Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
Division of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
Urol Oncol. 2019 Mar;37(3):182.e17-182.e27. doi: 10.1016/j.urolonc.2018.10.028. Epub 2019 Jan 8.
To investigate national utilization trends of minimally-invasive partial nephrectomy (PN) and minimally-invasive radical nephrectomy (RN), and to identify disparities in the usage of these techniques across different sociodemographic subgroups.
A retrospective cohort study was conducted using the National Cancer Database to identify patients undergoing partial or RN for cT1N0M0 renal cancer diagnosed between 2010 and 2015. Main outcomes of interest were the utilizations of minimally-invasive (robotic and laparoscopic) PN and RN.
A total of 46,346 and 37,712 subjects who underwent PN and RN, respectively, were analyzed. During the study interval, increased utilization of robotic surgery paralleled the decreased utilization of open surgery. Robotic PN increased from 35.2% to 63.7% and robotic RN increased from 10.3% to 26.3%. The utilization of laparoscopic surgery was decreasing for PN but stable for RN through the study period. In the PN cohort, multivariable logistic regression showed non-Hispanic black (odds ratio [OR] = 0.90 [95% CI, 0.84-0.96]) and Hispanic (OR = 0.91 [0.84-0.99]) subjects were associated with less utilization of minimally invasive surgery (MIS) (vs. non-Hispanic white). Younger (18-64 years) Medicare (OR = 0.83 [0.77-0.90]), Medicaid (OR = 0.80 [0.74-0.87]), and uninsured (OR = 0.55 [0.49-0.62]) were also associated with less utilization of MIS (vs. private insurance). Compared with low socioeconomic status (SES), upper middle (OR = 1.14 [1.07-1.21]) and high (OR = 1.24 [1.16-1.33]) SES were associated with higher utilization of MIS. Similar demographic, insurance, and SES-related disparities were identified in the RN cohort.
Utilization of MIS for localized renal cancer has increased significantly and was mainly attributed to increased usage of robotic surgery. Racial/ethnic, insurance, and SES related disparities in MIS utilization were identified. Our findings demonstrate a targetable subgroup of patients who do not have the same access to advances in surgical technology.
调查国内微创部分肾切除术（PN）和微创根治性肾切除术（RN）的应用趋势，并确定这些技术在不同社会人口亚组中的使用差异。
本研究采用国家癌症数据库进行回顾性队列研究，纳入 2010 年至 2015 年间诊断为 cT1N0M0 肾肿瘤并行部分或 RN 治疗的患者。主要观察指标为微创（机器人和腹腔镜）PN 和 RN 的使用情况。
共分析了 46346 例行 PN 和 37712 例行 RN 的患者。研究期间，机器人手术的应用增加，而开放手术的应用减少。机器人 PN 从 35.2%增加到 63.7%，机器人 RN 从 10.3%增加到 26.3%。PN 组腹腔镜手术的应用减少，但 RN 组在研究期间保持稳定。在 PN 队列中，多变量逻辑回归显示非西班牙裔黑人（比值比 [OR] = 0.90 [95% CI，0.84-0.96]）和西班牙裔（OR = 0.91 [0.84-0.99]）患者接受微创手术（MIS）的比例较低（与非西班牙裔白人相比）。18-64 岁的医疗保险（OR = 0.83 [0.77-0.90]）、医疗补助（OR = 0.80 [0.74-0.87]）和无保险（OR = 0.55 [0.49-0.62]）患者接受 MIS 的比例也较低（与私人保险相比）。与低社会经济地位（SES）相比，中上 SES（OR = 1.14 [1.07-1.21]）和高 SES（OR = 1.24 [1.16-1.33]）与 MIS 的高使用率相关。在 RN 队列中也发现了类似的与人口统计学、保险和 SES 相关的差异。
局部肾肿瘤 MIS 的应用显著增加，主要归因于机器人手术的应用增加。确定了 MIS 使用的种族/民族、保险和 SES 相关差异。我们的研究结果表明，有一个可靶向的患者亚组，他们无法获得同样的手术技术进步。
