Department of Urology, University Hospital Frankfurt, Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany.
Young Academics in Urology (YAU) Working Group Robotic Surgery, Arnhem, The Netherlands.
World J Surg Oncol. 2023 Jun 22;21(1):189. doi: 10.1186/s12957-023-03061-2.
Partial nephrectomy (PN) is the gold standard surgical treatment for resectable renal cell carcinoma (RCC) tumors. However, the decision whether a robotic (RAPN) or open PN (OPN) approach is chosen is often based on the surgeon's individual experience and preference. To overcome the inherent selection bias when comparing peri- and postoperative outcomes of RAPN vs. OPN, a strict statistical methodology is needed.
We relied on an institutional tertiary-care database to identify RCC patients treated with RAPN and OPN between January 2003 and January 2021. Study endpoints were estimated blood loss (EBL), length of stay (LOS), rate of intraoperative and postoperative complications, and trifecta. In the first step of analyses, descriptive statistics and multivariable regression models (MVA) were applied. In the second step of analyses, to validate initial findings, MVA were applied after 2:1 propensity-score matching (PSM).
Of 615 RCC patients, 481 (78%) underwent OPN vs 134 (22%) RAPN. RAPN patients were younger and presented with a smaller tumor diameter and lower RENAL-Score sum, respectively. Median EBL was comparable, whereas LOS was shorter in RAPN vs. OPN. Both intraoperative (27 vs 6%) and Clavien-Dindo > 2 complications (11 vs 3%) were higher in OPN (both < 0.05), whereas achievement of trifecta was higher in RAPN (65 vs 54%; p = 0.028). In MVA, RAPN was a significant predictor for shorter LOS, lower rates of intraoperative and postoperative complications as well as higher trifecta rates. After 2:1 PSM with subsequent MVA, RAPN remained a statistical and clinical predictor for lower rates of intraoperative and postoperative complications and higher rates of trifecta achievement but not LOS.
Differences in baseline and outcome characteristics exist between RAPN vs. OPN, probably due to selection bias. However, after applying two sets of statistical analyses, RAPN seems to be associated with more favorable outcomes regarding complications and trifecta rates.
部分肾切除术（PN）是可切除肾细胞癌（RCC）肿瘤的金标准手术治疗方法。然而，选择机器人辅助肾部分切除术（RAPN）还是开放肾部分切除术（OPN）的决定往往基于外科医生的个人经验和偏好。为了克服比较 RAPN 与 OPN 的围手术期结局时固有的选择偏差，需要严格的统计方法。
我们依靠机构的三级护理数据库来确定 2003 年 1 月至 2021 年 1 月期间接受 RAPN 和 OPN 治疗的 RCC 患者。研究终点为估计出血量（EBL）、住院时间（LOS）、术中及术后并发症发生率和 trifecta。在分析的第一步中，应用描述性统计和多变量回归模型（MVA）。在分析的第二步中，为了验证初始发现，在 2:1 倾向评分匹配（PSM）后应用 MVA。
615 例 RCC 患者中，481 例（78%）接受 OPN 治疗，134 例（22%）接受 RAPN 治疗。RAPN 患者年龄较小，肿瘤直径较小，RENAL 评分总和较低。中位 EBL 相似，RAPN 患者的 LOS 较短。OPN 术中（27%对 6%）和 Clavien-Dindo > 2 级并发症（11%对 3%）发生率更高（均<0.05），而 RAPN 患者 trifecta 更高（65%对 54%；p=0.028）。在 MVA 中，RAPN 是 LOS 缩短、术中及术后并发症发生率降低以及 trifecta 发生率升高的显著预测因子。经过 2:1 PSM 后，随后进行 MVA，RAPN 仍然是术中及术后并发症发生率降低和 trifecta 发生率升高的统计学和临床预测因子，但与 LOS 无关。
RAPN 与 OPN 之间存在基线和结局特征的差异，可能是由于选择偏差。然而，在应用两组统计分析后，RAPN 似乎与并发症和 trifecta 发生率的更有利结局相关。
