后腹腔镜肾部分切除术热缺血时间的临床研究

目的探讨后腹腔镜肾部分切除术热缺血时间对术后患肾肾功能的影响。方法将2010年1月至2012年1月开展的后腹腔镜下肾部分切除术43例分为3组:短缺血组11例(热缺血时间≤20min),中缺血组23例(20min热缺血时间≤30min),长缺血组9例(30 min热缺血时间≤40 min)。分别于术前、术后2周、3月、6月、1年、1.5年、2年测定患肾肾小球滤过率(GFR),比较其变化情况,分析后腹腔镜肾部分切除术对肾功能的影响。结果短缺血组:术后2周患肾GFR较术前差异有统计学意义(P0.05),其余时间点患肾GFR较术前差异无统计学意义(P0.05)。中缺血组:术后2周、3月患肾GFR较术前差异有统计学意义(P0.05),其余时间点患肾GFR较术前差异无统计学意义(P0.05)。长缺血组:术后2周、3月、6月及1年患肾GFR较术前差异有统计学意义(P0.05),其余时间点患肾GFR较术前差异无统计学意义。结论后腹腔镜肾部分切除术时,应尽力缩短热缺血时间。     

腹腔镜保留肾单位肾部分切除术后肾功能分析

目的 寻求影响腹腔镜下保留肾单位肾部分切除术(LNSS)后肾功能恢复的主要因素,检测LNSS的安全性,明确肾脏热缺血安全时间.方法 回顾性分析本院30例次LNSS患者的临床资料,术前及术后3个月采用99Tcm-二乙三胺五乙酸肾动态显象检测肾小球滤过率(GFR),术前、术后24h及术后一周检测血肌酐水平,统计分析影响术后...     

肾部分切除术治疗肾肿瘤的安全性及疗效分析

目的 评价肾部分切除术治疗肾肿瘤的安全性及有效性.方法 回顾性分析56例行肾部分切除术患者的临床资料.术中肾动脉阻断时间≤30 min者28例.＞30 min者28例.采用99Tcm-DTPA肾核素扫描检测术前术后分肾的肾小球滤过率(GFR),比较两组患者术中出血量、手术时间、术后住院日、并发症发生率以及术前、术后1周和术后6个月的GFR值,明确肾热缺血安全时限,并随访远期生存情况.结果 术后随访30～48个月,平均36个月,总体生存率和肿瘤无复发生存率分别为100%和98%.阻断时间≤30 min和＞30 min组患者术中失血量、手术时间、术后住院日及并发症比较,差异均无统计学意义(P＞0.05).两组术前患肾GFR分别为(42.9±4.9)、(42.8±5.6)ml/min,术后1周为(34.2±4.9)和(30.4±5.2)ml/min,前者GFR降低程度低于后者,差异有统计学意义(p=0.007).术后6个月时肾热缺血时间≤30 min组患肾GFR为(41.2±4.3)ml/min,与术前相比,差异无统计学意义(P＞0.05);＞30 min组GFR为(38.1±5.0)ml/min,仍明显低于术前水平(P=0.001).结论 肾部分切除术治疗肾肿瘤局部复发率低,远期生存率高,并发症发生率低,而且能最大限度地保留功能性肾单位,安全有效.术中阻断肾血管可以有效减少术中失血,将热缺血时间控制在30 min内,对肾功能影响较小,安全可行.

