Spectrum Health Hospital System and Michigan State University College of Human Medicine, Grand Rapids, Michigan 49546, USA.
J Urol. 2013 Jun;189(6):2047-53. doi: 10.1016/j.juro.2013.01.007. Epub 2013 Jan 9.
Partial nephrectomy has become a reference standard for tumors amenable to a kidney sparing approach but reported utilization rates vary widely. The R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior, location relative to polar lines and hilar tumor touching main renal artery or vein) nephrometry score was developed to standardize the reporting of tumor complexity with applicability in academic and community based settings. We hypothesized that tumor and surgeon factors account for variable use of partial nephrectomy.
Clinical and R.E.N.A.L. nephrometry score data were analyzed on 1,433 cases performed between 2004 and 2011 by a total of 19 surgeons with varying partial nephrectomy utilization rates (0% to 100%) who practiced at a total of 2 academic centers and 1 community based health system.
Partial nephrectomy use increased during the study period from 36% before 2007 to 73% for 2010 to 2012 (p <0.0001). Increasing proportions of intermediate and high R.E.N.A.L. nephrometry score tumors were treated with partial nephrectomy during this time (35% to 86% and 11% to 36%, respectively, p <0.0001). Partial nephrectomy use was stable for low complexity tumors at 91% overall. Individual surgeons performed partial nephrectomy for 0% to 100% of intermediate complexity and 0% to 45% of high complexity tumors. On multivariable analysis surgery year, tumor size, each R.E.N.A.L. nephrometry score component, surgeon and annual surgeon volume predicted partial vs radical nephrectomy (each p <0.05). On multivariable analysis several surgeon factors, including surgeon volume, setting, fellowship training, and proportional use of minimally invasive and robotic partial nephrectomy, were associated with higher partial nephrectomy use (each p <0.002).
Surgeon and tumor factors contribute significantly to the choice of partial nephrectomy. The significant variation in partial nephrectomy use by individual surgeons appears to be caused by differential treatment for intermediate and high complexity tumors. This may be due to surgical volume, training, setting and the use of minimally invasive techniques.
部分肾切除术已成为一种适用于保留肾脏方法的肿瘤的参考标准，但报告的利用率差异很大。R.E.N.A.L.（半径、外生性/内生性、肿瘤与收集系统或窦腔的接近程度、前后、相对于极线的位置以及与主肾动静脉接触的 hilar 肿瘤）肾切除术评分的制定是为了标准化肿瘤复杂性的报告，适用于学术和社区环境。我们假设肿瘤和外科医生因素解释了部分肾切除术使用的差异。
对 2004 年至 2011 年间由 19 名外科医生进行的 1433 例病例进行了临床和 R.E.N.A.L. 肾切除术评分数据分析，这些外科医生的部分肾切除术利用率（0%至 100%）各不相同，他们在 2 个学术中心和 1 个社区卫生系统中进行手术。
研究期间，部分肾切除术的使用率从 2007 年前的 36%上升到 2010 年至 2012 年的 73%（p<0.0001）。在此期间，接受部分肾切除术治疗的中、高 R.E.N.A.L. 肾切除术评分肿瘤的比例也有所增加（分别为 35%至 86%和 11%至 36%，p<0.0001）。对于低复杂性肿瘤，整体部分肾切除术使用率稳定在 91%。个别外科医生对中、高复杂性肿瘤的部分肾切除术使用率分别为 0%至 100%和 0%至 45%。多变量分析显示，手术年份、肿瘤大小、每个 R.E.N.A.L. 肾切除术评分成分、外科医生和年度外科医生手术量预测了部分肾切除术与根治性肾切除术的比较（均 p<0.05）。多变量分析显示，几个外科医生因素，包括外科医生的手术量、手术环境、是否接受过专科培训以及微创和机器人辅助部分肾切除术的使用比例，与更高的部分肾切除术使用率相关（均 p<0.002）。
外科医生和肿瘤因素对部分肾切除术的选择有重要影响。个别外科医生之间部分肾切除术使用率的显著差异似乎是由于对中、高复杂性肿瘤的不同治疗造成的。这可能是由于手术量、培训、环境以及微创技术的使用。
