Analysis Of Risk Factors For Conversion From Laparoscopic Adrenalectomy To Open Surgery And Evaluation Of Clinical Efficacy Of Different Surgical Methods

Objective To explore the risk factors of conversion from laparoscopic adrenalectomy(LA)to open adrenalectomy(OA),establish a clinical prediction model,and analyze the intraoperative and postoperative clinical effects of patients combined with efficacy indicators of different surgical methods,so as to guide clinicians to decide the surgical methods.Methods A retrospective study was performed on 1068 patients who were diagnosed with adrenal tumors and underwent adrenal surgery in the Department of Urology,Second Hospital of Lanzhou University from January 2013 to June 2022.According to the different surgical methods,the patients were divided into whole-course laparoscopic group,conversion to OA group and OA group.The relevant risk factors of LA transfer to OA were selected by univariate logistic regression analysis,and then,the factors with statistically significant differences were included in multivariate logistic regression analysis to analyze the independent risk factors of conversion,and the logistic regression equation was established according to the results.The optimal cut-off value of the regression equation was selected by the receiver operating characteristic(ROC)curve and Youden’s index.Then,a nomogram model for predicting LA conversion to OA was developed by R software based on independent risk factors,and the discrimination and consistency of this model were assessed.Finally,the perioperative clinical efficacy indicators between the conversion to OA group and the whole-course laparoscopic group,and the conversion to OA group and the OA group were compared to evaluate the influence of different surgical methods on the surgical effect and postoperative rehabilitation of patients.Results A total of 1068 patients undergoing adrenal surgery were included and divided into whole-course laparoscopic group(n=1006),conversion to OA group(n=40)and OA group(n=22):including 484 males(45.3%)and 584 females(54.7%),with mean age of 47.9 years(2～79);847 patients(79.3%)with tumor<5cm and 221patients(20.7%)with tumor≥5cm.The conversion rate of LA in this study was3.82%(40/1046).Univariate analysis showed that BMI,admission blood potassium,tumor location,tumor size,surgical route,surgeon experience and tumor pathology type was significantly associated with conversion from LA to OA;multivariate logistic regression analysis showed that ectopic tumors,diameter≥5cm,transperitoneal surgery,Pheochromocytoma/Paraganglioma(PPGL),malignant tumors,the cumulative number of LA completed by surgeons≤20 and the cumulative number ranged from 21 to 40 were independent risk factors for conversion from LA to OA.The logistic regression equation was established using the above 7independent risk factors to predict LA conversion to OA,and the goodness-of-fit tests showed that the equation model was reasonable(χ~2=2.390,P=0.967)and the predictive efficacy was good.The sensitivity and specificity of the equation were85.0%and 82.6%,respectively.A nomogram prediction model was established based on the above 5 different types of independent risk factors and internal verification was carried out.The calibration curve revealed that the nomogram model had good consistency,and the AUC was 0.901 which indicating that the model had high accuracy.Finally,the clinical efficacy of different surgical methods was compared,and the results showed that:compared with patients in whole-course laparoscopic group,the estimated blood loss(EBL),intraoperative blood transfusion ratio,operation time(OT),drainage volume on the first day after surgery,drainage tube indwelling time(DTIT),urinary catheter indwelling time(UCIT),postoperative fasting time(PFT),postoperative length of stay(PLOS)and total hospital costs of patients who in the conversion to OA group were significantly increased,and the differences were statistically significant(P<0.05 for all);compared with patients who initially underwent open surgery,the EBL,intraoperative blood transfusion ratio,OT and PLOS of patients who in the conversion to OA group were significantly increased,and the differences were statistically significant(P<0.05 for all).Conclusions Ectopic tumors,tumor diameter≥5cm,transperitoneal surgery,PPGL,malignant tumors,and cumulative number of surgery cases by the surgeon≤20and 21～40 are independent risk factors leading to conversion from LA to OA,and the operator should fully understand and evaluate the above factors,rather than a single factor.For patients who plan to undergo LA,surgeons can quantify the risk of conversion from LA to OA based on the regression equation or nomogram model,early preoperative assessment and management of controllable factors can provide an objective and reliable theoretical basis for clinicians to develop individual surgical strategies,thus reducing the conversion rate.For patients with high possibility of conversion,need at the same time combined with the comparison results of intraoperative and postoperative clinical efficacy of different surgical methods,taking the life safety of patients as the center rather than simply pursuing minimally invasive incision of surgery,open surgery should be directly considered or can improve the efficiency of surgery and promote patient rehabilitation,which is of great significance to improve the postoperative conditions and improve the medical quality.Currently,OA is still critical for special types such as malignant or giant adrenal tumors.Therefore,all urologists should master OA in order to calmly handle emergencies that must be converted to OA.