Impact of temporary hilar clamping during laparoscopic partial nephrectomy on postoperative renal function: a prospective study

PURPOSE: Laparoscopic partial nephrectomy for small renal tumors has been increasingly performed in the last few years. We prospectively evaluated preoperative and postoperative differential renal function by renal scan in patients with contralaterally functioning kidneys who underwent laparoscopic partial nephrectomy with hilar clamping. MATERIALS AND METHODS: From July 2002 to June 2003, 17 consecutive patients were included in this prospective protocol and underwent laparoscopic partial nephrectomy for exophytic tumors using en bloc hilar clamping. Preoperative renal scan with differential function was performed 1 month before and 3 months after surgery in all patients. technetium labeled diethylenetetraminepentaacetic acid scan was performed in all patients. RESULTS: Mean warm ischemia time was 22.50 +/- 9.78 minutes (range 10 to 44). Preoperative differential renal function and glomerular filtration rate (GFR) in the affected kidneys were 50.20% +/- 4.90% (range 43 to 58) and 75.56 +/- 16.45 ml per minutes (range 39.4 to 105). At postoperative month 3 differential renal function and GFR in the affected kidney were 48.07% +/- 7.16% (range 39% to 63%) and 72.03 +/- 18.17 ml per minutes (range 31 to 101). There was a nonsignificant negative association between hilar clamp time and change in renal function (postoperative - preoperative) of the affected kidney (r = -0.26, p = 0.31), and a positive correlation between clamp time and change in GFR (r = 0.39, p = 0.12) that did not reach statistical significance. CONCLUSIONS: In patients with contralaterally functioning kidney, temporary hilar clamping with a mean warm ischemia time of 22.5 minutes results in preservation of renal function in the affected kidney. Larger studies with longer followup are necessary to study the impact of warm ischemia further.     

Laparoscopic partial nephrectomy using microwave tissue coagulator for small renal tumors: usefulness and complications

OBJECTIVES: We evaluated the usefulness and complications of laparoscopic partial nephrectomy for small renal tumors using a microwave tissue coagulator without renal pedicle clamping. METHODS: Between September 1999 and March 2003, 19 patients with small renal tumors 11 to 45 mm in diameter underwent laparoscopic partial nephrectomy without renal ischemia. RESULTS: Six and 13 patients were treated by the transperitoneal and retroperitoneal approaches, respectively. Excluding a case with open conversion due to dense perirenal adhesions, 18 patients successfully underwent laparoscopic procedures. The mean operative time was 240 minutes with minimal blood loss in 14 patients and 100 to 400 ml in 4. In a patient, frozen sections revealed a positive surgical margin and additional resection was performed. Postoperative complications included extended urine leakage for 14 days, arteriovenous fistula and almost total loss of renal function, respectively, in a patient. With the median follow-up of 19 months, no patients showed local recurrence or distant metastasis by CT scan. CONCLUSIONS: Laparoscopic non-ischemic partial nephrectomy using a microwave tissue coagulator may be useful for treating small renal tumors because it does not require advanced laparoscopic skill. However, the indication of this procedure should be highly selective in order to minimize serious complications secondary to unexpected collateral damage to surrounding structures.     

Posterior retroperitoneoscopic partial nephrectomy using microwave tissue coagulator for small renal tumors

BACKGROUND AND PURPOSE: Laparoscopic partial nephrectomy remains surgically challenging because of the potential for excessive blood loss, infection, and the development of urinary fistulas. In addition, posterior retroperitoneoscopic partial nephrectomy is not popular because of the limited space for surgical manipulation. We evaluated the usefulness of a microwave tissue coagulator in posterior retroperitoneoscopic partial nephrectomy for small posterior renal tumor. PATIENTS AND METHODS: Posterior retroperitoneoscopic partial nephrectomy was performed without renal pedicle clamping using a microwave tissue coagulator in six patients with small posterior renal tumors. RESULTS: The mean operative time was 136 minutes (range 78-180 minutes), and the blood loss was <20 mL. No serious operative complications occurred, and there was no significant deterioration of renal function. CONCLUSION: Posterior retroperitoneoscopic partial nephrectomy using a microwave tissue coagulator can be a safe and less invasive method for the treatment of small posterior renal tumors.     