Abstract：

Objective To report the safety and efficacy of partial nephrectomy (PN) in 56 patients with renal tumors. Methods A retrospective analysis was performed for 56 patients who were treated with PN.Patients were divided into two groups according to the occlusion time.The occlusion time for Group 1 was≤30 min in 28 cases,and Group 2＞30 min in 28 cases.All patients underwent pre-and post-operation 99Tcm-diethylenetriamine pentoacetic acid renal scintigraphy, to determine the renal glomerular filtration rate (GFR).The GFR values, amount of blood loss during operation,operative time,postoperative hospital stay and the complications rate were compared between the two groups prior to surgery and one week and six months post-surgery.All patients were followed-up.Results The average follow-up time was 36 (30-48) months.The overall survival rate and tumor recurrence-free survival rate were 100% and 98%.There was no significant difference between vessel clamp time≤30 min and＞30 min in the amount of intraoperative blood loss,operative time,postoperative hospital stay and complications rate,P values were 0.266,0.487,0.879 and 1.000.The preoperative and 1 week postoperative GFR values of the two groups were (42.9±4.9) and (34.2±4.9),(42.8±5.6) and (30.4±5.2) ml/min.The difference was significant(P=0.007).The GFR values were (41.2±4.3)ml/min at 6 months after surgery for Group 1,compared with that before surgery,but the difference was not significant (P＞0.05).While the GFR values were (38.1±5.0) ml/min for Group 2,and the GFR for Group 2 did not recover to the preoperative level (P=0.001). Conelusions PN for renal tumors could be a safe and effective treatment option.The damage on renal function could be minimal when the renal artery clamping time is controlled to within 30 min.     

肾动脉阻断对腹腔镜下保留肾单位术后肾功能的影响

目的：探讨阻断肾动脉主干对腹腔镜下保留肾单位术后患者肾功能的影响.方法回顾分析因肾肿瘤行腹腔镜下保留肾单位手术患者的临床资料,根据术中肾动脉阻断时间、出血量、肿瘤分期、肿瘤病理、术后随访及肾小球滤过率变化,分析肾动脉阻断对保留肾单位手术后肾功能的影响.结果82例患者中,肾透明细胞癌75例,乳头状肾细胞癌3例,嫌色细胞癌4例;肾动脉阻断时间平均(24．5±8．6)min,术中失血量(249．4±66．9)ml.热缺血时间在25 min 以内的患者与26~30 min 患者比较,术后患肾肾功能受损差异无统计学意义(P ＞0．05);热缺血时间为31~40 min 的患者与前两组比较,术后患肾肾功能受损差异有统计学意义(P ＜0．05).结论保留肾单位手术均会使患侧肾功能下降,但阻断肾动脉主干热缺血时间控制在30 min 内对肾功能影响相对较小.     

术中热缺血对T_1期肾癌微创手术患者肾脏功能损伤的研究

目的:探讨术中热缺血时间(warm ischemia time,WIT)对T1期肾癌微创手术患者肾脏功能损伤的影响。方法:选取行腹腔镜肾部分切除术(laparoscopic partial nephrectomy,LPN)T1期肾癌患者41例,观察患者术前、术后3个月及12个月的术侧肾小球滤过率(single glomerular filtration rates,sGFR)值,分析患者术后肾功能状况,回归分析肾功能损害的影响因素。结果:术后3个月[(26.6±5.1)ml/min]、12个月[(28.7±5.2)ml/min]患侧肾sGFR均显著低于术前[(31.8±5.8)ml/min](P<0.05);术后3个月与术后12个月相比,差异无统计学意义(P>0.05)。WIT与术前sGFR值无相关性(r=0.232,P>0.05),与术后3个月(r=-0.374,P<0.01)、12个月(r=-0.395,P<0.01)分别成负相关。术前sGFR值为正向预测(β=0.192,P<0.01)肾功能损害,WIT(β=-0.183,P<0.05)为负向预测肾功能损害。WIT≤30 min患者的肿瘤最大径[(3.3±1.2)cm vs.(4.7±1.8)cm]、术后3个月患侧肾sGFR与术前比较的损失值[(3.1±1.9)ml/min vs.(8.4±6.3)ml/min]显著低于WIT>30 min的患者(P<0.05)。WIT在30 min内对肾功能的损害相对较小。结论:T1期肾癌患者行LPN术中WIT越长、术前sGFR值越低,对肾功能的损害越严重。     

