肾后唇部分切除术治疗复杂性肾结石

目的 探讨复杂性肾结石的手术方法。方法 应用肾后唇部分切除术治疗复杂性肾结石48例。结果 术中无需阻断肾蒂，无一例输血，术后复查腹部平片，结石一次性取净44例(91．7％)，残留结石4例(8．3％)。结论 本术式具有操作较简单，易掌握，取石容易且结石一次性取出率高，出血少的优点，是治疗复杂性结石的较好方法。     

常温下阻断肾蒂肾切开取石治疗复杂性铸型肾结石

目的 探讨常温下阻断肾蒂肾实质切开取石治疗复杂性铸型肾结石的临床疗效.方法 对20例复杂性铸型肾结石患者均采取常温下阻断肾蒂肾实质或+肾盂切开取石术.手术前、后检查包括腹部平片、静脉尿路造影、CT、B超、尿素氮、肌酐等项目并术后随访.结果 20例患者均顺利完成取石,一次性取净结石17例,结石残余残留率为15％.手术时间...     

指间阻断肾血流肾实质切开治疗复杂性肾结石

目的:探讨肾实质切开治疗复杂性肾结石的效果。方法:采用静脉滴注肌苷2.0,指间阻断肾血流肾实质切开治疗复杂性肾结石30例。十二肋缘下切口,游离肾脏,沿Brodel氏线纵行切开肾实质全层,直视下取石,冲洗。用4-0肠线或可吸收缝合线间断缝合肾盂肾盏粘膜,1-0肠线或可吸收缝合线缝合肾实质全层。结果:28例结石一次取净,2例小结石残留,经ESWL(体外冲击波碎石)治愈,1例为肾盂钙化灶。结论:手指间阻断肾血流肾实质切开适合于肾内型肾盂鹿角形(铸形)结石和复杂性肾结石手术治疗。     

阻断肾蒂肾下极切除治疗鹿角形肾结石42例

复杂性鹿角形肾结石临床治疗较棘手。我院1990年1月—2006年10月采用低温阻断肾蒂行肾下极切除取石术治疗42例,疗效满意,现报道如下。1临床资料本组男36例,女6例;年龄26～65岁,平均34.5岁。右侧22例,左侧20例,双侧8例,均为肾内型肾盂。巨大鹿角形结石或铸形结石36例,合并肾积水34例,为轻、中度积水。结石最大4.2cm×4.0cm×3.0cm,大多结石充填整个肾盂及肾盏,6例术前多次经体外冲击波碎石治疗失败后改行手术治疗。术前经B超、KUB、IVU及CT等影像学检查明确诊断。术前常规应用抗生素。2手术方式采用硬膜外麻醉。侧卧位,经11肋间切口,切开…     

非阻断肾蒂的腹腔镜肾部分切除术

目的探讨非阻断肾蒂的腹腔镜肾部分切除术的手术技巧与临床效果。方法回顾性分析2006年6月至2008年12月间24例肾肿瘤行肾部分切除术的治疗效果,术中均采用大圆针贯穿缝扎肾实质的方法阻断肿瘤部分肾实质的血流,将肿瘤切除后,腹腔镜下缝扎包埋创面,记录手术时间、术中出血量、术后并发症及术后恢复情况。结果 24例腹腔镜肾部分切除手术均获成功。手术时间75～160分钟,平均95分钟。术中出血量20～320 ml,平均115 ml。术后住院时间6～12天,平均7.5天。术中术后未出现明显并发症。术后随访12～42个月,剩余肾脏功能良好,未见肿瘤复发。结论采用肾实质贯穿缝合的方法行肾部分切除术,可不需阻断肾蒂,术中出血量少,可避免肾脏热缺血对肾功能的影响。     