Renal-tissue damage induced by laparoscopic partial nephrectomy using microwave tissue coagulator

BACKGROUND AND PURPOSE: The microwave coagulator is a useful instrument that enables surgeons to perform partial nephrectomy without vascular clamping. The extent of postoperative thermal damage in surgically spared renal tissue has not been well examined. The present study was conducted to evaluate the tissue damage caused by microwave coagulation in laparoscopic partial nephrectomy (LPN) for small renal tumors. MATERIALS AND METHODS: Seven cases of LPN with a microwave tissue coagulator were entered in the present study. The median tumor diameter was 1.5 cm, and the median size of the resected specimen was 2.2 cm. Postoperative tissue damage was evaluated by contrast-enhanced CT 1 month after surgery. Surgically spared renal-tissue volume and functioning renal-tissue volume were estimated from the images by NIH Image 1.62 software. RESULTS: Postoperative CT revealed unenhanced renal tissue adjacent to the surgical margin. The median estimated volumes of surgically spared and functioning renal tissue were 96.1% (range 74.3%-99.8%) and 88.4% (range 68.0%-92.7%) of preoperative normal renal tissue, respectively. The percentile volume of functioning to surgically spared renal tissue ranged from 89.9% to 96.0% (median 92.8%). CONCLUSIONS: The microwave coagulator enables us to carry out partial nephrectomy without vascular clamping. Although 96% of normal renal tissue was surgically spared, 4% to 10% of this tissue was nonfunctioning as a result of microwave-induced thermal damage.     

Retroperitoneoscopic partial nephrectomy using microwave coagulation for small renal tumors

OBJECTIVES: The outcome of laparoscopic partial nephrectomy using a microwave tissue coagulator for treatment of small renal tumors was studied.PATIENTS AND METHODS: From June 1999 to May 2001, eight patients with small renal tumors of less than 5.0cm in diameter (1.0-5.0cm, T1N0M0) underwent retroperitoneoscopic partial nephrectomy. To control bleeding during the partial nephrectomy, the renal parenchyma around the tumor was coagulated using a microwave tissue coagulator with a needle of 1.5cm length. The tumor was circumscribed within the coagulated area with 8-13 punctures of the coagulation needle, and partial nephrectomy was performed using scissors and bipolar forceps.RESULTS: All eight patients successfully underwent the procedure retroperitoneoscopically. The average operative time was 295 minutes and the average blood loss was 129ml. Three patients showed urine leakage from the renal calyces, which was controlled by suturing retroperitoneoscopically. In two patients, the surgical margin was revealed to be positive for renal cell carcinoma by frozen section pathology and additional resection was performed in these individuals. The patients were discharged from the hospital with almost full convalescence on day 10 on average. Within the mean follow-up period of 10.4 months, no recurrence was found when examined with computer tomography (CT) using contrast media. As a complication, one patient experienced a decrease in function of the operated kidney caused by unknown reason.CONCLUSION: Retroperitoneal partial nephrectomy using a microwave tissue coagulator is useful for treatment of small renal tumors located at the peripheral area of the kidney. Bleeding from the renal parenchymal incision site is well controlled without occlusion of the renal artery with additional use of a bipolar coagulator, when necessary. Further experience and long-term follow-up are mandatory however, to establish the usefulness of this technique.     

