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Purpose: To examine trends in utilization of open, laparoscopic and robot-assisted surgical approaches for treatment of patients with chronic kidney disease (CKD) undergoing partial nephrectomy (PN) within the USA., Methods: We analyzed a weighted sample of 112,117 patients from the Premier administrative dataset who underwent PN for renal mass between 2003 and 2015. Proportions of surgical approach utilization were evaluated by CKD status and further stratified by surgery year and surgeon volume. A multivariate logistic regression model was created to predict receipt of minimally invasive PN., Results: Seven thousand five hundred and sixty-five (6.7%) patients with CKD were identified. The proportion of CKD patients receiving open PN decreased from 72.4% in 2003-2007 to 36.1% in 2012-2015 (p < 0.001). Although the robot-assisted PN was the dominant surgical approach for both patients with and without CKD in 2012-2015, the proportion receiving open PN was higher in patients with CKD compared to those without CKD (p = 0.018). Multivariate analysis showed that the presence of CKD was independently associated with lower odds of receiving a minimally invasive approach (OR 0.47 for the entire study cohort, OR 0.27 for high volume robot-assisted PN surgeons, and OR 0.51 for recent years, all p < 0.001). These trends remained when CKD stages were evaluated individually., Conclusion: Patients with CKD undergoing PN were preferentially treated with open surgery despite an overall increase in robot-assisted PN use over the past 13 years. Further studies evaluating surgical outcomes in this population are warranted for determination of optimal approach and construction of evidence-based guidelines.

Importance: Use of robotic surgery has increased in urological practice over the last decade. However, the use, outcomes, and costs of robotic nephrectomy are unknown., Objectives: To examine the trend in use of robotic-assisted operations for radical nephrectomy in the United States and to compare the perioperative outcomes and costs with laparoscopic radical nephrectomy., Design, Setting, and Participants: This retrospective cohort study used the Premier Healthcare database to evaluate outcomes of patients who had undergone robotic-assisted or laparoscopic radical nephrectomy for renal mass at 416 US hospitals between January 2003 and September 2015. Multivariable regression modeling was used to assess outcomes., Exposures: Robotic-assisted vs laparoscopic radical nephrectomy., Main Outcomes and Measures: The primary outcome of the study was the trend in use of robotic-assisted radical nephrectomy. The secondary outcomes were perioperative complications, based on the Clavien classification system, and defined as any complication (Clavien grades 1-5) or major complications (Clavien grades 3-5, for which grade 5 results in death); resource use (operating time, blood transfusion, length of hospital stay); and direct hospital cost., Results: Among 23 753 patients included in the study (mean age, 61.4 years; men, 13 792 [58.1%]), 18 573 underwent laparoscopic radical nephrectomy and 5180 underwent robotic-assisted radical nephrectomy. Use of robotic-assisted surgery increased from 1.5% (39 of 2676 radical nephrectomy procedures in 2003) to 27.0% (862 of 3194 radical nephrectomy procedures) in 2015 (P for trend <.001). In the weighted-adjusted analysis, there were no significant differences between robotic-assisted and laparoscopic radical nephrectomy in the incidence of any (Clavien grades 1-5) postoperative complications (adjusted rates, 22.2% vs 23.4%, difference, -1.2%; 95% CI, -5.4 to 3.0%) or major (Clavien grades 3-5) complications (adjusted rates, 3.5% vs 3.8%, difference, -0.3%; 95% CI, -1.0% to 0.5%). The rate of prolonged operating time (>4 hours) for patients undergoing the robotic-assisted procedure was higher than for patients receiving the laparoscopic procedure in the adjusted analysis (46.3% vs 25.8%; risk difference, 20.5%; 95% CI, 14.2% to 26.8%). Robotic-assisted radical nephrectomy was associated with higher mean 90-day direct hospital costs ($19 530 vs $16 851; difference, $2678; 95% CI, $838 to $4519), mainly accounted for operating room ($7217 vs $5378; difference, $1839; 95% CI, $1050 to $2628) and supply costs ($4876 vs $3891; difference, $985; 95% CI, $473 to $1498)., Conclusions and Relevance: Among patients undergoing radical nephrectomy for renal mass between 2003 and 2015, the use of robotic-assisted surgery increased substantially. The use of robotic-assistance was not associated with increased risk of any or major complications but was associated with prolonged operating time and higher hospital costs compared with laparoscopic surgery.