低温下肾蒂阻断肾实质切开取石术治疗复杂性肾结石25例报告

目的：探讨低温下肾蒂阻断肾实质切开取石术在复杂性肾结石治疗中的应用。方法：选择复杂性肾结石患者25例,阻断前静脉注射肌苷2．0g,均采用低温下阻断肾蒂,沿Brodel线作肾实质切开取石术。结果：25例肾蒂阻断17～45min,术中出血150～450ml,手术时间100～160mln,结石残留2例。术后随访6个月～4年,术后肾功能恢复良好。结论：低温肾蒂阻断肾实质切开取石术是治疗复杂性肾结石的重要方法,结石取净率高,并发症少,对肾功能无影响。     

肾窦内肾盂加肾后下部实质联合切开治疗复杂性肾结石

我院自1996—1999年起采用肾窦内肾盂加肾后下部实质联合切开治疗复杂性肾结石24例，手术操作简单。疗效满意。现报告如下。     

区域性肾低温及肾动脉阻断在复杂性肾结石术中的应用

1 临床资料 我院近10 a来对363例(436例肾脏)不易行ESWL的复杂性肾结石手术中,采用区域性肾低温及肾动脉阻断下行肾切开取石86例(102个肾脏)男60例,女26例,年龄18～65岁,左侧43例,右侧33例,双侧13例。其中孤立肾2例,并发肾盂输尿管连接部狭窄6例,肾迷走血管压迫3例,肾积脓3例。所有患者均有不同程度的反复尿路     

采用2 μm激光不阻断肾蒂行腹腔镜肾部分切除术

目的 评估应用2 μm激光在不阻断肾蒂、腹腔镜下肾部分切除术中的应用价值.方法 2012年5月～2013年1月,共治疗肾占位病变5例,CT显示肿瘤位于上极2例,中极2例,下极1例,肿瘤直径2.5～3.8 cm,平均3.1 cm,临床分期均为T1a期,应用2μm激光(60 ～80 W)在不阻断肾蒂下行腹腔镜肾部分切除术.结果 所有手术均成功完成,手术时间60 ～140 min,平均86 min,术中出血10 ～40 ml,平均20 ml.无一例输血和术后出血.术后病理示透明细胞癌3例,嫌色细胞癌1例,错构瘤1例,切缘全部阴性.术后随访2～8个月,中位数5个月,未见肿瘤复发及转移.结论 在腹腔镜肾部分切除术中,应用2 μm激光切除肿瘤止血好、不用阻断肾蒂,是安全有效切除肿瘤的一种方法.     

经皮肾镜取石术治疗复杂性肾结石96例报告

目的：探讨二维超声引导下经皮肾镜取石术治疗复杂性肾结石的安全性和有效性。方法：对2010年～201i年收治的96例复杂性肾结石患者行二维超声引导下经皮肾镜取石术。总结治疗手术时间、结石清除率、严重并发症发生率。结果：96例患者均在超声引导下建立取石通道进行手术,其中1例因术中严重出【血停止手术,其余均顺利手术取石,平均手术时间85（60～120）min。术后复查KUB、超声,一次结石清除率为56．2％（54／96）。术后发生严重出血需行选择性动脉栓塞2例,未发生气胸、肠管损伤等并发症。结论：二维超声引导下经皮肾镜取石术能安全、有效治疗复杂性肾结石。     

Prospective study of robotic partial nephrectomy for renal cancer in Japan: Comparison with a historical control undergoing laparoscopic partial nephrectomy

Objectives

To evaluate the outcomes of robotic partial nephrectomy compared with those of laparoscopic partial nephrectomy for T1 renal tumors in Japanese centers.

Methods

Patients with a T1 renal tumor who underwent robotic partial nephrectomy were eligible for inclusion in the present study. The primary end‐point consisted of three components: a negative surgical margin, no conversion to open or laparoscopic surgery and a warm ischemia time ≤25 min. We compared data from these patients with the data from a retrospective study of laparoscopic partial nephrectomy carried out in Japan.

Results

A total of 108 patients were registered in the present study; 105 underwent robotic partial nephrectomy. The proportion of patients who met the primary end‐point was 91.3% (95% confidence interval 84.1–95.9%), which was significantly higher than 23.3% in the historical data. Major complications were seen in 19 patients (18.1%). The mean change in the estimated glomerular filtration rate in the operated kidney, 180 days postoperatively, was ?10.8 mL/min/1.73 m² (95% confidence interval ?12.3–9.4%).