后腹腔镜下肾脏肿瘤铥激光部分切除术10例报告

目的 探讨后腹腔镜下铥激光在肾脏肿瘤部分切除术中的操作要点和临床应用价值.方法 对10例肾脏肿瘤患者采用后腹腔镜下肾脏肿瘤铥激光部分切除术进行治疗,肿瘤直径(3.10 ±0.70)cm,均位于肾脏的一侧或突出于肾脏表面.术前检查临床分期均为T1aNoMo期.对10例肾脏肿瘤患者均采用后腹腔镜下肾脏肿瘤铥激光切除术进行治疗.结果 10例患者手术均成功,未中转开放手术.手术平均时间(105.14±19.63) min.术中未阻断肾血管;术中平均出血量(112.63±20.21)mL,未输血.术后无大出血、感染、继发性出血、漏尿等并发症.术后住院时间为7d.术后病理结果1例为肾乳头状细胞癌,9例为肾透明细胞癌,术后随访6个月至1年内均未见肿瘤复发及转移.结论 后腹腔镜下肾脏肿瘤铥激光切除术具有创伤小、恢复快、术中止血快、切除精确、视野清晰等优点,可能将成为一种新的安全可行的微创治疗方法.     

Non-ischemic partial nephrectomy using microwave tissue coagulator

PURPOSE: The indications and the safety of non-ischemic partial nephrectomy using a microwave tissue coagulator were studied. MATERIALS AND METHODS: Non-ischemic partial nephrectomy was performed on 17 kidneys of 16 patients using a microwave tissue coagulator. The diagnosis was renal tumor and renal stones in eleven and five patients, respectively. Renal tumors were less than 4 centimeters in diameter, while the stones were associated with a caliceal diverticulum or secondary cortical atrophy. Excision of the tumors was done via the retroperitoneal approach through an oblique lumbar incision. The needle of the microwave tissue coagulator was inserted around the tumor (stone) 10 to 20 times, and the coagulator was activated. Then the tumor (stone) was excised with a sharp knife or scissors. Patients were encouraged to walk on the first postoperative day. RESULTS: Vascular clamping was necessary in one patient to reduce bleeding. Nephrectomy was done after partial nephrectomy in one patient because it was difficult to close the urinary collecting system after it was widely exposed. Although urine leakage was seen postoperatively in two patients, it ceased spontaneously at 14 and 23 days after surgery. Postoperative complications developed in one of seven patients (14%) with protruding renal tumor, in three of five patients (60%) with non-protruding renal tumor and in two patients with renal stone. Allogenic or autologous blood transfusion was not necessary, nor was any bleeding noticed post-operatively. In one patient, atrophy of the renal parenchyma occurred gradually after surgery and function was eventually lost. However, renal function was well preserved and recurrence of the problem was not observed in the other 15 patients, excluding one who died of esophageal cancer. CONCLUSIONS: The microwave tissue coagulator is a useful surgical instrument for non-ischemic partial nephrectomy, not only in patients with renal tumors but also in patients with complicated kidney stones. However, non-protruding renal tumor in a patient with solitary kidney should be avoided for this surgery. Thermal injury to the renal parenchyma or large vessels should be avoided and urine leakage from the collecting system should be meticulously treated during the operation.     

Partial nephrectomy using microwave tissue coagulator--application for laparoscopic operation

We report our clinical findings on 12 tumors (11 patients) successfully resected by partial nephrectomy with a microwave tissue coagulator (MTC) without renal pedicle clamping, including laparoscopic operation in 4 patients. All patients presented with a renal tumor detected incidentally by ultrasonography or computed tomography. The mean size of renal tumor was 1.9 (range 0.8-3.4) cm. Pathological diagnosis was renal cell carcinoma in 9 tumors and hemorrhagic cyst in 3 tumors. Mean operative time was 249 minutes. Mean blood loss was 183 ml in cases with a laparoscopic operation, that was statistically less than 486 ml in cases with an open operation (p<0.05), and 376 ml in all cases. There was no significant change in the creatinine clearance of cases with laparoscopic operation, compared with that of cases with an open operation. There were no other serious complications postoperatively. These findings suggested that partial nephrectomy with the MTC can be safely and successfully carried out while sparing renal function. Moreover, partial nephrectomy with the MTC for a laparoscopic operation may provide these patients with more benefits.     