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。     

腹腔镜与开放保留肾单位手术治疗小肾癌的临床比较

目的通过腹腔镜保留肾单位手术(LNSS)与开放保留肾单位手术(ONSS)切除小肾癌的临床指标的对比研究,评价腹腔镜保留肾单位手术治疗小肾癌的安全性和有效性。方法选取本中心2009年6月至2011年6月期间行保留肾单位手术治疗的小肾癌患者51例,其中27例行腹腔镜保留肾单位手术,余24例行开放保留肾单位手术。对两组患者肿瘤大小、手术时间、肾脏热缺血时间、术中出血量、输血例数、引流管留置时间、术后住院时间、切口长度、相关并发症、术前及术后3个月患侧肾的肾小球滤过率(GFR)等指标进行回顾性分析。结果 51例患者均成功施行保留肾单位手术,患者年龄、性别、肿瘤大小、肿瘤侧别、术前患肾GFR、术后引流管留置时间、术后3个月患肾功能等均没有明显差异;手术时间、术中出血量、切口长度、并发症、术后住院天数等,LNSS组明显低于ONSS组(P<0.05);肾脏热缺血时间,LNSS组明显长于ONSS组(P<0.05)。结论腹腔镜保留肾单位手术能完整切除肿瘤,有效控制术中出血,最大限度的保留肾单位,保护肾脏功能。与开放保留肾单位手术相比,LNSS是一种创伤小、手术时间短、并发症少、术后恢复快的手术方式,是治疗小肾癌的有效方法。     

早期肾癌行后腹腔镜肾部分切除术11例报告

目的探讨早期肾癌行后腹腔镜肾部分切除术的临床疗效。方法回顾性研究2008年7月至2012年1月11例早期肾癌行后腹腔镜肾部分切除术的患者资料。结果11例手术全部成功,肿瘤直径为1．7～5．2cm,平均3．3cm;手术时间73～189rain,平均（135±27）rain;术中出血80～740ml,平均（260±50）ml;热缺血时间16～57min,平均（29±9）min;术后住院7～12d,平均（9．3±2．1）d。随访9～51个月,均无瘤生存,肾功能良好。结论早期‘肾癌行后腹腔镜肾部分切除术创伤小、疗效确切,可以有效保留肾脏功能。     

术前MSCTA联合术中超声辅助腹腔镜保肾手术治疗小肾癌

目的观察术前多层螺旋CT血管成像(MSCTA)联合术中超声用于辅助腹腔镜保肾手术治疗小肾癌(肿瘤直径≤4 cm)的效果。方法对85例小肾癌患者行后腹腔镜保留肾单位手术。对其中43例以术前MSCTA联合术中辅助超声(观察组),42例以术前常规肾脏超声及CT检查(对照组)辅助,比较2组相关指标。结果观察组术前MSCTA所示肾肿瘤及肾血管情况与术中所见一致,手术时间、术中热缺血时间、术出血量及术后住院时间均低于对照组(P均0.05)。观察组术中超声发现微小癌灶1例,术后未见切缘阳性及漏尿。对照组术后2例出现漏尿,置入D-J管保守治疗后痊愈;2例切缘阳性,随访中肿瘤均复发,1例接受后腹腔镜肾肿瘤根治术,1例接受保留肾单位的开放手术。2组间术前、术后血肌酐、尿素氮及患肾肾小球滤过率(GFR)差异均无统计学意义(P均0.05),对照组术后GFR低于术前(P=0.040)。结论对小肾癌患者行后腹腔镜保留肾单位手术时,术前MSCTA联合术中辅助超声能够减少术中出血量,降低切缘阳性率,尽可能多地保留肾单位,促进患肾功能恢复。     

术前多层螺旋CT血管成像、术中超声在后腹腔镜阻断肾段动脉肾部分切除术中的应用

目的探讨术前多层螺旋CT血管成像(multi-slice spiral CT angiography,MSCTA)及术中超声在小肾癌阻断肾段动脉后腹腔镜肾部分切除术中的应用价值。方法小肾癌病人55例,常规术前行MSCTA检查,根据是否行术中超声,将其分为术中超声组28例,非术中超声组27例。比较两组手术时间、出血量、术中热缺血时间、微小癌灶发现率、中转开放率、术后漏尿、切缘阳性率、术肾肾小球滤过率(glomerular filtration rate,GFR)。结果术中超声组各项观测指标均优于非术中超声组,其手术时间分别为(172. 1±3. 5)分钟和(216. 3±4. 8)分钟,术中出血量分别为(70. 2±5. 0) ml和(90. 3±4. 0) ml,术中热缺血时间分别为(24. 5±4. 2)分钟和(29. 3±2. 8)分钟,差异有统计学意义(P 0. 05)。术中超声组术前、术后患肾GFR分别为(55. 1±7. 2) ml/min和(54. 1±7. 7) ml/min(P 0. 05),非术中超声组术前、术后患肾GFR分别为(55. 8±7. 0) ml/min和(41. 4±6. 5) ml/min(P 0. 05)。结论术中超声可以快速准确的定位肿瘤组织,尽可能的保留肾单位,减少切缘阳性率,并有利于术后患肾功能的恢复。     

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.     

