title: 30-Day Morbidity and Mortality Outcomes of Prolonged Minimally Invasive Kidney Procedures Compared with Shorter Open Procedures: National Surgical Quality Improvement Program Analysis.
abstract: OBJECTIVE
  Prolonged operative time (ORT) is often considered a drawback to minimally invasive surgery (MIS) because of increased morbidity. Limited data exist comparing long laparoscopic ORT with similar or shorter open ORT. This study aims to identify ORT when a minimally invasive procedure becomes inferior to its open counterpart.
  
  
  METHODS
  Minimally invasive and open total and partial nephrectomies and nephroureterectomies were identified in the National Surgical Quality Improvement Program (NSQIP) from 2005 to 2012. Procedures were split into open and minimally invasive nephrectomy and then stratified into four ORT groups: 0 to 90 minutes, 91 minutes to 3 hours, 3 to 6 hours, and ≥ 6 hours. Thirty-day mortality and morbidity were analyzed. Univariate analysis was performed using chi-square and Fisher exact tests. Significant univariate results were then tested using stepwise logistic regression, controlling for demographics, comorbidities, and preoperative treatments.
  
  
  RESULTS
  There were 14,813 patients identified. Both partial and total minimally invasive kidney procedures had significantly improved outcomes compared with open counterparts of similar ORT. In the total nephrectomy group, a minimally invasive approach had a lower rate of surgical site infections, sepsis, pneumonia, return to operating room, and overall length of stay when compared with open procedures of the same duration. Length of hospital stay decreased in MIS regardless of operative time, except when comparing minimally invasive cases longer than 6 hours with open cases less than 90 minutes. Transfusion rates also significantly decreased in minimally invasive total nephrectomy cases. In the partial nephrectomy group, similar outcomes were seen in terms of length of stay and infectious outcomes. Interestingly, transfusion risk was decreased in the open partial nephrectomy group when comparing cases less than 90 minutes with minimally invasive partial nephrectomies lasting 3 to 6 hours; otherwise there was no significant correlation with transfusion risk.
  
  
  CONCLUSIONS
  Minimally invasive operations are less morbid than open operations of similar ORT. Longer and likely more complex laparoscopic procedures continue to provide a benefit to patients when compared with shorter and possibly less complex open procedures. These data should be considered during a surgeon's preoperative and operative decision-making.
authors: 1 Department of Urology, George Washington University School of Medicine & Health Sciences , Washington, D.C.
authors: Alice
authors: A
authors: Semerjian
authors: 2 Department of Surgery, George Washington University School of Medicine & Health Sciences , Washington, D.C.
authors: Sara L
authors: SL
authors: Zettervall
authors: 2 Department of Surgery, George Washington University School of Medicine & Health Sciences , Washington, D.C.
authors: Richard
authors: R
authors: Amdur
authors: 1 Department of Urology, George Washington University School of Medicine & Health Sciences , Washington, D.C.
authors: Thomas W
authors: TW
authors: Jarrett
authors: 2 Department of Surgery, George Washington University School of Medicine & Health Sciences , Washington, D.C.
authors: Khashayar
authors: K
authors: Vaziri
mesh_terms: D000368:Aged; D000704:Analysis of Variance; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007680:Kidney Neoplasms / Q000401:mortality / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods; D007902:Length of Stay / Q000706:statistics & numerical data; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects; D009392:Nephrectomy / Q000379:methods*; D061646:Operative Time; D011183:Postoperative Complications; D058996:Quality Improvement; D014513:Ureter / Q000601:surgery; D055815:Young Adult