Advances in laparoscopic partial nephrectomy

PURPOSE OF REVIEW: The advantages of the laparoscopic approach in the management of kidney tumors are unequivocal and the role of laparoscopy in nephron-sparing surgery is evolving. In a selected group of patients with small exophytic renal tumors laparoscopic partial nephrectomy became an alternative to open partial nephrectomy. However, the application of laparoscopic partial nephrectomy to larger, centrally located tumors or tumors in unfavorable sites is limited by the difficulty of achieving adequate, prompt collecting system closure and hemostasis with a limited warm ischemia time. The most recent developments in laparoscopic partial nephrectomy are the subject of this review. RECENT FINDINGS: A number of sealant products have been used as an adjunct or principal hemostatic agent in the animal model. Their application in the clinical setting remains limited to small parenchymal bleeding; larger vessels and pelvicaliceal openings are better managed by vascular clamping and intracorporeal suturing. Vascular clamping confers warm ischemia, and attempts at renal hypothermia included cold kidney irrigation through either a ureteral stent or a renal artery cannulation, and the application of ice slush for parenchymal surface cooling. SUMMARY: Laparoscopic partial nephrectomy is technically demanding; efforts directed towards facilitating hemostasis, improving renal cooling or shortening the warm ischemia time will expand its indications further.     

Laparoscopic total and partial nephrectomy

Laparoscopic radical nephrectomy has established its role as a standard of care for the management of renal neoplasms. Long term follow-up has demonstrated laparoscopic radical nephrectomy has shorter patient hospitalization and effective cancer control, with no significant difference in survival compared with open radical nephrectomy. For renal masses less than 4cm, partial nephrectomy is indicated for patients with a solitary kidney or who demonstrate impairment of contralateral renal function. The major technical issue for success of laparoscopic partial nephrectomy is bleeding control and several techniques have been developed to achieve better hemostatic control. Development of new laparoscopic techniques for partial nephrectomy can be divided into 2 categories: hilar control and warm ischemia vs. no hilar control. Development of a laparoscopic Satinsky clamp has achieved en bloc control of the renal hilum in order to allow cold knife excision of the mass, with laparoscopic repair of the collecting system, if needed. Combination of laparoscopic partial nephrectomy with ablative techniques has achieved successful excision of renal masses with adequate hemostasis without hilar clamping. Other techniques without hilar control have been investigated and included the use of a microwave tissue coagulator. In conclusion, laparoscopic radical nephrectomy for renal cell carcinoma has clearly demonstrated low morbidity and equivalent cancer control. The rates for local recurrences and metastatic spread are low and actuarial survival high. Furthermore, laparoscopic partial nephrectomy has demonstrated to be technically feasible, with low morbidity. With short term outcomes demonstrating laparoscopic partial nephrectomy as an efficacious procedure, the role of laparoscopic partial nephrectomy should continue to increase.     

Retroperitoneoscopic nephron-sparing surgery of renal tumor using a microwave tissue coagulator without renal ischemia: comparison with open procedure

PURPOSE: It is ideal to use not a transperitoneal but a retroperitoneal approach for both open and endoscopic partial nephrectomy. We compared the results of retroperitoneoscopic nephron-sparing surgery for small renal tumors using a microwave tissue coagulator without renal pedicle clamping with those of a retroperitoneal open procedure. PATIENTS AND METHODS: Between 1996 and 2002, eight patients with small renal tumors underwent retroperitoneoscopic partial nephrectomy without renal ischemia, and nine patients with small renal tumors underwent open partial nephrectomy via a retroperitoneal approach. Both groups were operated on using a microwave tissue coagulator. RESULTS: Retroperitoneoscopic partial nephrectomy without renal ischemia was performed without any major or minor complications in any patient. The mean operation time for retroperitoneoscopic surgery was significantly longer than that for open partial nephrectomy (221.9 minutes v 145.9 minutes; P = 0.0004). However, the mean estimated blood loss for retroperitoneoscopic surgery was less than that for open partial nephrectomy (137.5 mL v 334.8 mL; P = 0.012). In addition, the retroperitoneoscopic group seemed to recover more rapidly than the open surgery group. CONCLUSIONS: Retroperitoneoscopic nephron-sparing surgery of small renal tumors using a microwave tissue coagulator without renal ischemia is feasible as minimally invasive procedure. It results in saving renal function, minimal blood loss, and rapid recovery.     