Conclusions

Robotic partial nephrectomy for patients with a T1 renal tumor is a safe, feasible and more effective operative method compared with laparoscopic partial nephrectomy. It can be anticipated that robotic partial nephrectomy will become more widely used in Japan in the future.

     

En bloc stapler ligation of the renal vascular pedicle during laparoscopic nephrectomy

OBJECTIVES

To evaluate, in a prospective series of laparoscopic nephrectomies (LNs), the safety and feasibility of en bloc stapling for resection and occlusion of the vascular renal pedicle.

PATIENTS AND METHODS

Between October 2003 and March 2006, we investigated the intra‐ and postoperative outcomes in patients undergoing planned en bloc stapling of the renal vein and artery during LN. We also assessed complications at 6 and 12 months.

RESULTS

In all, 57 patients, with a mean (range) age of 59.8 (10–83) years, were enrolled. The indications for LN were: renal cell carcinoma (RCC) in different stages in 66.7%, transitional cell carcinoma in 3.5% and oncocytoma in 5.2%. In a further 19.2% the patients presented with nontumoral lesions and the remaining 5.4% consisted of several rarer entities. The mean (sd ) tumour size was 4.7 (1.75) cm. In one case (1.8%) a conversion to open nephrectomy was necessary because of a stapling device failure. Three patients (5.4%) underwent revision for bleeding. The median (range) blood loss was 100 (50–1000) mL. The median operating duration was 145 (95–410) min; in 19.3% this included additional surgical or diagnostic procedures. At 6 and 12 months after LN, there were no complications related to the surgical technique, in particular there was no arterio‐venous fistula.

CONCLUSIONS

We conclude that in our prospective series, en bloc stapling of the renal vascular pedicle during LN was a safe technique and that it was feasible in a time at the lower limit of the range of reported durations for similar procedures.     

Evaluation of renal function after laparoscopic partial nephrectomy with renal scintigraphy using 99mtechnetium-mercaptoacetyltriglycine

AIM: We evaluated the functions of an affected kidney after laparoscopic partial nephrectomy (LPN) using renal scintigraphy with (99m)technetium-mercaptoacetyltriglycine ((99m)Tc-MAG3). METHODS: Split renal function of 10 patients who underwent LPN for renal tumors was assessed using renal scintigraphy with (99m)Tc-MAG3 before surgery, and 1 week and 3 months post-surgery. RESULTS: Median operating time was 196.5 min, median tumor diameter was 2.3 cm, mean blood loss was 64 mL and mean ischemic time was 38.5 min. Median change in serum creatinine level pre- to post-surgery was 0.15 mg/dL. Median contribution of the affected kidney to total renal function (calculated using (99m)Tc-MAG3) was 50.0%, 41.7% and 36.1% before surgery, 1 week and 3 months after LPN, respectively. In one patient, the tumor was resected after cooling of the affected kidney with ice slush for 15 min, and the split renal function ratio remained as high as 50% at 3 months post-operatively despite a total ischemic time of 61 min. CONCLUSIONS: This paper evaluated renal function on the affected side before and after surgery by measuring split renal function with renal scintigraphy using (99m)Tc-MAG3. Risk factors for renal dysfunction in the affected kidney after LPN include age over 70 years with more than 30 min warm ischemic time, re-clamping of the renal artery procedure, and a warm ischemic time greater than 60 min. We believe that renal cooling with slush ice prevents renal dysfunction of the affected kidney after LPN with longer warm ischemic times. However, an easier renal cooling technique should be sought for regular use of cooling procedures in LPN.     

