离夹与夹闭机器人辅助部分肾切除术：来自两个高容量中心的倾向评分匹配的围手术期、功能和肿瘤学结果。

Off-clamp vs on-clamp robotic partial nephrectomy: Perioperative, functional and oncological outcomes from a propensity-score matching between two high-volume centers.

机构信息

Glickman Urological and Kidney Institute, Department of Urology, Cleveland Clinic, Cleveland, OH, USA.

Department of Urology, "Regina Elena" National Cancer Institute, Rome, Italy.

出版信息

Eur J Surg Oncol. 2019 Jul;45(7):1232-1237. doi: 10.1016/j.ejso.2018.12.005. Epub 2018 Dec 9.

DOI:10.1016/j.ejso.2018.12.005

PMID:30553632

Abstract

INTRODUCTION

Aim of the study was to compare perioperative, functional and oncological outcomes after off-clamp vs on-clamp robotic partial nephrectomy (RPN).

MATERIALS AND METHODS

Patients who underwent off-clamp or on-clamp (warm ischemia) RPN were extracted from 2 institutional prospectively-maintained databases. 123 patients who underwent off-clamp RPN at one institution were excluded, so that each institution contributed with unselected patients (institution 1:on-clamp RPN vs institution 2:off-clamp). 2:1 propensity-score matching (age, sex, smoking, diabetes, hypertension, ASA score, solitary kidney, preoperative eGFR, tumor size and R.E.N.A.L.score). Perioperative outcomes were compared. A linear mixed model was fitted to eGFR as the outcome regressed on fixed effects for 1) management of clamping (on-clamp/off-clamp), 2) time (at baseline, at discharge, at 12 and 24 months postoperatively), and 3) clamp/time interaction. Survival events were compared between groups.

RESULTS

1983 patients were pooled. After matching, 400 on-clamp vs 200 off-clamp patients were analyzed. No significant differences were found in key perioperative outcomes. The effect of on-clamp on eGFR changed over time. At discharge, groups had similar drop in eGFR. The difference between groups was greatest at 12-months postoperatively, with on-clamp patients showing a deficit of 5 ml/min. At 24-months follow-up, this gap shrunk to 2 ml/min. There were no significant differences in overall survival (p = 0.1), recurrence (χ = 0.008, p = 0.9), or metastasis free survival (χ = 0.962 p = 0.3). Only one cancer-specific death occurred in off-clamp group.

CONCLUSION

We confirm no significant differences in the perioperative and oncological outcomes between off-clamp and on-clamp RPN. Avoided ischemia benefits renal function within 1-year follow-up after surgery. At longer follow-up, difference with on-clamp is softened.

摘要

简介

本研究旨在比较无夹闭（off-clamp）与夹闭（on-clamp）机器人辅助部分肾切除术（RPN）的围手术期、功能和肿瘤学结果。

材料和方法

从 2 个机构前瞻性维护的数据库中提取接受 off-clamp 或 on-clamp（温热缺血）RPN 的患者。排除在一个机构接受 off-clamp RPN 的 123 名患者，以使每个机构提供未经选择的患者（机构 1：on-clamp RPN 与机构 2：off-clamp）。2:1 倾向评分匹配（年龄、性别、吸烟、糖尿病、高血压、ASA 评分、单肾、术前 eGFR、肿瘤大小和 R.E.N.A.L.评分）。比较围手术期结果。使用线性混合模型将 eGFR 作为因变量进行回归，固定效应包括 1）夹闭管理（on-clamp/off-clamp），2）时间（基线时、出院时、术后 12 个月和 24 个月），3）夹闭/时间交互作用。比较组间生存事件。

结果

共纳入 1983 名患者。匹配后，分析了 400 名 on-clamp 与 200 名 off-clamp 患者。关键围手术期结局无显著差异。on-clamp 对 eGFR 的影响随时间而变化。出院时，两组 eGFR 下降相似。术后 12 个月时，两组间的差异最大，on-clamp 患者的 eGFR 下降 5ml/min。24 个月随访时，差距缩小至 2ml/min。总生存（p=0.1）、复发（χ=0.008，p=0.9）或无转移生存（χ=0.962，p=0.3）无显著差异。off-clamp 组仅发生 1 例癌症特异性死亡。