Predictors of benign histology in clinical T1a renal cell carcinoma tumors undergoing partial nephrectomy

The anatomical characteristics of renal tumors have been classified using several systems. An association between tumor anatomical characteristics and postoperative histological diagnosis can be expected. The present study aimed to assess the rate of and predictive factors for benign histological findings for renal tumors diagnosed as T1a by preoperative imaging. From January 2000 through December 2010, 149 patients underwent partial nephrectomy (either open or laparoscopic) for T1a renal cell carcinoma. The frequency of benign histological findings was evaluated. Logistic regression analysis estimated the relative importance of predictive factors. The overall frequency of benign lesions was 8.1%. Multivariate analysis identified three statistically significant predictive factors for benign lesions: age, sex and exophytic tumor property (P = 0.0356, 0.0183 and 0.0330, respectively). The present findings suggest that exophytic tumors on preoperative imaging are more likely to be benign at histology after partial nephrectomy.     

Laparoscopic partial nephrectomy: the European experience.

Laparoscopic partial nephrectomy is technically difficult but oncologically effective. The operation should be performed in centers with expertise. Hemostasis can be achieved using bipolar coagulation and fibrin glue-coated cellulose. Further studies will determine whether less invasive alternatives (focused ultrasound, cryotherapy) will meet the high standard of open (or laparoscopic) nephron-sparing surgery for small renal cell carcinoma.CommentaryThe technique of laparoscopic partial nephrectomy for the treatment of renal cell carcinoma (RCC) is in its very early stages. The cumulative experience reported in the literature comprises fewer than 100 cases and these have been confounded by a lack of standardized technique and variable experience. There has been difficulty in reproducing the essential elements of open partial nephrectomy using contemporary laparoscopic instrumentation. In this large multicenter European study, hemostasis was achieved with bipolar coagulation and fibrin-coated cellulose. Notwithstanding that case selection was limited to very small (≤3 cm) peripheral renal tumors, the morbidity of partial nephrectomy in this study was greater than that of open partial nephrectomy for small peripheral tumors.At the Cleveland Clinic, we have recently developed a technique for laparoscopic partial nephrectomy which duplicates established open surgical principles. The key technical steps in this approach include:Since August 1999, this technique has been used to perform laparoscopic partial nephrectomy in 36 patients with small, exophytic renal tumors. Mean tumor size was 2.9 cm (range 1.4–7.0 cm). The operation was successful in all cases without any open conversions. Mean operative time was 2.9 h, warm ischemia time was 20 min and blood loss was 237 ml. Formal calyceal suture repair was performed in 7 patients. Mean hospital stay was 1.7 days. The final pathology revealed renal cell carcinoma in 20 patients and other tumors in the remainder. All margins of resection were negative for tumor.Our initial experience suggests that laparoscopic partial nephrectomy can be performed for small exophytic renal tumors with adherence to established principles and techniques of the open surgical approach and with significant benefits for the patient.Andrew C. Novick, M.D.     

