分肾切除术似乎更容易实现三联征，这可能成为微创部分肾切除术的新标准。
