Association of Robotic-Assisted vs Laparoscopic Radical Nephrectomy With Perioperative Outcomes and Health Care Costs, 2003 to 2015
Association of Robotic-Assisted vs Laparoscopic Radical Nephrectomy With Perioperative Outcomes and Health Care Costs, 2003 to 2015
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DOI：
10.1001/jama.2017.14586
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发表时间：
2017-10-24
影响因子：
120.7
通讯作者：
Chung, Benjamin I.
中科院分区：
文献类型：
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作者：
Jeong, In Gab;Khandwala, Yash S.;Chung, Benjamin I.
在过去的十年里，机器人手术在泌尿外科实践中的重要性有所增加。然而，机器人肾切除术的用途、结果和成本尚不清楚。目的了解在美国使用机器人辅助手术进行根治性肾切除术的趋势，并比较机器人辅助手术和腹腔镜根治性肾切除术的围手术期结果和成本。设计、设置和参与者这项回顾性队列研究使用Premier Healthcare数据库来评估2003年1月至2015年9月期间在美国416家医院接受机器人辅助或腹腔镜根治性肾切除术的患者的结果。采用多变量回归模型对结果进行评估。比较机器人辅助与腹腔镜下根治性肾切除术的疗效。主要结果和测量本研究的主要结果是机器人辅助根治性肾切除术的使用趋势。根据Clavien分类系统，次要结果是围手术期并发症，定义为任何并发症(Clavien分级1~5级)或主要并发症(Clavien分级3~5级，其中Clavien分级5级导致死亡)；资源使用(手术时间、输血、住院时间)；以及直接住院费用。结果纳入研究的23753例患者(平均年龄61.4岁；男性13792例(58.1%))中，18573例行腹腔镜根治性肾切除术，5180例行机器人辅助根治性肾切除术。在调整后的分析中，机器人辅助手术的使用率从1.5%(2003年2676例根治性肾切除术中的39例)增加到2015年的27.0%(3194例根治性肾切除术中的862例)(趋势为4小时)，接受机器人辅助手术的患者高于接受腹腔镜手术的患者(46.3%对25.8%；风险差异，20.5%；95%可信区间，14.2%至26.8%)。机器人辅助根治性肾切除术与较高的平均90天直接住院费用(19530美元比16851美元；差异2678美元；95%CI，838美元到4519美元)相关，主要是手术室(7217美元比5378美元；差异1839美元；95%CI，1050美元到2628美元)和供应成本(4876美元比3891美元；差异985美元；95%CI，473美元到1498美元)。结论2003至2015年间，在接受肾肿块根治性肾切除术的患者中，机器人辅助手术的使用大幅增加。使用机器人辅助手术与增加任何或主要并发症的风险无关，但与腹腔镜手术相比，与延长手术时间和更高的医院费用有关。
IMPORTANCE Use of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy are unknown.OBJECTIVES To examine the trend in use of robotic-assisted operations for radical nephrectomy in the United States and to compare the perioperative outcomes and costs with laparoscopic radical nephrectomy.DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used the Premier Healthcare database to evaluate outcomes of patients who had undergone robotic-assisted or laparoscopic radical nephrectomy for renal mass at 416 US hospitals between January 2003 and September 2015. Multivariable regression modeling was used to assess outcomes.EXPOSURES Robotic-assisted vs laparoscopic radical nephrectomy.MAIN OUTCOMES AND MEASURES The primary outcome of the study was the trend in use of robotic-assisted radical nephrectomy. The secondary outcomes were perioperative complications, based on the Clavien classification system, and defined as any complication (Clavien grades 1-5) or major complications (Clavien grades 3-5, for which grade 5 results in death); resource use (operating time, blood transfusion, length of hospital stay); and direct hospital cost.RESULTS Among 23 753 patients included in the study (mean age, 61.4 years; men, 13 792 [58.1%]), 18 573 underwent laparoscopic radical nephrectomy and 5180 underwent robotic-assisted radical nephrectomy. Use of robotic-assisted surgery increased from 1.5% (39 of 2676 radical nephrectomy procedures in 2003) to 27.0%(862 of 3194 radical nephrectomy procedures) in 2015 (P for trend 4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients receiving the laparoscopic procedure in the adjusted analysis (46.3% vs 25.8%; risk difference, 20.5%; 95% CI, 14.2% to 26.8%). Robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19 530 vs $16 851; difference, $2678; 95% CI, $838 to $4519), mainly accounted for operating room ($7217 vs $5378; difference, $1839; 95% CI, $1050 to $2628) and supply costs ($4876 vs $3891; difference, $985; 95% CI, $473 to $1498).CONCLUSIONS AND RELEVANCE Among patients undergoing radical nephrectomy for renal mass between 2003 and 2015, the use of robotic-assisted surgery increased substantially. The use of robotic-assistance was not associated with increased risk of any or major complications but was associated with prolonged operating time and higher hospital costs compared with laparoscopic surgery.