保留肾单位手术后肾功能预后的影响因素分析

目的:探讨肾肿瘤行保留肾单位手术(NSS)后肾功能预后的影响因素。方法:回顾性分析西京医院2016年12月至2018年12月行NSS治疗的115例肾肿瘤患者的临床资料。男75例,女40例。年龄(49.50±12.94)岁;体质指数(24.59±3.59)kg/m 2;肿瘤最大径(3.66±1.32)cm;R.E.N.A.L.评分(6.43±1.60)分。术前患肾肾小球滤过率(GFR)(48.22±11.48)ml/(min·1.73m 2),健肾GFR(49.73±11.96)ml/(min·1.73m 2),总GFR(97.95±21.32)ml/(min·1.73m 2)。术前患肾有功能肾组织体积(FPV)(132.23±9.11)cm 3。61例行腹腔镜肾部分切除术,54例行机器人辅助腹腔镜肾部分切除术。记录手术时间、热缺血时间(WIT)、术后病理结果。记录术后6个月的血肌酐、患肾GFR、健肾GFR、总GFR、GFR保存率(术后GFR与术前GFR的比值)、患肾FPV、患肾FPV保存率(术后患肾FPV与术前FPV的比值)。患肾FPV通过手术前后的CT影像使用椭球体近似法测量。手术前后GFR和患肾FPV比较采用配对样本t检验。采用Spearman秩相关分析评估各研究因素与患肾GFR保存率间的相关性。多因素分析采用多元线性回归模型分析患肾功能的独立预测因素。以WIT=25 min为截断点将患者分为≤25 min组和>25 min组,比较两组术前患肾GFR,以及术后6个月的患肾GFR和患肾GFR保存率。结果:本组115例手术均顺利完成,中位手术时间135(75~245)min,WIT(24.57±5.51)min。患肾术后GFR(35.50±7.81)ml/(min·1.73 m 2),与术前比较差异有统计学意义(P<0.001),患肾GFR保存率为(74.65±11.10)%。术后6个月患肾FPV保存率为(84.28±4.37)%,与术前比较明显减少(P<0.001)。患肾FPV保存率与患肾GFR保存率呈极强正相关(r=0.802);WIT与患肾GFR保存率呈中等程度负相关(r=-0.503)。多元线性回归分析结果显示,术前患肾GFR(b=-0.150,P=0.008)、WIT(b=-0.443,P<0.001)、患肾FPV保存率(b=1.638,P<0.001)是患肾GFR保存率的独立预测因素。WIT>25 min组和≤25 min组的患肾GFR保存率分别为(68.77±10.88)%和(79.34±8.88)%,差异有统计学意义(P<0.001)。结论:在WIT较短(<30 min)的情况下,正常肾组织数量的保留是影响NSS术后肾功能预后的重要因素,有限的WIT起次要作用。在保证肿瘤完整切除的前提下,应尽可能保留更多的正常肾组织,同时尽量将WIT控制在25 min以内。     

后腹腔镜无功能肾切除术的临床体会(附16例报告)

目的:总结后腹腔镜无功能肾切除术的安全性及手术方法、技巧。方法:回顾分析2013年1月至2016年1月为16例无功能肾患者行后腹腔镜肾切除术的临床资料,观察术前患肾体积、手术时间、手术出血情况、术后并发症情况。结果:16例手术均完成,无一例中转开放手术。患肾直径20~200 mm,平均(102.5±11.3)mm;手术时间105~450 min,平均(208.1±24.1)min;术中出血量40~280 ml,平均(160.0±14.3)ml;术中、术后均未输血;术后发生不全性肠梗阻1例,予以灌肠后恢复;切口拆线后均愈合良好。结论:后腹腔镜无功能肾切除术中对肾动静脉的处理是手术关键。对于积水明显的肾脏可先吸出积水,缩小肾脏体积,沿肾脏边缘分离,这是保证手术安全可靠的方法;后腹腔镜无功能肾切除术后无明显并发症发生,是微创治疗的发展方向,值得进一步推广应用。     

后腹腔镜保留肾单位的肾部分切除术治疗T1期肾肿瘤（附22例报道）

目的探讨后腹腔镜保留肾单位的肾部分切除术治疗T1期肾肿瘤的手术方法及临床疗效。方法回顾性分析22例行后腹腔镜保留肾单位的肾部分切除术的T1期肾肿瘤患者的临床资料,其中男8例,女14例,平均年龄48岁。双侧肾肿瘤1例,单侧双瘤灶1例;左侧13例,右侧10例。肿瘤平均直径3cm。所有患者均行后腹腔镜保留肾单位的肾部分切除术。结果 22例手术均顺利完成。平均手术时间135min,平均肾动脉阻断时间29min,平均出血量55ml,平均住院时间10d。术中未见外科并发症,术后仅1例发生漏尿。术中切缘组织病理均阴性。24个瘤灶术后病理证实为肾透明细胞癌19例、多房囊性肾细胞癌2例、肾嗜酸细胞瘤2例、肾嫌色细胞腺癌1例。随访时间1～28个月,平均10个月,肿瘤无局部复发及远处转移。结论后腹腔镜保留肾单位的肾部分切除术治疗T1期肾肿瘤安全、可行,其远期疗效尚待长期随访。     