T_(1b)期肾肿瘤外科治疗方式的选择:根治性肾切除术与肾部分切除术

近十余年来,局限性肾肿瘤的外科治疗方式发生了明显的变化。目前对于肿瘤直径4cm且≤7cm的临床T1b期肾肿瘤,外科手术方式的选择仍存在争议。本文介绍了T1b期肾肿瘤的外科手术治疗情况,并对手术方式的选择进行了探讨。     

Baseline renal function,ischaemia time and blood loss predict the rate of renal failure after partial nephrectomy

OBJECTIVE

To identify independent predictors of renal failure after partial nephrectomy (PN) in patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

Data were available for 166 patients with pathological T1‐3 N0M0 RCC treated with PN. Renal failure after PN was defined as a decrease in glomerular filtration rate (GFR) of >25% (RIFLE criteria). The GFR before and after PN was estimated using the Modification of Diet in Renal Disease study group equation. Univariable and multivariable logistic regression models were used to assess a decrease of >25% in GFR from the preoperative level. Candidate predictor variables were age, gender, PN indication (absolute vs relative), preoperative GFR, tumour size, perioperative blood loss, surgery duration and clamping time.

RESULTS

After PN, 22 (13.3%) patients had a decrease in GFR of >25%. The perioperative blood loss (P = 0.02), clamping time (P = 0.04) and preoperative GFR (P = 0.002) were independent predictors of a decrease in GFR of >25%.

CONCLUSIONS

We identified two important potentially modifiable variables that should be considered in the planning of PN, i.e. the clamping time and blood loss. It is possible that selective referral to experienced surgeons who can perform PN within short surgical and clamping times, and with minimal blood loss, could minimize the rate of renal failure, especially in patients with an underlying renal function impairment.     

Modified anatrophic partial nephrectomy with selective renal segmental artery clamping to preserve renal function: A preliminary report

Objectives: Partial nephrectomy is effective for preserving renal function, but temporary clamping of the renal artery for hemorrhagic control may impair renal function due to ischemia/reperfusion injury. Anatrophic partial nephrectomy (APNx) has been proposed to minimize renal ischemia/reperfusion injury by clamping only the feeding artery. We aimed to evaluate whether anatrophic partial nephrectomy (APNx) is useful in preserving renal function and to assess variations in renal artery anatomy to determine the feasibility of selective segmental artery clamping. Methods: We performed preoperative renal angiography to evaluate the utility of APNx. Perioperative changes in renal function were compared between the APNx group and a standard partial nephrectomy group. Results: APNx was successful in 18 patients. The mean lengths of the feeding artery on preoperative angiography were 20.5 and 6 mm for successful and unsuccessful cases, respectively. It was not difficult to clamp the feeding artery in 16 patients with lengths >10 mm or with multiple renal arteries. Evaluation of renovascular variations on 116 renal angiograms indicated that APNx was feasible for 60% and 40% on the right and left sides, respectively. The short‐term increase in the serum creatinine level was significantly smaller after APNx than it was after standard partial nephrectomy. Conclusions: APNx minimizes ischemic/reperfusion injury and preserves renal function while achieving hemorrhage control. As it can be performed safely in about 50% of cases, it may be the option for patients with renal impairment or a solitary kidney.     

C index is associated with both short-term and long-term renal functional outcome after partial nephrectomy

ObjectivesPartial nephrectomy is the standard treatment for the small renal mass. C index, one of the nephrometric systems, was found to be associated with short-term renal functional outcome after laparoscopic partial nephrectomy. We conducted this study to externally validate the application of C index as a prognostic factor of long-term renal functional outcome after open partial nephrectomy (OPN) for small renal mass.Materials and MethodsThe medical records of 65 consecutive patients undergoing OPN from June 2004 to November 2011 were reviewed. C index was calculated on preoperative computed tomography or magnetic resonance images. The estimated glomerular filtration rate was calculated using the modification of diet in renal disease 2 equation. Short-term and long-term renal functional outcomes were assessed by the nadir estimated glomerular filtration rate within postoperative 1 week and 1 to 2 years. The correlation between C index, perioperative parameters, and renal functional outcomes were examined.ResultsThe median C index in our cohort was 2.2. C index was associated with operative time, cold ischemia time, estimated blood loss, and length of hospital stay (p = 0.03, 0.001, 0.001, and 0.02, respectively). On logistic linear regression analysis, C index (p = 0.01) and operative time (p < 0.001) were associated with the short-term percent decrease of the estimated glomerular filtration rate, whereas C index (p = 0.03) was associated with the long-term percent decrease of the estimated glomerular filtration rate. Under the criteria of C index ≤ 2.5, the sensitivity/specificity were 83.3%/53.8% and 80%/52% in predicting chronic kidney disease stage 3 or greater in the short-term and long-term follow-up, respectively. Moreover, the mean long-term percent decrease of the estimated glomerular filtration rate in patients with C index ≤ 2.5 was much higher compared with that of patients with C index > 2.5 (18.1% vs. 0%, p = 0.001).ConclusionC index could serve as an indicator for both short-term and long-term renal functional decrease after OPN. For patients with C index ≤ 2.5, a comprehensive analysis of vascular anatomy and planning for dissection are crucial in preoperative assessment, and every effort should be exerted to minimize renal parenchymal damage during surgery.     

