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Minimal-invasive vs. offene Nierenteilresektionen

Perioperative Erfolgs- und Komplikationsraten

Minimally invasive vs. open partial nephrectomy

Perioperative success and complication rates

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Zusammenfassung

Hintergrund

Bei der organerhaltenden Nierentumorresektion zeigt sich ein Trend zu minimal-invasiven und robotisch assistierten Verfahren.

Ziel der Arbeit

Es erfolgte ein retrospektiver perioperativer Ergebnisvergleich zwischen minimal-invasiver Nierenteilresektion und offener Technik.

Material und Methoden

Alle Patienten, mit nierenerhaltender Operation zwischen 2006 und 2016, wurden in zwei Gruppen („offen“ = Gruppe O und „minimal-invasiv“ = Gruppe M) eingeteilt. Die prä- und perioperative Daten, Comorbidity-Index, pT-Stadium, R‑Status und PADUA-Score, Trifecta-Kriterien, Komplikationen (Clavien-Klassifikation) und die perioperative Veränderung der Nierenfunktion wurden erhoben.

Ergebnisse

In die Auswertung flossen 310 von 329 Patienten ein (Gruppe O 123, Gruppe M 187). Gruppe O hatte einen signifikant höheren ASA-Score (bei vergleichbarem Charlson-Index) und signifikant mehr pT3/pT4-Tumoren bei vergleichbarem PADUA-Score als möglicher Ausdruck eines Selektionsbias. Gruppe M hatte eine signifikant geringere Krankenhausverweildauer (p < 0,001) und Transfusionsrate (p < 0,05). Die Trifecta-Zielkriterien wurden mittels minimal-invasiver Techniken signifikant häufiger erreicht als in Gruppe O (Gruppe M 66,8 % vs. Gruppe 0 49,6 %; p < 0,001). Hinsichtlich des Auftretens von Komplikationen (Major 10,7 %, Minor 13,9 % vs. 17,1 % bzw. 26,0 % bei Gruppe O) war die Gruppe M signifikant überlegen (p < 0,05). Es zeigte sich kein Unterschied im Erhalt der Nierenfunktion bei Entlassung. Die R0-Raten betrugen 97,8 % (M) vs. 97,5 % (O). Die Operationszeit war in Gruppe M signifikant länger (p < 0,001; mean 30 min). Der Anteil der robotisch assistierten Verfahren stieg über die Jahre kontinuierlich.

Schlussfolgerungen

Die minimal-invasive Nierenteilresektion erwies sich als sicher auch bei komplexen Tumorgeschehen und wurde  an unserer Klinik nahezu vollständig robotisch assistiert durchgeführt. In allen verglichenen Punkten zeigte sich sie sich als dem offenen Verfahren zumindest gleichwertig.

Abstract

Background

Solid renal masses are increasingly treated with nephron-sparing surgery. As in other uro-oncological surgical techniques, minimally invasive and robotic-assisted techniques are becoming increasingly popular.

Objectives

The perioperative results from minimally invasive nephron-sparing surgery versus open surgery were retrospectively compared.

Materials and methods

In our single center retrospective study, all patients who underwent nephron-sparing tumor excision between 2006 and 2016 were divided into two groups (group O = open approach and group M = minimally invasive approach). The (pre-)operative data, complications, and change in renal function were compared. Trifecta criteria (R0, no perioperative complications, ischemia ≤25 min) were used to determine success rates.

Results

Of 329 patients, 310 were included for analysis (group O 123, group M 187). Patients in group O had significantly worse ASA score but comparable Charlson Index and significantly more pT3/4 tumors but equal PADUA-score when compared with group M. Otherwise, preoperative patient and tumor characteristics were comparable. Patients in group M had significantly shorter hospital stays (p < 0.001) and lower transfusion rates (p < 0.05). Trifecta criteria were more frequently met in group M than in O (M: 66.8% vs. 0: 49.6%; p < 0.001). Both major and minor complications were lower in group M (major: 10.7% vs 17.1%; minor: 13.9% vs. 26.0%; p < 0.05). Preservation of renal function was comparable in both groups. R0 rates did not differ significantly between groups (M: 97.8% vs O: 97.5%). Surgical procedure times were significantly longer in group M (p < 0.001; mean 30 min).

Conclusions

Minimally invasive, robotic assisted partial nephrectomy also proved to be successful in complex cases. In all aspects studied, the minimally invasive approach was shown to be at least equivalent to the open approach.

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Authors and Affiliations

  1. Klinik für Urologie Bochum, Universität Witten/Herdecke, Augusta Kranken-Anstalt gGmbH, Bergstr. 26, 44791, Bochum, Deutschland

    A. Boy, J. Hein, A. Roosen &  B. Ubrig

  2. Klinik für Radiologie, Augusta Kranken-Anstalt gGmbH, Bergstr. 26, 44791, Bochum, Deutschland

    M. Bollow

  3. Klinik für Urologie und Kinderurologie, Agaplesion Diakonieklinikum Rotenburg gGmbH, Elise-Averdieck-Str. 17, 27356, Rotenburg (Wümme), Deutschland

    D. Lazica

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  1. A. Boy
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  4. D. Lazica
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Correspondence to B. Ubrig.

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Interessenkonflikt

A. Boy, J. Hein, M. Bollow, D. Lazica, A. Roosen und B. Ubrig geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Glossar

eGFR

abgeschätzte („estimated“) GFR

GFR

glomeruläre Filtrationsrate

KDIGO

Kidney Disease – Improving Global Outcomes (Internationale Nephrologenvereinigung; koordiniert Entwicklung globaler Leitlinien)

MDRD-Formel

zur Berechnung der eGFR. Alter, Geschlecht, Hautfarbe und Serum-Kreatinin gehen ein

PADUA-Score

Preoperative Aspects and Dimensions Used for an Anatomical Classification

Trifecta

R0-Resektion + Ischämie ≤25 min + keine perioperativen Komplikationen

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Boy, A., Hein, J., Bollow, M. et al. Minimal-invasive vs. offene Nierenteilresektionen. Urologe 57, 821–827 (2018). https://doi.org/10.1007/s00120-018-0646-y

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  • DOI: https://doi.org/10.1007/s00120-018-0646-y

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