Weinberg Aaron C, Whalen Michael J, Paulucci David J, Woldu Solomon, Deibert Christopher M, Korets Ruslan, Badani Ketan K
Department of Urology, Columbia University College of Physicians and Surgeons, New York, New York.
Department of Urology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York.
Urol Pract. 2016 May;3(3):187-194. doi: 10.1016/j.urpr.2015.07.007. Epub 2016 Feb 22.
The robotic platform in surgery has been widely adopted as it facilitates complex surgical reconstructions such as renorrhaphy during partial nephrectomy. Although the robotic approach to radical nephrectomy has higher costs and a lack of perioperative and oncologic evidence, the use of robotic platforms for radical nephrectomy is increasing. We evaluated a national database to explain the increased use of robotic radical nephrectomy despite a lack of perioperative and oncologic evidence.
The current retrospective cohort study used NIS (Nationwide Inpatient Sample) to identify patients who underwent radical nephrectomy from the last quarter of 2008 through 2010. We investigated hospital and patient specific factors associated with the robotic approach to radical nephrectomy, including hospital volume of robotic partial nephrectomy and robot-assisted radical prostatectomy.
Of the 124,462 radical nephrectomies 4.7% were performed robotically. The median cost of robotic radical nephrectomy was $1,324 to $2,759 higher than that of open and laparoscopic radical nephrectomy. No differences in complications, length of stay, blood transfusion rates or mortality were found between laparoscopic and robotic radical nephrectomy. However the rate of open and laparoscopic radical nephrectomy decreased during the study period while the use of robotic radical nephrectomy increased almost fourfold. At hospitals in the middle or highest tertile of robotic partial nephrectomy the procedure was more likely to be performed. Patients younger than 60 years were less likely to undergo the surgery than those older than 80 years (p <0.001). Robotic radical nephrectomy was less likely to be done at large and medium medical centers (p <0.05). The hospital volume of robot-assisted radical prostatectomy did not predict that of robotic radical nephrectomy.
Although increased median costs and equivalent outcomes (perioperative and oncologic) question the benefit of robotic radical nephrectomy, its use is increasing. Robotic radical nephrectomy is more likely to be done at medium-high volume robotic centers for partial nephrectomy. This nationwide overtreatment and inefficiency may reflect the use of robotic radical nephrectomy as a training tool to facilitate the robotic learning curve and the proliferation of robotic partial nephrectomy.
手术中的机器人平台已被广泛采用，因为它有助于进行复杂的手术重建，如部分肾切除术中的肾缝合术。尽管机器人辅助根治性肾切除术成本更高，且缺乏围手术期和肿瘤学方面的证据，但机器人平台在根治性肾切除术中的应用正在增加。我们评估了一个全国性数据库，以解释尽管缺乏围手术期和肿瘤学证据，但机器人辅助根治性肾切除术使用增加的原因。
当前的回顾性队列研究使用国家住院患者样本（NIS）来识别2008年最后一个季度至2010年期间接受根治性肾切除术的患者。我们调查了与机器人辅助根治性肾切除术相关的医院和患者特定因素，包括机器人辅助部分肾切除术和机器人辅助根治性前列腺切除术的医院手术量。
在124,462例根治性肾切除术中，4.7%是通过机器人辅助完成的。机器人辅助根治性肾切除术的中位成本比开放和腹腔镜根治性肾切除术高1324美元至2759美元。腹腔镜和机器人辅助根治性肾切除术在并发症、住院时间、输血率或死亡率方面没有差异。然而，在研究期间，开放和腹腔镜根治性肾切除术的比例下降，而机器人辅助根治性肾切除术的使用增加了近四倍。在机器人辅助部分肾切除术处于中等或最高三分位数的医院，该手术更有可能进行。60岁以下的患者比80岁以上的患者接受该手术的可能性更小（p<0.001）。机器人辅助根治性肾切除术在大中型医疗中心进行的可能性较小（p<0.05）。机器人辅助根治性前列腺切除术的医院手术量并不能预测机器人辅助根治性肾切除术的手术量。
尽管中位成本增加且结果相当（围手术期和肿瘤学方面），这对机器人辅助根治性肾切除术的益处提出了质疑，但其使用仍在增加。机器人辅助根治性肾切除术更有可能在中等至高手术量的机器人中心进行部分肾切除术时进行。这种全国性的过度治疗和低效率可能反映了将机器人辅助根治性肾切除术用作培训工具，以促进机器人学习曲线以及机器人辅助部分肾切除术的扩散。