射频辅助后腹腔镜下肾部分切除治疗肾肿瘤的临床应用

目的评价腹腔镜下射频消融辅助保留肾单位肾部分切除术治疗肾脏肿瘤的临床效果。方法自2008年3月~2009年12月期间,有10例患者采用了射频辅助腹腔镜下肾部分切除术治疗肾脏肿瘤。其中肾细胞癌6例（肿瘤直径2.0~4.5cm,平均2.3cm）,肾脏错构瘤4例（肿瘤直径3.5~6.0cm,平均4.2cm）。均经后腹腔镜途径先显露肿瘤然后射频,〈3cm的肿瘤射频1个周期（12min）,〉3cm的肿瘤行射频24~36min。射频消融后再沿肿瘤的边缘将肿瘤锐性切除,肿瘤基底采用电凝止血,出血明显的予以射频止血（2~4min）。结果 10例手术均获成功,无中转开放。手术时间63~95min（平均71min）,术中出血50~150mL（平均100mL）,无术后出血、无尿瘘、肾盂输尿管狭窄等并发症发生。术后住院3~5d（平均3.5d）,随访时间3~18个月（平均10个月）,尚未发现肿瘤局部复发或者远处转移。结论射频消融辅助后腹腔镜下保留肾单位肾部分切除术治疗肾肿瘤出血少,无需腹腔镜下缝合止血,明显缩短了手术时间。     

肾部分切除术和肾癌根治术治疗T1b期肾癌疗效比较的Meta分析

目的总结对侧肾功能正常的T1b期肾癌患者行肾部分切除术和根治性肾切除术的疗效差异,为临床上T1b期肾癌患者在手术方式的选择上提供循证学证据。方法收集Pubmed／Medline、Cochrane图书馆、Embase、CNKI中国期刊全文数据库、维普数据库和万方数字化期刊群2012年6月30日前国内外公开发表的有关T1b期肾癌患者行肾部分切除术（PN）和根治性肾切除术（RN）疗效比较的临床对照研究文献,对符合要求的文献进行Meta法系统分析。结果按照严格的纳入标准,最终PN和RN疗效和安全性比较的临床对照研究文献共6篇,总共纳入15740例患者,PN组1841例,RN组13926例。两种手术方式术后5年总生存率、5年肿瘤特异性生存率、5年无瘤生存率和肿瘤转移情况的相对危险度分别为1．02（95％CI为0．94～1．12）、1．11（95％CI为1．04～1．18）、0．67（95％CI为0．19～2．40）和0．21（95％CI为0．08～0．51）。结论两种手术方式术后患者5年总的生存率、5年无瘤生存率差别无统计学意义;PN组术后5年肿瘤特异性生存率优于RN组,PN组比RN组术后更容易合并肿瘤转移。因肾部分切除术能最大限度地保存残肾的肾单位和残肾功能,所以对T1b期肾癌行肾部分切除术是一种有效和可靠的治疗方法。但由于存在发表偏倚、选择偏倚的可能,我们期待出现更高质量的研究为以上结论提供更为可靠的证据。