Paulucci David J, Abaza Ronney, Eun Daniel D, Hemal Ashok K, Badani Ketan K
Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA.
Robotic Urologic Surgery, OhioHealth Dublin Methodist Hospital, Columbus, OH, USA.
BJU Int. 2017 May;119(5):748-754. doi: 10.1111/bju.13709. Epub 2016 Nov 28.
To evaluate trends in peri-operative outcomes of 250 consecutive cases beyond the initial learning curve (LC) of robot-assisted partial nephrectomy (RAPN) among multiple surgeons.
A multi-institutional database was used to evaluate trends in patient demographics (e.g. age, gender, comorbidities), tumour characteristics (e.g. size, complexity) and peri-operative outcomes (e.g. warm ischaemia time [WIT], operating time, complications, estimated blood loss [EBL], trifecta achievement) in consecutive cases 50-300 (n = 960) from 2008 to 2016 among four experienced surgeons. Trends in outcomes were assessed using multivariable regression models adjusted for demographic and tumour-specific variables. Outcomes for cases 50-99 were compared with those for cases 250-300.
In the study period RAPN was increasingly performed in patients with larger tumours (β = 0.001, P = 0.048), hypertension (odds ratio [OR] 1.003; P = 0.008) diabetes (OR 1.003; P = 0.025) and previous abdominal surgery (OR 1.003; P = 0.006). Surgeon experience was associated with more trifecta achievement (OR 1.006; P < 0.001), shorter WIT (β = -0.036, P < 0.001), less EBL (β = -0.154, P = 0.009), fewer blood transfusions (OR 0.989, P = 0.024) and a reduced length of hospital stay (β = -0.002, P = 0.002), but not with operating time (P = 0.243), complications (P = 0.587) or surgical margin status (P = 0.102). Tumour size and WIT in cases 50-99 vs 250-300 were 2.7 vs 3.2 cm (P = 0.001) and 21.4 vs 16.2 min (P < 0.001), respectively.
Refinement of RAPN outcomes, concomitant with the treatment of a patient population with larger tumours and more comorbidities, occurs after the initial LC is reached. Although RAPN can consistently be performed safely with acceptable outcomes after a small number of cases, improvement in trifecta achievement, WIT, EBL, blood transfusions and a shorter hospitalization continues to occur up to 300 procedures.
评估在多位外科医生中，250例连续病例超出机器人辅助部分肾切除术（RAPN）初始学习曲线（LC）后的围手术期结局趋势。
使用多机构数据库评估2008年至2016年间，四位经验丰富的外科医生所做的连续病例50 - 300例（n = 960）的患者人口统计学特征（如年龄、性别、合并症）、肿瘤特征（如大小、复杂性）及围手术期结局（如热缺血时间[WIT]、手术时间、并发症、估计失血量[EBL]、三连胜达成情况）。使用针对人口统计学和肿瘤特异性变量进行调整的多变量回归模型评估结局趋势。将病例50 - 99的结局与病例250 - 300的结局进行比较。
在研究期间，RAPN越来越多地应用于肿瘤更大（β = 0.001，P = 0.048）、患有高血压（比值比[OR] 1.003；P = 0.008）、糖尿病（OR 1.003；P = 0.025）及既往有腹部手术史（OR 1.003；P = 0.006）的患者。外科医生的经验与更多的三连胜达成情况（OR 1.006；P < 0.001）、更短的WIT（β = -0.036，P < 0.001）、更少的EBL（β = -0.154，P = 0.009）、更少的输血次数（OR 0.989，P = 0.024）及缩短的住院时间（β = -0.002，P = 0.002）相关，但与手术时间（P = 0.243）、并发症（P = 0.587）或手术切缘状态（P = 0.102）无关。病例50 - 99与250 - 300相比，肿瘤大小和WIT分别为2.7 cm对3.2 cm（P = 0.001）和21.4分钟对16.2分钟（P < 0.001）。
在达到初始学习曲线后，RAPN结局得到改善，同时治疗的患者群体肿瘤更大且合并症更多。尽管在少数病例后RAPN可以持续安全地进行且结局可接受，但直至300例手术，三连胜达成情况、WIT、EBL、输血及住院时间仍持续改善。
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