Is Renal Warm Ischemia over 30 Minutes during Laparoscopic Partial Nephrectomy Possible? One-Year Results of a Prospective Study

OBJECTIVE: To evaluate renal damage and impairment of renal function 1 yr after laparoscopic partial nephrectomy (LPN) with warm ischemia >30 min. METHODS: From July 2004 to June 2005, 18 patients underwent LPN with warm ischemia time >30 min. Kidney damage markers (daily proteinuria and tubular enzymes) and renal function (serum creatinine, cystatin C, and creatinine clearances) were assessed on postoperative days 1 and 5 and at 12 mo. Glomerular filtration rate (GFR) was evaluated before surgery and at 3 mo. Renal scintigraphy was performed before the procedure, at 5 d and at 3 and 12 mo postoperatively. Statistical analysis was performed using the Student t test and logistic regression analysis. RESULTS: In terms of kidney damage and renal function markers, the statistical analysis demonstrated that at 1 yr there was complete return to the normal range and no statistical difference between the values at the various time points. The GFR was not significantly different before and 3 mo after surgery. In terms of scintigraphy of the operated kidney, the values were 48.35+/-3.82% (40-50%) before the procedure, 36.88+/-8.42 (16-50%) on postoperative day 5 (p=0.0001), 40.56+/-8.96 (20-50%) at 3 mo (p=0.003), and 42.8+/-7.2% (20-50%) 1 yr after surgery (p=0.001). CONCLUSION: Our results demonstrate that kidney damage occurs during LPN when warm ischemia is >30 min. This damage is only partially reversible and efforts should be made to keep warm ischemia within 30 min.     

CT血管成像技术在腹腔镜下肾肿瘤保留肾单位手术中的应用价值

目的 探讨CT血管成像(CTA)技术对肾血管解剖形态的评估,以及在腹腔镜下肾肿瘤保留肾单位手术(LNSS)中对肾动脉的控制指导价值. 方法 肾肿瘤患者87例,均行LNSS.CTA组40例,术前行CTA检查,采用容积再现(VR)、最大密度投影(MIP)等重建技术评估肾动脉血管解剖形态;未行CTA检查47例作为对照组.比较2组手术时间,术中热缺血时间、出血量、中转开放手术率,住院时间,术后并发症发生率及疗效. 结果 CTA组和对照组手术时间分别为94(76～118)和115(90～190)min,术中热缺血时间分别为23(12～39)和29(18～40)min,2组间比较差异均有统计学意义(P<0.05);术中出血量分别为90(20～160)和130(90～600)ml,2组间比较差异有统计学意义(P<0.01);中转开放手术分别为0例和1例,中转原因为术中分离肾动脉时出血严重,影响视野;术后住院时间分别为4.1(3～5)和5.5(3～9)d,2组间比较差异均有统计学意义(P<0.05).2组肾癌患者病理检查切缘均为阴性.术后随访4～32个月,平均16个月,2组患者均无肾功能损害和肿瘤复发或转移,2组各有1例尿瘘. 结论 CTA作为LNSS术前了解肾动脉的有效方法,能指导操作者术中更快速、准确地处理肾动脉,缩短手术时间和热缺血时间,减少术中出血量及术后并发症的发生,同时并不增加患者经济负担.     

