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Safety of Minimally-Invasive Partial vs Radical Nephrectomy for cT1-T2 Renal Masses: An NSQIP Analysis
Jonathan Song, BA, Nancy Donohoo, BA, Samuel Lee, BA, James Jones, III, MD, Daniel Chen, MD, Frank Meng, PhD, Mark Katz, MD, David Wang, MD.
Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
BACKGROUND: Minimally-invasive (MIS) management of cT1b-T2 renal masses with partial (MIPN) or radical (MIRN) nephrectomy varies with tumor characteristics and surgeon experience. Post-operative complication trends may help guide surgical planning.
METHODS: We reviewed the ACS NSQIP for all MIPN and MIRN with cT1-T2/N0/M0 for 30-day post-operative outcomes. Patients were excluded for pre-operative dialysis, eGFR < 15, sepsis, disseminated cancer, or ventilator-dependency. Univariate logistic regression modeling (p<0.10) was used to select covariates and screen outcomes for inclusion in multivariate modeling.
RESULTS: 13,024 patients were included with 9,418 (72%) patients undergoing MIPN. 8496 (65%), 3584 (28%), 716 (5%), and 228 (2%) patients had cT1a, cT1b, cT2a, and cT2b tumors, respectively. There was no difference in transfusion (2.0 vs 2.4%), post-operative dialysis (0.2 vs 0.3%), related readmission (3.6 vs 3.3%), or related reoperation (1.0 vs 1.2%) rates. MIRN was associated with higher odds of AKI (OR 2.83; 95% CI 2.12-3.80), delayed return of bowel function (OR 2.23; 95% CI 1.51-3.28), and delayed discharge (OR 2.48; 95% CI 2.12-2.89). MIRN was not significantly associated with prolonged operation or death. cT1b-T2 tumors were independently associated with transfusion (OR 1.61; 95% CI 1.16-2.24) and delayed discharge (OR 1.14; 95% CI 1.00-1.31) vs cT1a tumors.
CONCLUSIONS: Complication rates for cT1-T2 renal masses after MIPN were favorable compared to MIRN. Larger cT1b-T2 tumors were associated with transfusion and delayed discharge, independent of approach. In properly selected patients, MIPN is safe and may reduce risk of AKI, ileus, and delayed discharge without impact on operative time, bleeding, reoperation, readmission, or death.
Multivariate Analysis of Association Between Surgical Approach and Outcomes| 30-Day Post-Operative Complications | MIRN (vs MIPN)OR (95% CI) |
| Wound Dehiscence | 5.25 (1.86-16.68)* |
| Urinary Leak/Fistula | 0.31 (0.09-0.80)* |
| Ileus | 2.23 (1.51-3.28)* |
| Prolonged Operation Time ≥5hr | 0.94 (0.68-1.28) |
| Delayed Discharge ≥3d | 2.48 (2.12-2.89)* |
| Post-operative AKI | 2.83 (2.12-3.80)* |
| Myocardial Infarction | 1.46 (0.76-2.74) |
| Major Adverse Cardiac Event | 1.71 (1.08-2.69)* |
| Death | 1.61 (0.66-3.93) |
Multivariate Analysis of Association Between Grouped Tumor Stage and Outcomes| 30-Day Post-Operative Complications | cT1b-T2b (vs cT1a)OR (95% CI) |
| Transfusion <72hr | 1.61 (1.16-2.24)* |
| Wound Dehiscence | 0.92 (0.38-2.35) |
| Prolonged Operation Time ≥5hr | 1.26 (0.98-1.60) |
| Delayed Discharge ≥3d | 1.14 (1.00-1.31)* |
| Post-operative Dialysis | 1.52 (0.69-3.41) |
| Post-operative AKI | 1.27 (0.97-1.65) |
| Cardiac Arrest | 1.79 (0.67-5.02) |
| Unplanned Related Readmission | 1.11 (0.91-1.36) |
| Death | 1.29 (0.54-3.18) |
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