原位肾低温灌注腹腔镜下肾部分切除术

目的 探讨一种改进的原位肾低温灌注方法在腹腔镜下肾部分切除术中的临床价值.方法 2009年3-5月,对5例解剖性或功能性孤立肾患者行原位肾低温灌注腹腔镜下肾部分切除术.男3例,女2例;平均年龄49(39～63)岁;肿瘤位于左侧2例,右侧3侧;肿瘤直径平均5.6(3.8～7.0)cm.慢性肾功能不全2例,孤立肾1例,对侧肾萎缩1例,较大良性肿瘤1例.术前经皮穿刺经股动脉介入方法在患侧肾动脉留置带球囊契压导管1根,术中契压导管的球囊注水以阻断患侧肾动脉,并通过契压导管在加压泵下持续向肾动脉内灌注4℃冰盐水约200 ml,以实现患侧肾脏低温原位灌注,同时行腹腔镜下肾部分切除术,术后抽出球囊水以解除肾动脉阻断.结果 5例均成功施行原位肾低温灌注腹腔镜下肾部分切除术,手术时间平均102(80～120)min,肾动脉阻断时间平均35(29～39)min,术中出血量平均190(50～300)ml.低温灌注后皮肤温度平均降低0.6℃,肾脏表面温度降低10.0℃,肿瘤表面温度平均降低9.8℃.术前、术后第1、3、5和10天患者肌酐清除率分别为(64.7±16.9),(48.9±14.5)、(52.1±12.4)、(54.5±13.8)和(54.6±11.7)ml/min,多个相关样本检验显示,各组之间肌酐清除率比较差异有统计学意义(P=0.001).术后第5天和第10天比较差异无统计学意义(P=0.125),其余组间比较差异有统计学意义(P=0.043),术后第5天肌酐清除率基本稳定.结论 原位肾低温灌注腹腔镜下肾部分切除术安全可行,同时解决了腹腔镜下动脉阻断和低温灌注难题,有利于延长肾缺血时间、保护肾功能.     

Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors

PURPOSE: Laparoscopic partial nephrectomy is an increasingly performed, minimally invasive alternative to open partial nephrectomy. We compared early postoperative outcomes in 1,800 patients undergoing open partial nephrectomy by experienced surgeons with the initial experience with laparoscopic partial nephrectomy in patients with a single renal tumor 7 cm or less. MATERIALS AND METHODS: Data on 1,800 consecutive open or laparoscopic partial nephrectomies were collected prospectively or retrospectively in tumor registries at 3 large referral centers. Demographic, intraoperative, postoperative and followup data were compared between the 2 groups. RESULTS: Compared to the laparoscopic partial nephrectomy group of 771 patients the 1,028 undergoing open partial nephrectomy were a higher risk group with a greater percent presenting symptomatically with decreased performance status, impaired renal function and tumor in a solitary functioning kidney (p<0.0001). More tumors in the open partial nephrectomy group were more than 4 cm and centrally located and more proved to be malignant (p<0.0001 and 0.0003, respectively). Based on multivariate analysis laparoscopic partial nephrectomy was associated with shorter operative time (p<0.0001), decreased operative blood loss (p<0.0001) and shorter hospital stay (p<0.0001). The chance of intraoperative complications was comparable in the 2 groups. However, laparoscopic partial nephrectomy was associated with longer ischemia time (p<0.0001), more postoperative complications, particularly urological (p<0.0001), and an increased number of subsequent procedures (p<0.0001). Renal functional outcomes were similar 3 months after laparoscopic and open partial nephrectomy with 97.9% and 99.6% of renal units retaining function, respectively. Three-year cancer specific survival for patients with a single cT1N0M0 renal cell carcinoma was 99.3% and 99.2% after laparoscopic and open partial nephrectomy, respectively. CONCLUSIONS: Early experience with laparoscopic partial nephrectomy is promising. Laparoscopic partial nephrectomy offered the advantages of less operative time, decreased operative blood loss and a shorter hospital stay. When applied to patients with a single renal tumor 7 cm or less, laparoscopic partial nephrectomy was associated with additional postoperative morbidity compared to open partial nephrectomy. However, equivalent functional and early oncological outcomes were achieved.     

