Department of Urology, Weill Cornell Medical College New York Presbyterian, New York, 10065, USA.
Division of Urology, Brigham and Women's Hospital, Boston, MA, USA.
World J Urol. 2017 Oct;35(10):1557-1568. doi: 10.1007/s00345-017-2040-6. Epub 2017 May 5.
To evaluate if the widespread adoption of a minimally invasive approach to radical nephrectomy has affected short- and long-term patient outcomes in the modern era.
A retrospective cohort study of patients who underwent radical nephrectomy from 2001 to 2012 was conducted using the US National Cancer Institute Surveillance Epidemiology and End Results (SEER) Program and Medicare insurance program database. Patients who underwent open surgery were compared to those who underwent minimally invasive surgery using propensity score matching.
10,739 (85.9%) underwent open surgery and 1776 (14.1%) underwent minimally invasive surgery. Minimally invasive surgery increased from 18.4% from 2001-2004 to 43.5% from 2009 to 2012. After median follow-up of 57.1 months, minimally invasive radical nephrectomy conferred long-term oncologic efficacy in terms of overall (HR 0.84; 95% CI 0.75-0.95) survival and cancer-specific (HR 0.68; 95% CI 0.54-0.86) survival compared to open radical nephrectomy. Minimally invasive surgery was associated with lower risk of inpatient death [risk ratio (RR) 0.45 with 95% CI: (0.20-0.99), p = 0.04], deep vein thrombosis [RR: 0.35 (0.18-0.69), p = 0.002], respiratory complications [RR: 0.73 (0.60-0.89), p = 0.001], infectious complications [RR: 0.35 (0.14-0.90), p = 0.02], acute kidney injury [RR: 0.66 (0.52-0.84), p < 0.001], sepsis [RR: 0.55 (0.31-0.98), p = 0.04], prolonged length of stay (18.6 vs 30.0%, p < 0.001), and ICU admission (19.7 vs 26.3%, p < 0.001). Costs were similar between the two approaches (30-day costs $15,882 vs $15,564; p = 0.70).
After widespread adoption of minimally invasive approaches to radical nephrectomy across the United States, oncologic standards remain preserved with improved perioperative outcomes at no additional cost burden.
评估微创根治性肾切除术在现代是否影响了短期和长期患者的预后。
利用美国国家癌症研究所监测、流行病学和最终结果（SEER）计划和医疗保险计划数据库，对 2001 年至 2012 年期间接受根治性肾切除术的患者进行回顾性队列研究。采用倾向评分匹配法比较行开放手术和微创手术的患者。
10739 例（85.9%）患者接受开放手术，1776 例（14.1%）患者接受微创手术。微创手术的比例从 2001-2004 年的 18.4%增加到 2009-2012 年的 43.5%。中位随访 57.1 个月后，微创根治性肾切除术在总生存（HR 0.84；95%CI 0.75-0.95）和癌症特异性生存（HR 0.68；95%CI 0.54-0.86）方面具有长期肿瘤学疗效，与开放根治性肾切除术相比。微创手术与住院死亡风险降低相关[风险比（RR）0.45，95%CI：（0.20-0.99），p=0.04]、深静脉血栓形成[RR：0.35（0.18-0.69），p=0.002]、呼吸并发症[RR：0.73（0.60-0.89），p=0.001]、感染并发症[RR：0.35（0.14-0.90），p=0.02]、急性肾损伤[RR：0.66（0.52-0.84），p<0.001]、脓毒症[RR：0.55（0.31-0.98），p=0.04]、住院时间延长（18.6% vs 30.0%，p<0.001）和 ICU 入院率（19.7% vs 26.3%，p<0.001）。两种方法的成本相似（30 天成本为 15882 美元 vs 15564 美元；p=0.70）。
在美国广泛采用微创根治性肾切除术方法后，保留了肿瘤学标准，同时改善了围手术期结果，且无额外的成本负担。