PADUA评分系统与保留肾单位手术中相关问题的研究

目的:探讨PADUA评分系统在保留肾单位手术(NSS)中与手术时间、热缺血时间、并发症等相关因素的关系。方法:回顾性分析127例次行NSS的124例肾肿瘤患者的临床资料,行PADUA评分,并利用χ2检验、Fisher确切检验等分析PADUA评分与手术时间、热缺血时间、并发症、出血量、术后住院时间、术后第1天血肌酐变化率的关系。结果:PADUA评分低、中、高度复杂肿瘤分别为40例、62例、25例,LNSS组手术时间与PADUA评分有关(P=0.012),ONSS组只有高度与低度复杂肿瘤之间有统计学意义(P=0.005)。对于低度复杂肿瘤,LNSS比ONSS手术时间短(P=0.009)。PADUA评分与热缺血时间相关,与围手术期并发症、术后第1天血肌酐变化率无关。ONSS组出血量与PADUA评分无关,而LNSS组两者有关(P=0.031)。LNSS组高度比低度复杂肿瘤术后住院时间长。结论:PADUA评分与NSS手术时间、热缺血时间等相关因素密切相关,可以预测手术相关结果,指导肾肿瘤的治疗。     

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.     

保留肾单位的腹腔镜与开放肾肿瘤切除术治疗小于4cm肾肿瘤的疗效比较

目的:对比腹腔镜保留肾单位手术(laparoscopic nephron-sparing surgery,LNSS)与开放保留肾单位手术(opennephron-sparing surgery,ONSS)治疗直径<4 cm肾肿瘤的临床疗效。方法:回顾分析2009年1月至2013年1月96例肾部分切除术的临床资料,其中39例行LNSS,57例行ONSS。对比分析两组患者手术时间、术中热缺血时间、术中失血量、术后胃肠功能恢复时间、术后住院时间及手术前后血清肌酐水平;并进行长期随访,比较两组患者生存率、肿瘤复发及转移情况。结果:LNSS组中2例因出血明显中转开放手术,术中输血800 ml,余均顺利完成腹腔镜手术,术后发生并发症5例(12.8%);ONSS组中2例输血400 ml,术后发生并发症6例(10.5%)。两组相比,LNSS组手术时间及术中肾脏热缺血时间长,差异有统计学意义(P<0.05);但术中出血量、术后胃肠功能恢复时间、术后住院时间LNSS组均优于ONSS组,差异有统计学意义(P<0.05)。两组患者术后血清肌酐升高幅度差异无统计学意义(P>0.05)。结论:尽管LNSS手术时间及术中热缺血损伤时间较长,术后并发症发生率相对较高,操作难度较大,对术者技术要求较高,但与开放手术相比,LNSS具有患者创伤小、出血少、康复快、住院时间短等优点。在合理选择适应证、熟练掌握腹腔镜操作与缝合技术的前提下,LNSS有望代替传统开放手术成为治疗小肾癌的新金标准。     

The impact of warm ischaemia on renal function after laparoscopic partial nephrectomy

