fellows的培训是否会影响机器人辅助部分肾切除术的围手术期结果？

Does training of fellows affect peri-operative outcomes of robot-assisted partial nephrectomy?

作者信息

Khene Zine-Eddine, Peyronnet Benoit, Bosquet Elise, Pradère Benjamin, Robert Corentin, Fardoun Tarek, Kammerer-Jacquet Solène-Florence, Verhoest Grégory, Rioux-Leclercq Nathalie, Mathieu Romain, Bensalah Karim

机构信息

Department of Urology, Rennes University Hospital, Rennes, France.

Department of Radiology, Rennes University Hospital, Rennes, France.

出版信息

BJU Int. 2017 Oct;120(4):591-599. doi: 10.1111/bju.13901. Epub 2017 May 24.

DOI:10.1111/bju.13901

PMID:28464554

Abstract

OBJECTIVE

To evaluate the impact of fellows' involvement on the peri-operative outcomes of robot-assisted partial nephrectomy (RAPN).

MATERIALS AND METHODS

We analysed 216 patients who underwent RAPN for a small renal tumour. We stratified our cohort into two groups according to the involvement of a fellow surgeon during the procedure: expert surgeon operating alone (expert group) and fellow operating under the supervision of the expert surgeon (fellow group). Peri-operative data were compared between the two groups. Linear and logistic regression analyses were performed to assess the impact of fellows' involvement on peri-operative and postoperative outcomes. Trifecta and margins ischaemia complications (MIC) score achievement rates were used to assess the quality of surgery in both the expert and fellow groups. Trifecta was defined as a combination of warm ischaemia time <25 min, negative surgical margins and no peri-operative complications. MIC score was defined as negative surgical margins, ischaemia time <20 min, and absence of complications grade ≥3.

RESULTS

Fellows were involved in a total of 89 procedures (41%). Patients' characteristics were similar in the two groups. Operating time and warm ischaemia time (WIT) were longer in the fellow group (180 vs 120 min, P < 0.001, and 18 vs 14 min, P = 0.002, respectively). Length of hospital stay (LOS) was longer in the fellow group (5 vs 4.3 days; P = 0.05) and patients in this group had higher estimated blood loss (EBL; 400 vs 300 mL; P = 0.01), but this had no impact on transfusion rate (14% vs 11%; P = 0.43). Positive surgical margin rates were similar in the fellow and expert groups (2.2% vs 3.1%; P = 0.70). Major complications were more frequent in the fellow group (12.3% vs 6.3%), but the difference was not significant (P = 0.10). In multivariable analysis, fellow involvement was predictive of longer WIT (β = 0.22; P = 0.003) and operating time (β = 0.49; P < 0.001), but was not associated with EBL (β = 0.12, P = 0.09) or LOS (β = 0.12, P = 0.11). Finally, fellow involvement was associated with a lower rate of trifecta and MIC score accomplishment (odds ratio [OR] 0.53, P = 0.05 and OR 0.46, P = 0.01, respectively).

CONCLUSION

Training fellows to perform RAPN is associated with longer operating time and WIT but does not appear to compromise other peri-operative outcomes.

摘要

目的

评估住院医师参与机器人辅助肾部分切除术（RAPN）对围手术期结局的影响。

材料与方法

我们分析了216例行RAPN治疗小肾肿瘤的患者。根据住院医师在手术过程中的参与情况，将我们的队列分为两组：经验丰富的外科医生单独手术（专家组）和在经验丰富的外科医生监督下由住院医师手术（住院医师组）。比较两组的围手术期数据。进行线性和逻辑回归分析，以评估住院医师参与对围手术期和术后结局的影响。采用三连胜和切缘缺血并发症（MIC）评分达成率来评估专家组和住院医师组的手术质量。三连胜定义为热缺血时间<25分钟、手术切缘阴性且无围手术期并发症。MIC评分定义为手术切缘阴性、缺血时间<20分钟且无≥3级并发症。

结果

住院医师共参与了89例手术（41%）。两组患者的特征相似。住院医师组的手术时间和热缺血时间（WIT）更长（分别为180分钟对120分钟，P<0.001；18分钟对14分钟，P = 0.002）。住院医师组的住院时间（LOS）更长（5天对4.3天；P = 0.05），该组患者的估计失血量（EBL）更高（400毫升对300毫升；P = 0.01），但这对输血率没有影响（14%对11%；P = 0.43）。住院医师组和专家组的手术切缘阳性率相似（2.2%对3.1%；P = 0.70）。住院医师组的主要并发症更常见（12.3%对6.3%），但差异不显著（P = 0.10）。在多变量分析中，住院医师参与可预测更长的WIT（β = 0.22；P = 0.003）和手术时间（β = 0.49；P<0.001），但与EBL（β = 0.12，P = 0.09）或LOS（β = 0.12，P = 0.11）无关。最后，住院医师参与与三连胜和MIC评分达成率较低相关（优势比[OR]分别为0.53，P = 0.05和OR 0.46，P = 0.01）。