Department ofUrology, University of California San Diego School of Medicine, La Jolla, CA, USA.
Department of Urology Virginia Commonwealth University, Richmond, VA, USA.
Eur Urol Focus. 2020 Sep 15;6(5):982-990. doi: 10.1016/j.euf.2019.02.010. Epub 2019 Feb 22.
Partial nephrectomy (PN) in elderly patients is underutilized with concerns regarding risk of complications and potential for poor outcomes.
To evaluate quality and functional outcomes of PN in patients >75 yr using trifecta as a composite outcome of surgical quality.
DESIGN, SETTING, AND PARTICIPANTS: Multicenter retrospective analysis of 653 patients aged >75 yr who underwent PN (REnal SURGery in Elderly [RESURGE] Group).
PN.
Primary outcome was achievement of trifecta (negative margin, no major [Clavien ≥3] urological complications, and ≥90% estimated glomerular filtration rate [eGFR] recovery). Secondary outcomes included chronic kidney disease (CKD) stage III and CKD upstaging. Multivariable analysis (MVA) was used to assess variables for achieving trifecta and functional outcomes. Kaplan-Meier survival analysis (KMA) was used to calculate renal functional outcomes.
We analyzed 653 patients (mean age 78.4 yr, median follow-up 33 mo; 382 open, 157 laparoscopic, and 114 robotic). Trifecta rate was 40.4% (n=264). Trifecta patients had less transfusion (p<0.001), lower intraoperative (5.3% vs 27%, p<0.001) and postoperative (25.4% vs 37.8%, p=0.001) complications, shorter hospital stay (p=0.045), and lower ΔeGFR (p <0.001). MVA for predictive factors for trifecta revealed decreasing RENAL nephrometry score (odds ratio [OR] 1.26, 95% confidence interval 1.07-1.51, p=0.007) as being associated with increased likelihood to achieve trifecta. Achievement of trifecta was associated with decreased risk of CKD upstaging (OR 0.47, 95% confidence interval 0.32-0.62, p<0.001). KMA showed that trifecta patients had improved 5-yr freedom from CKD stage 3 (93.5% vs 57.7%, p<0.001) and CKD upstaging (84.3% vs 8.2%, p<0.001). Limitations include retrospective design.
PN in elderly patients can be performed with acceptable quality outcomes. Trifecta was associated with decreased tumor complexity and improved functional preservation.
We looked at quality outcomes after partial nephrectomy in elderly patients. Acceptable quality outcomes were achieved, measured by a composite outcome called trifecta, whose achievement was associated with improved kidney functional preservation.
老年患者的部分肾切除术（PN）的应用不足，这是因为人们担心会出现并发症风险和潜在的不良结果。
使用 trifecta 作为手术质量的综合结果来评估 >75 岁患者行 PN 的质量和功能结果。
设计、地点和参与者：对 >75 岁行 PN 的 653 例患者（REnal SURGery in Elderly [RESURGE] 组）进行多中心回顾性分析。
PN。
主要结局是达到 trifecta（阴性切缘、无主要（Clavien≥3）泌尿系统并发症和≥90%估计肾小球滤过率[eGFR]恢复）。次要结局包括慢性肾脏病（CKD）3 期和 CKD 升级。多变量分析（MVA）用于评估达到 trifecta 和功能结局的变量。Kaplan-Meier 生存分析（KMA）用于计算肾功能结局。
我们分析了 653 例患者（平均年龄 78.4 岁，中位随访 33 个月；382 例开放手术，157 例腹腔镜手术，114 例机器人手术）。trifecta 率为 40.4%（n=264）。trifecta 患者的输血更少（p<0.001）、术中（5.3%比 27%，p<0.001）和术后（25.4%比 37.8%，p=0.001）并发症更少、住院时间更短（p=0.045）和 eGFR 下降更少（p<0.001）。MVA 分析表明，预测 trifecta 的因素是 RENAL 肾切除术评分降低（优势比[OR]1.26，95%置信区间 1.07-1.51，p=0.007），这与更有可能达到 trifecta 相关。达到 trifecta 与 CKD 升级风险降低相关（OR 0.47，95%置信区间 0.32-0.62，p<0.001）。KMA 显示，trifecta 患者 5 年时 CKD 3 期（93.5%比 57.7%，p<0.001）和 CKD 升级（84.3%比 8.2%，p<0.001）的无风险率更高。局限性包括回顾性设计。
PN 可在老年患者中安全进行，且具有可接受的质量结果。trifecta 与肿瘤复杂性降低和功能保存改善相关。
我们观察了老年患者部分肾切除术后的质量结局。我们使用 trifecta 这一综合结果来衡量质量，结果表明达到了可接受的质量水平，其达成与改善肾脏功能保存相关。