Authors from Cleveland assessed the impact of warm ischaemia on renal function, using their large database of laparoscopic partial nephrectomies for tumour. While agreeing that renal hilar clamping is essential for precise excision of the tumour, and other elements of the operation, the authors indicate that warm ischaemia may potentially damage the kidney. However, they found that there were virtually no clinical sequelae from warm ischaemic of up to 30 min. They also found that advancing age and pre-existing renal damage increased the risk of postoperative renal damage. OBJECTIVE: To assess the effect of warm ischaemia on renal function after laparoscopic partial nephrectomy (LPN) for tumour, and to evaluate the influence of various risk factors on renal function. PATIENTS AND METHODS: Data were analysed from 179 patients undergoing LPN for renal tumour under warm ischaemic conditions, with clamping of the renal artery and vein. Renal function was primarily evaluated in two groups of patients: 15 with tumour in a solitary kidney, who were evaluated by serial serum creatinine measurements; and 12 with two functioning kidneys undergoing unilateral LPN, and evaluated by renal scintigraphy before and 1 month after LPN to quantify differential renal function. Also, in all 179 patients, mean serum creatinine data at baseline, 1 day after LPN, at hospital discharge, and at the last follow-up were provided as supportive evidence. Logistic regression analyses were used to assess the effect of various risk factors on renal function after LPN, i.e. patient age, baseline serum creatinine, tumour size, solitary kidney status, duration of warm ischaemia, pelvicalyceal suture repair, urine output and intravenous fluids during LPN. RESULTS: In the group of patients with a solitary kidney the mean warm ischaemia time was 29 min, kidney parenchyma excised 29%, and serum creatinine at baseline, discharge, the peak after LPN and at the last follow-up (mean 4.8 months) 1.3, 2.3, 2.8, and 1.8 mg/dL, respectively. One patient (6.6%) required temporary dialysis. In the second group, assessed by renal scintigraphy, the function of the operated kidney was reduced by a mean of 29%, commensurate with the amount of parenchyma excised. For all 179 patients, a combination of age > or = 70 years and a serum creatinine level after LPN of > or = 1.5 mg/dL correlated with a higher serum creatinine after LPN. On logistic regression, baseline serum creatinine and solitary kidney status were the only variables significant for serum creatinine status after LPN. CONCLUSIONS: The bloodless field provided by renal hilar clamping is important for precise tumour excision, pelvicalyceal suture repair and securing parenchymal haemostasis during LPN. However, renal hilar clamping causes warm ischaemia. These data indicate that the clinical sequelae of warm ischaemic renal injury of approximately 30 min are minimal. Advancing age and pre-existing azotaemia increase the risk of renal dysfunction after LPN, especially when the warm ischaemia exceeds 30 min.     

腹腔镜与开放保留肾单位手术治疗囊性肾癌的比较

【摘要】目的 评价腹腔镜保留肾单位手术(laparoscopice nephron-sparing surgery,LNSS)与开放保留肾单位手术(open nephron-sparing surgery,ONSS)治疗囊性肾癌的优劣。方法 回顾性分析14例分别行 LNSS 患者(n=6)与行 ONSS 患者(n=8)的临床资料,比较两组患者术中出血量、手术时间、热缺血时间、术后疼痛评分、术后引流管天数、住院天数及术后随访资料并行统计学分析。结果 LNSS 组术中出血量、术后疼痛评分明显小于 ONSS 组,LNSS 组热缺血时间及手术时间长于 ONSS 组,差异有统计学意义(P<0.05),引流管留置时间及住院天数两者差异无统计学差异。结论 LNSS与ONSS 两种术式在囊性肾癌的治疗中各有优势,LNSS创伤更小,术后恢复更快,但手术要求高。     

Is laparoscopic donor nephrectomy the new criterion standard?

HYPOTHESIS: The posttransplantation renal function outcomes between consecutive open donor and laparoscopic donor nephrectomies (LDNs) are similar and affect living donation. DESIGN: Using the medical records of renal living donor-recipient pairs, 36 consecutive open donor nephrectomies were compared with the subsequent 100 LDNs. Data collected on donor characteristics included demographics (age, race, sex, weight, and height), renal vascular and ureteral anatomical features, surgical information (blood loss, number of blood transfusions, operating time, warm ischemia time, and renal injury), complications, and length of hospital stay. Recipients' data also included renal function information (serum creatinine level on postoperative days 7 and 30) and ureteral complications during the initial hospital stay. SETTING: A not-for-profit tertiary care teaching hospital in a metropolitan area. PATIENTS: Adults who had end-stage renal disease and received a living donation kidney. MAIN OUTCOME MEASURES: Operative time, warm ischemia time, blood loss, and posttransplantation serum creatinine level. RESULTS: Patient characteristics were not significantly different between the open donor nephrectomy and LDN groups. No right kidney LDNs were done because of the shortness of the right renal vein; and, after the initial experience, left kidneys with more than 2 arteries were excluded. Warm ischemia time was recorded only for LDN, and it was found that a warm ischemia time of 10 minutes or longer was associated with difficulty in extraction and was uniformly associated with elevated mean serum creatinine levels on postoperative day 7. CONCLUSIONS: The length of hospital stay was decreased and cosmetic result enhanced. The number of living donors has increased from 28 in 1997 to 53 in 1998 and to 63 in 1999 at our institution. The length of hospital stay, incidence of complications, and comparable kidney quality indicate that LDN should be the initiating procedure for most patients.