Khandwala Yash S, Jeong In Gab, Kim Jae Heon, Han Deok Hyun, Li Shufeng, Wang Ye, Chang Steven L, Chung Benjamin I
1 Department of Urology, Stanford University Medical Center , Stanford, California.
2 San Diego School of Medicine, University of California , San Diego, California.
J Endourol. 2017 Sep;31(9):851-857. doi: 10.1089/end.2017.0207. Epub 2017 Jun 21.
Little is known about the impact of surgeon volume on the success of the robot-assisted partial nephrectomy (RAPN). The objective of this study was to compare the perioperative outcomes and cost related to RAPN by annual surgeon volumes.
Using the Premier Hospital Database, we retrospectively analyzed 39,773 patients who underwent RAPN between 2003 and 2015 in the United States. Surgeons for each index case were grouped into quintiles for each respective year. Outcomes were 90-day postoperative complications, operating room time (ORT), blood transfusion, length of stay, and direct hospital costs. Logistic regression and generalized linear models were used to identify factors predicting complications and cost.
After accounting for patient and hospital demographics, high- and very high-volume surgeons had 40% and 42% decreased odds of having major complications (p = 0.045 and p = 0.027, respectively). Surgeons with higher volumes were associated with fewer odds of prolonged ORT (0.68 for low, 0.72 for intermediate, 0.56 for high, 0.44 for very high volume, all p < 0.05) and length of hospital stay (0.67 for intermediate, 0.51 for high, 0.45 for very high volume, all p < 0.01) compared with very low-volume surgeons. The 90-day hospital cost was also significantly lower for the surgeons with higher volume, but the statistical significance diminished after consideration of hospital clustering.
Surgeons with very high RAPN volumes were found to have superior perioperative outcomes. Although cost of care appeared to correlate with surgeon volume, there may be other more influential factors predicting cost.
关于外科医生手术量对机器人辅助部分肾切除术（RAPN）成功率的影响，目前所知甚少。本研究的目的是按外科医生的年度手术量比较与RAPN相关的围手术期结局和成本。
利用Premier医院数据库，我们回顾性分析了2003年至2015年在美国接受RAPN的39773例患者。每年将各索引病例的外科医生分为五组。结局指标包括术后90天并发症、手术室时间（ORT）、输血情况、住院时间和直接住院费用。采用逻辑回归和广义线性模型来确定预测并发症和成本的因素。
在考虑患者和医院人口统计学因素后，高手术量和极高手术量的外科医生发生主要并发症的几率分别降低了40%和42%（p分别为0.045和0.027）。与极低手术量的外科医生相比，手术量较高的外科医生延长ORT的几率较低（极低手术量为0.68，中等手术量为0.72，高手术量为0.56，极高手术量为0.44，均p<0.05），住院时间也较短（中等手术量为0.67，高手术量为0.51，极高手术量为0.45，均p<0.01）。手术量较高的外科医生90天的住院费用也显著较低，但在考虑医院聚类后，统计学意义减弱。
发现极高RAPN手术量的外科医生具有更好的围手术期结局。虽然护理成本似乎与外科医生手术量相关，但可能还有其他更具影响力的因素预测成本。
