USC Institute of Urology, and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Urology, University of Verona, Verona, Italy.
USC Institute of Urology, and Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
J Urol. 2018 Aug;200(2):258-274. doi: 10.1016/j.juro.2017.12.086. Epub 2018 Mar 24.
Utilization of robotic partial nephrectomy has increased significantly. We report a literature wide systematic review and cumulative meta-analysis to critically evaluate the impact of surgical factors on the operative, perioperative, functional, oncologic and survival outcomes in patients undergoing robotic partial nephrectomy.
All English language publications on robotic partial nephrectomy comparing various surgical approaches were evaluated. We followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement and AHRQ (Agency for Healthcare Research and Quality) guidelines to evaluate PubMed®, Scopus® and Web of Science™ databases (January 1, 2000 to October 31, 2016, updated June 2017). Weighted mean difference and odds ratio were used to compare continuous and dichotomous variables, respectively. Sensitivity analyses were performed as needed. To condense the sheer volume of analyses, for the first time data are presented using novel summary forest plots. The study was registered at PROSPERO (https://www.crd.york.ac.uk/prospero/, ID CRD42017062712).
Our meta-analysis included 20,282 patients. When open partial nephrectomy was compared to robotic partial nephrectomy, the latter was superior for blood loss (weighted mean difference 85.01, p <0.00001), transfusions (OR 1.81, p <0.001), complications (OR 1.87, p <0.00001), hospital stay (weighted mean difference 2.26, p = 0.001), readmissions (OR 2.58, p = 0.005), percentage reduction of latest estimated glomerular filtration rate (weighted mean difference 0.37, p = 0.04), overall mortality (OR 4.45, p <0.0001) and recurrence rate (OR 5.14, p <0.00001). Sensitivity analyses adjusting for baseline disparities revealed similar findings. When robotic partial nephrectomy was compared to laparoscopic partial nephrectomy, the former was superior for ischemia time (weighted mean difference 4.21, p <0.0001), conversion rate (OR 2.61, p = 0.002), intraoperative (OR 2.05, p >0.0001) and postoperative complications (OR 1.27, p = 0.0003), positive margins (OR 2.01, p <0.0001), percentage decrease of latest estimated glomerular filtration rate (weighted mean difference -1.97, p = 0.02) and overall mortality (OR 2.98, p = 0.04). Hilar control techniques, selective and unclamped, are effective alternatives to clamped robotic partial nephrectomy. An important limitation is the overall suboptimal level of evidence of publications in the field of robotic partial nephrectomy. No level I prospective randomized data are available. Oxford level of evidence was level II, III and IV in 5%, 74% and 21% of publications, respectively. No study has indexed functional outcomes against volume of parenchyma preserved.
Based on the contemporary literature, our comprehensive meta-analysis indicates that robotic partial nephrectomy delivers mostly superior, and at a minimum equivalent, outcomes compared to open and laparoscopic partial nephrectomy. Robotics has now matured into an excellent approach for performing partial nephrectomy for renal masses.
机器人辅助部分肾切除术的应用显著增加。我们进行了一项广泛的文献系统回顾和累积荟萃分析，以批判性地评估手术因素对接受机器人辅助部分肾切除术患者的手术、围手术期、功能、肿瘤学和生存结果的影响。
评估了比较各种手术方法的所有英语语言机器人辅助部分肾切除术文献。我们遵循 PRISMA（系统评价和荟萃分析的首选报告项目）声明和 AHRQ（医疗保健研究和质量局）指南，评估了 PubMed®、Scopus®和 Web of Science™数据库（2000 年 1 月 1 日至 2016 年 10 月 31 日，2017 年 6 月更新）。分别使用加权均数差和优势比来比较连续和二分类变量。需要时进行敏感性分析。为了压缩分析的数量，本文首次使用新的汇总森林图呈现数据。该研究在 PROSPERO（https://www.crd.york.ac.uk/prospero/，ID CRD42017062712）上进行了注册。
我们的荟萃分析包括 20,282 名患者。与开放性部分肾切除术相比，机器人辅助部分肾切除术在出血量（加权均数差 85.01，p<0.00001）、输血（OR 1.81，p<0.001）、并发症（OR 1.87，p<0.00001）、住院时间（加权均数差 2.26，p=0.001）、再入院率（OR 2.58，p=0.005）、最新估计肾小球滤过率的百分比下降（加权均数差 0.37，p=0.04）、总死亡率（OR 4.45，p<0.0001）和复发率（OR 5.14，p<0.00001）方面具有优势。调整基线差异的敏感性分析得出了类似的发现。与腹腔镜部分肾切除术相比，机器人辅助部分肾切除术在缺血时间（加权均数差 4.21，p<0.0001）、转换率（OR 2.61，p=0.002）、术中（OR 2.05，p>0.0001）和术后并发症（OR 1.27，p=0.0003）、阳性切缘（OR 2.01，p<0.0001）、最新估计肾小球滤过率的百分比下降（加权均数差-1.97，p=0.02）和总死亡率（OR 2.98，p=0.04）方面具有优势。选择性和无夹闭的肾蒂控制技术是夹闭机器人辅助部分肾切除术的有效替代方法。一个重要的局限性是机器人辅助部分肾切除术领域的文献整体证据水平不佳。没有 I 级前瞻性随机数据。牛津证据水平在 5%、74%和 21%的研究中分别为 II、III 和 IV 级。没有研究将功能结果与保留的肾实质体积进行对照索引。
根据当代文献，我们的综合荟萃分析表明，与开放性和腹腔镜部分肾切除术相比，机器人辅助部分肾切除术大多提供了更好的、至少是等效的结果。机器人技术现已成熟，成为治疗肾肿瘤的绝佳方法。
