1 Department of Urology, Glickman Urologic and Kidney Institute , Cleveland Clinic, Cleveland, Ohio.
2 Virginia Commonwealth University Health System , Urology, Richmond, Virginia.
J Endourol. 2018 Jul;32(7):615-620. doi: 10.1089/end.2018.0134. Epub 2018 Jun 21.
To report a comparative analysis of outcomes in patients who underwent multiple excisions for unilateral synchronous multifocal renal tumors using both open and robotic approaches.
We retrospectively reviewed 110 patients who underwent robotic and open partial nephrectomy and had multiple tumor excisions in an ipsilateral kidney. "Trifecta" was defined as negative surgical margins, no urologic complications, and a glomerular filtration rate (GFR) preservation of ≥90% at last follow-up. Inverse probability of treatment weighting (IPTW) was applied to equilibrate treatment groups, minimize selection bias, and optimize inference on the basis of each patient's clinicodemographic characteristics.
Sixty-eight robotic and 42 open patient approaches had sufficient data for IPTW. After weighting, there were no statistical differences in baseline characteristics between the two groups. On adjusted analyses, robotic partial nephrectomy achieved equivalent rates of trifecta to open surgery (16.3% vs 16.5%, p = 0.99), which persisted on subgroup analyses of patients with two (20.1% vs 23.7%, p = 0.82) or more than two tumors (6.8% vs 7.4%, p = 0.95). There were no differences between robotic and open cohorts for negative margin rates, absence of complications, or GFR ≥90%. The robotic cohort had a shorter mean length of stay (3.4 vs 4.9 days, p < 0.001).
Surgical resection remains the mainstay for patients with unilateral, synchronous, and multifocal renal tumors. Our analysis found that both open and robotic approaches to partial nephrectomy are equally likely to achieve the "trifecta" outcome in an equilibrated high-risk group of patients. The robotic approach for these complex patients may be safe and feasible for a carefully selected group of patients.
报告采用开放和机器人两种方法对单侧同步多灶性肾肿瘤进行多次切除的患者结局的对比分析。
我们回顾性分析了 110 例接受机器人和开放部分肾切除术且单侧肾脏有多个肿瘤切除的患者。“三联征”定义为手术切缘阴性、无尿外科学并发症和肾小球滤过率（GFR）保留≥90%。采用逆概率治疗加权（IPTW）对治疗组进行均衡处理，以最小化选择偏差，并根据每位患者的临床病理特征进行最佳推断。
68 例机器人和 42 例开放患者方法的数据足够进行 IPTW。加权后，两组患者的基线特征无统计学差异。在调整分析中，机器人部分肾切除术与开放手术达到三联征的比例相当（16.3%比 16.5%，p=0.99），在两组各有两个或两个以上肿瘤的患者亚组分析中也保持不变（20.1%比 23.7%，p=0.82）。机器人组和开放组在切缘阴性率、无并发症和 GFR≥90%方面无差异。机器人组的平均住院时间较短（3.4 天比 4.9 天，p<0.001）。
手术切除仍然是单侧、同步和多灶性肾肿瘤患者的主要治疗方法。我们的分析发现，在均衡的高危患者组中，开放和机器人两种部分肾切除术方法都有可能达到“三联征”的结局。对于这些复杂的患者，机器人方法可能是安全可行的，适用于经过精心选择的患者群体。
