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Decreased Morbidity of Minimally Invasive vs Open Partial Nephrectomy: A National Surgical Quality Improvement Program Analysis
Casey Kowalik, MD, Shiv Patel, MD, Andrea Sorcini, MD, Alireza Moinzadeh, MD, David Canes, MD. Lahey Hospital & Medical Center, Burlington, MA, USA.
Background: Benefits of minimally invasive partial nephrectomy (MIPN) compared to open partial nephrectomy (OPN) include reduced narcotic requirements, shorter hospital stay, and faster convalescence. Some comparative studies suggest that this comes at the price of higher perioperative bleeding risk for MIPN, which may no longer be the case as techniques have evolved. Using a national database, we sought to compare 30 day complication rates between OPN and MIPN. Methods: Utilizing the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data file, patients undergoing OPN or MIPN between January 2007 and December 2010 were identified using Current Procedural Terminology (CPT) codes 50240 and 50543, respectively. NSQIP is an outcomes-based database measuring surgical quality of care. Preoperative and intraoperative variables, as well as 30-day perioperative complications, were collected and analyzed. Results: A total of 1,243 patients were identified who underwent OPN (n=718, 58%) or MIPN (n=525, 42%). The percentage of MIPN increased from 14% in 2007 to 45% in 2010. Pre-operative patient characteristics were similar between the two groups (Table 1). Operative time was significantly longer with MIPN (185.5 vs. 209.7 mins, p<0.001). Hospital stay was shorter following MIPN (5.4 vs. 3.2 days, p<0.001). Postoperatively, the OPN cohort had significantly more superficial wound infections, organ space infections, urinary tract infections, and bleeding events requiring transfusion (Table 2). Conclusions: The number of partial nephrectomies being performed using minimally invasive techniques (laparoscopic or robotic) is increasing. We acknowledge the limitations of this dataset as we are unable to evaluate nephrometry scores or tumor characteristics. However, in this large national database, MIPN was associated with longer operative times, but shorter hospital stay. OPN was associated with more wound complications, urinary tract infections, and post-operative transfusions.
Table.1. Demographics and pre-operative risk factors of patients undergoing OPN and MIPN | | OPN n=718 | MIPN n=525 | p-value | Male, no. (%) | 441 (61) | 306 (58) | 0.26 | Age, yrs (mean) | 58.6 | 59.8 | 0.101 | BMI (mean) | 30.4 | 30.3 | 0.752 | Pre-operative creatinine, mg/dL | 1.07 | 1.01 | 0.141 | Bleeding disorder, no. (%) | 15 (2.1) | 8 (1.5) | 0.465 | Diabetes, no. (%) | 152 (20.1) | 89 (17) | 0.063 | Smoker, no. (%) | 150 (21.2) | 99 (19) | 0.376 | Chronic obstructive pulmonary disease, no. (%) | 32 (4.5) | 17 (3.2) | 0.275 | Dialysis dependent, no. (%) | 8 (1.1) | 4 (0.8) | 0.53 | Peripheral vascular disease, no. (%) | 7 (1) | 5 (0.9) | 0.692 | Hypertension, no. (%) | 447 (62) | 309 (59) | 0.225 | History of myocardial infarction, no. (%) | 2 (0.3) | 0 (0) | 0.512 | History of stroke, no. (%) | 22 (3.1) | 10 1.9) | 0.204 | Operative time, mins (mean) | 185.5 | 209.7 | <0.001 | Length of hospitalization, days (mean) | 5.4 | 3.2 | <0.001 |
| | | | Table 2. 30-day outcomes of patients undergoing OPN and MIPN | Complication, no. (%) | OPN n=718 | MIPN n=525 | p-value | Superficial wound infection | 10 (1.4) | 1 (.2) | 0.03 | Deep wound infection | 4 (0.6) | 1 (.2) | 0.404 | Organ space infection | 12 (1.7) | 2 (0.4) | 0.033 | Wound dehiscence | 3 (0.4) | 3 (0.6) | 0.7 | Urinary tract infection | 22 (3.1) | 7 (1.3) | 0.046 | Deep vein thrombosis | 3 (0.4) | 7 (1.3) | 0.106 | Bleeding requiring transfusion | 41 (5.7) | 12 (2.2) | 0.003 | Pneumonia | 6 (0.8) | 5 (1) | 1 | Pulmonary embolism | 6 (0.8) | 5 (1) | 1 | Re-intubation | 7 (0.9) | 2 (0.4) | 0.317 | Acute renal failure | 13 (1.8) | 3 (0.6) | 0.056 | Stroke | 3 (0.4) | 0 (0) | 0.267 | Cardiac arrest | 5 (0.7) | 2 (0.28) | 0.706 | Sepsis/septic shock | 21 (2.9) | 7 (0.96) | 0.062 | Return to operating room | 22 (3.1) | 12 (1.65) | 0.406 |
Disclosure: The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
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