Organ preservation in kidney cancer more likely at facilities that are early adopters of robotic surgery

Patients with operable kidney cancers were more likely to have a partial nephrectomy, which is the recommended treatment for localized tumors, when treated in hospitals that were early adopters of robotic surgery, according to a new study.

By 2008, partial nephrectomies were performed more often (38% of cases) in hospitals that had adopted robotic surgery at the start of the 21st century (between 2001 and 2004) compared with late adopters (2005 to 2008), at which partial nephrectomies were performed in only 24% of cases. This was reported by researchers from New York University Langone Medical Center in New York, New York, and elsewhere, and published in Medical Care (2015; doi:10.1097/MLR.0000000000000259).

Partial nephrectomy is preferred over total nephrectomy because it can achieve similar outcomes in cancer while avoiding the long-term risks associated with total kidney removal, such as cardiovascular disease, chronic kidney failure, and premature death.

"Our study is the first to show, at the hospital level, that more institutional experience with robotic surgery is likely to have resulted in this increase in partial nephrectomy," said the study's lead author, Ganesh Sivarajan, MD, a postdoctoral fellow in the Department of Urology at NYU Langone. Hospitals that had not adopted robotics by 2008 performed partial nephrectomies in only 20% of cases.

For their study, the research team analyzed retrospective data on all nephrectomies from all payers from seven states (Arizona, Florida, Maryland, North Carolina, New York, New Jersey, and Washington) to extract data on 21,569 kidney cancer surgeries. They then sorted these procedures by hospital, and associated their frequency with the timing of each hospital's acquisition of surgical robotics.

"Robotic surgery was not originally designed for treatment of kidney tumors, but what we see here is a case of reinvention, or adaptation. In this case, the reinvention has served to provide patients increased access to an underutilized, guideline-supported procedure," said the study's senior author Danil V. Makarov, MD, MHS, Director of Urological Health Services Research at NYU Langone

Robotics offers other important advantages over laparoscopic and open surgery, according to Sivarajan. "It has outstanding magnification and permits improved manual dexterity," he said.

Robotic surgery has been the focal point of many debates, specifically over its high acquisition and operating costs, but also over its role in improving patient outcomes. However, as this study demonstrates, it allows surgeons in many cases to preserve vital organs, improve quality of care, and keep up with new clinical practice guidelines.

"We strongly believe that our analysis offers significant public health implications for the delivery of guideline-based care for kidney cancer," Makarov said. "As we move toward expanded use of cost effectiveness data, we need to leave room for this sort of evolution."

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