RESUMEN
BACKGROUND: Local tumour ablation (LTA) may yield better perioperative outcomes than partial nephrectomy (PN), however the impact of each treatment on perioperative mortality and health care expenditures is unknown. The aim of the study was to compare mortality, morbidity and health care expenditures between LTA and PN. PATIENTS AND METHODS: A population-based assessment of 2471 patients with cT1a kidney cancer treated with either LTA or PN, between 2000 and 2009, in the SEER-Medicare database was performed. After propensity score matching, 30-day mortality, overall and specific complication rates, length of stay, readmission rates and health care expenditures according to LTA or PN were estimated. Multivariable logistic and linear models addressed the effect of each specific LTA approach on overall complication rates, length of stay, readmission rates and health care expenditures. RESULTS: The 30-day mortality was <2% after either LTA or PN (OR 2.27, p = 0.2). The overall complication rate was 21% after LTA and 40% after PN (OR 0.38, p < 0.001). Blood transfusions, infection/sepsis, wound infections, respiratory complications, gastrointestinal complications, acute kidney injury, and accidental puncture or laceration/foreign body left during procedure rates resulted lower after LTA relative to PN (all p < 0.05). Similarly, length of stay and health care expenditures resulted lower after LTA relative to PN (all p < 0.05). Conversely, readmission rate was not significantly different in LTA relative to PN (p = 0.1). CONCLUSIONS: Despite similar perioperative mortality, LTA is associated with lower complications rate, shorter length of stay and lower health care expenditure relative to PN.
Asunto(s)
Carcinoma de Células Renales/cirugía , Ablación por Catéter/métodos , Gastos en Salud , Neoplasias Renales/cirugía , Nefrectomía/métodos , Complicaciones Posoperatorias/epidemiología , Lesión Renal Aguda/economía , Lesión Renal Aguda/epidemiología , Anciano , Anciano de 80 o más Años , Transfusión Sanguínea/economía , Transfusión Sanguínea/estadística & datos numéricos , Carcinoma de Células Renales/economía , Ablación por Catéter/efectos adversos , Ablación por Catéter/economía , Femenino , Humanos , Enfermedad Iatrogénica/economía , Enfermedad Iatrogénica/epidemiología , Neoplasias Renales/economía , Laparoscopía , Laparotomía , Modelos Lineales , Modelos Logísticos , Masculino , Medicare , Mortalidad , Análisis Multivariante , Nefrectomía/efectos adversos , Nefrectomía/economía , Complicaciones Posoperatorias/economía , Puntaje de Propensión , Enfermedades Respiratorias/economía , Enfermedades Respiratorias/epidemiología , Estudios Retrospectivos , Programa de VERF , Sepsis/economía , Sepsis/epidemiología , Infección de la Herida Quirúrgica/economía , Infección de la Herida Quirúrgica/epidemiología , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Current guidelines recommend local tumour ablation (LTA) over partial nephrectomy (PN) in nonsurgical candidates; however, objective definitions of these candidates are lacking. OBJECTIVE: To identify specific patients who would benefit from LTA more than PN. DESIGN, SETTING, AND PARTICIPANTS: A population-based assessment was performed of 2476 patients in the Surveillance Epidemiology and End Results-Medicare database who had cT1a kidney cancer treated with either LTA or PN, between 2000 and 2009. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The outcome of the study was the relevant perioperative complications rate. A multivariable logistic regression model was fitted to predict the risk of complications after PN. Model-derived coefficients were used to calculate the risk of complication in case of PN among patients treated with LTA. Locally weighted scatterplot smoothing method was used to plot the observed complication rate against the predicted risk of complication in case of PN. RESULTS AND LIMITATIONS: At multivariable logistic regression, age (odds ratio [OR]: 1.04; p<0.001), Charlson comorbidity index (OR: 1.14; p<0.001), acute kidney injury (OR: 1.91; p=0.04), or chronic kidney disease (OR: 2.16; p=0.002), tumour size (OR: 1.02; p=0.01), and minimally invasive approach (OR: 0.77; p<0.03) emerged as significant predictors of complications. When LTA was chosen over PN, the reduction in the risk of complications was greatest in high-risk patients, intermediate in intermediate-risk patients, and least in low-risk patients. CONCLUSIONS: When postoperative complications are evaluated, the benefit of choosing LTA is not the same in all patients diagnosed with T1a kidney cancer. Specifically, patients at high risk of complications in case of PN may benefit the most from LTA and represent ideal LTA candidates. PATIENT SUMMARY: Elderly patients at high risk of complications in case of surgical treatment with partial nephrectomy for kidney cancer should be instructed that local tumour ablation might decrease their perioperative morbidity.
Asunto(s)
Técnicas de Ablación/efectos adversos , Neoplasias Renales/cirugía , Nefrectomía/efectos adversos , Complicaciones Posoperatorias/etiología , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Humanos , Neoplasias Renales/mortalidad , Neoplasias Renales/patología , Modelos Logísticos , Masculino , Medicare , Análisis Multivariante , Estadificación de Neoplasias , Nefrectomía/métodos , Nefrectomía/mortalidad , Oportunidad Relativa , Selección de Paciente , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Programa de VERF , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVES: To examine, using competing risks regression, differences in cancer-specific mortality (CSM) that might distinguish between local tumour ablation (LTA) and observation (OBS) for patients with kidney cancer. PATIENTS AND METHODS: The study focused on 1 860 patients with cT1a kidney cancer treated with either LTA or OBS between 2000 and 2009 in the Surveillance Epidemiology and End Results-Medicare database. Propensity-score matching was used. The study outcome was CSM. Multivariable competing risks regression analyses, adjusting for other-cause mortality as well as patient (including comorbidities) and tumour characteristics, were fitted. RESULTS: Overall, fewer patients underwent LTA than OBS (30 vs 70%; n = 553 vs n = 1 307). Compared with patients in the OBS group, those in the LTA group were younger (median age 77 vs 78 years; P < 0.001), more likely to be white (84 vs 78%; P = 0.005), more frequently married (59 vs 52%; P = 0.02) and more frequently of high socio-economic status (54 vs 45%; P = 0.001). After propensity-score matching, 553 patients who underwent LTA and 553 who underwent OBS remained for subsequent analyses. The mean standardized differences of patient characteristics between the two groups were <10%, indicating a high degree of similarity. After LTA or OBS, the 5-year CSM estimates from Poisson regression-derived smoothed plots were 3.5 and 9.1%, respectively. In multivariable competing risks regression analyses, LTA use was found to have a protective effect on CSM (hazard ratio 0.47 [95% confidence interval 0.25-0.89]; P = 0.02). CONCLUSIONS: After adjustment for comorbidity and tumour characteristics in elderly patients with kidney cancer, LTA was associated with a clinically and statistically significant protective effect on CSM, compared with OBS. This advantage of LTA deserves consideration when obtaining informed consent.