Application of the microwave tissue coagulator: is it beneficial to partial nephrectomy?

BACKGROUND/AIM: The indications of partial nephrectomy have expanded after the introduction of new techniques for preventing excessive blood loss and avoiding deterioration of the renal function after clamping the renal pedicle. We present our clinical experience of partial nephrectomy for renal tumors using a microwave tissue coagulator. PATIENTS AND METHODS: Between April 1996 and January 2000, 34 patients underwent open partial nephrectomies in the Kobe City General Hospital. The microwave tissue coagulator was used for resection of the renal parenchyma, but in deeper lesions a sharp dissection was performed. Twenty-two patients (groups 1 and 2) underwent partial nephrectomy without vascular control (14 renal pedicles were not disturbed in group 1 patients, and 8 renal pedicles were dissected but not clamped in group 2 patients). Another 12 patients (group 3) underwent vascular control with ligation of the tumor-feeding segmental arteries before parenchymal resection. The patients of group 1 underwent wedge resections, while those of groups 2 and 3 underwent segmental or transverse partial nephrectomies. RESULTS: Complete tumor resection was done in all 34 patients. In group 1, the microwave tissue coagulator was very effective to control the blood loss (mean 330 ml). In larger resections, this method only was inadequate to control the blood loss (mean 489 ml in group 2), so that we needed vascular control. However, despite vascular control, mean blood losses of about 943 ml because of deeper venous bleeding occurred in group 3, and, moreover, postoperative renal infarctions occurred in 2 patients. Other complications were urinary fistula formation in 16 patients (47%) and renal pelvic stenoses in 2 patients (5.8%). All of the urinary fistulas were easily repaired by simple suturing intraoperatively. CONCLUSIONS: Especially in wedge resection, the microwave tissue coagulator achieved safe resection without vascular control which differs from other new techniques. However, in larger resections, a combination with other techniques may be necessary to decrease blood loss and the rate of complications.     

Early impact of robot-assisted partial nephrectomy on renal function as assessed by renal scintigraphy

To measure the early impact of robot-assisted partial nephrectomy (RAPN) on renal function as assessed by renal scan (Tc 99m-DTPA), addressing the issue of risk factors for ischemic damage to the kidney. All patients undergoing RAPN for cT1 renal masses between June 2013 and May 2014 were included in this prospective study. Renal function as expressed by glomerular filtration rate (GFR) was assessed by Technetium 99m-diethylenetriaminepentaacetic acid (Tc 99m-DTPA) renal scan preoperatively and postoperatively at 1 month in every patient. A multivariable analysis was used for the determination of independent factors predictive of GFR decrease of the operated kidney. Overall, 32 patients underwent RAPN in the time interval. Median tumor size, blood loss, and ischemia time were 4 cm, 200 mL, and 24 min, respectively. Two grade III complications occurred (postoperative bleeding in the renal fossa, urinoma). The GFR of the operated kidney decreased significantly from 51.7 ± 15.1 mL/min per 1.73 m² preoperatively to 40, 12 ± 12.4 mL/min per 1.73 m² 1 month postoperatively (p = 0.001) with a decrease of 22.4 %. On multivariable analysis, only tumor size (p = 0.05) was a predictor of GFR decrease of the operated kidney. Robotic-assisted partial nephrectomy had a detectable impact on early renal function in a series of relatively large tumors and prevailing intermediate nephrometric risk. A mean decrease of 22 % of GFR as assessed by renal scan in the operated kidney was found at 1 month postoperatively. In multivariable analysis, tumor size only was a significant predictor of renal function loss.