肾部分切除术后肾动脉假性动脉瘤形成的危险因素分析

目的 探讨肾部分切除术后发生肾动脉假性动脉瘤(RAP)的危险因素。 方法 2003年7月至2010年5月,肾细胞癌行肾部分切除术患者464例,术后发生RAP 5例(1.1％)。均为男性,左侧2例,右侧3例。对肾部分切除术的手术方法、RAP的临床表现、影像学特点及治疗进行回顾性分析。肿瘤的解剖学特征按照肾脏测量评分系统进行定量分析。 结果 5例RAP肾脏测量评分总分8 ～ 10分,属中、重度复杂性肿瘤。肿瘤直径3.6 cm,平均2.5 ～5.0 cm(直径评分1 ～2分)。4例呈外生性生长,其中3例≥50％肿瘤体积位于肾实质内（外生部分所占比例评分2分）,1例为完全内生性肿瘤（外生部分所占比例评分3分）。肿瘤与肾集合系统的距离均≤4 mm(距离集合系统或肾窦评分3分)。4例肿瘤跨越肾极线和（或）肾中轴线（位置与极线关系评分3分）,1例位于下极线下方（位置与极线关系评分1分）,但肿瘤靠近肾门。5例术后3 ～23 d,平均12 d,发生肉眼血尿和不同程度贫血,4例伴有背部疼痛,2例有明显低血容量表现,分别输血1000 ml和1800 ml。增强CT和选择性动脉造影检查显示RAP主要来源于肾段动脉分支。4例经超选择性动脉栓塞治愈（3例栓塞1次,1例2次）,1例栓塞治疗失败行患肾切除。随访12 ～30个月,平均21个月,5例肾功能正常,RAP无复发。 结论 肾部分切除术后迟发血尿的患者均应警惕RAP的可能性。肿瘤位置及其与肾段动脉分支的关系可能是发生RAP的危险因素。选择合适病例、仔细缝合血管断面和肾实质可减少RAP的发生。早期选择性动脉栓塞是RAP首选治疗方法。     

Prediction of complications after partial nephrectomy by RENAL nephrometry score

Introduction

Discussing and planning the appropriate management for suspicious renal masses can be challenging. With the development of nephrometry scoring methods, we aimed to evaluate the ability of the RENAL nephrometry score to predict both the incidence of postoperative complications and the change in renal function after a partial nephrectomy.

Methods

This was a retrospective study including 128 consecutive patients who underwent a partial nephrectomy (open and laparoscopic) for renal lesions in a tertiary UK referral centre. Univariate and multivariate ordinal regression models were used to identify associations between Clavien–Dindo classification and explanatory variables. The Kendall rank correlation coefficient was used to examine an association between RENAL nephrometry score and a drop in estimated glomerular filtration rate (eGFR) following surgery.

Results

An increase in the RENAL nephrometry score of one point resulted in greater odds of being in a higher Clavien–Dindo classification after controlling for RENAL suffix and type of surgical procedure (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.04–1.64, p=0.043). Furthermore, a patient with the RENAL suffix ‘p’ (ie posterior location of tumour) had increased odds of developing more serious complications (OR: 2.60, 95% CI: 1.07–6.30, p=0.042). A correlation was shown between RENAL nephrometry score and postoperative drop in eGFR (Kendall’s tau coefficient -0.24, p=0.004).

Conclusions

To our knowledge, this is the first study that has shown the predictive ability of the RENAL nephrometry scoring system in a UK cohort both in terms of postoperative complications and change in renal function.     

Visceral fat is associated with high-grade complications in patients undergoing minimally invasive partial nephrectomy for small renal masses

Introduction:Minimally invasive partial nephrectomy is standard of care treatment for small renal masses.Objective:We evaluated the relationship between subcutaneous and visceral obesity with high-grade postoperative 30-day complications in patients undergoing minimally invasive partial nephrectomy.Methods:We retrospectively identified 98 patients at our institution from 2014 to 2017 who underwent laparoscopic or robotic-assisted partial nephrectomy due to suspected renal cell carcinoma. Patients were stratified based on presence or absence of high-grade (Clavien ≥ IIIa) 30-day postoperative complications. Means were compared with the independent t test and proportions with chi-square analysis. Multivariate logistic regression was performed to determine independent predictors of high-grade 30-day complications.Results:Mean nephrometry score was 6.7 with 21 (21.4%) patients having hilar tumors. Mean estimation of blood loss was 207 mL, mean operating time was 223 min, and mean warm ischemia time was 23 min. The majority of patients had clear renal cell carcinoma (n = 83, 84.7%) and pT1a disease (n = 76, 77.6%) with negative margins (n = 89, 90.8%) on pathology. There were 5 (5.1%) patients who experienced a high-grade postoperative 30-day complication. Mean visceral fat index was an independent predictor of high-grade 30-day complications (odds ratio: 1.02; 95% confidence interval: 1.002–1.03; p = 0.027).Conclusions:Visceral obesity should be considered as a prognostic indicator of outcomes in patients undergoing surgical treatment for a small renal mass.     

Salvage robot-assisted partial nephrectomy for the management of renal cell carcinoma following failed stereotactic radiotherapy

Nephron-sparing surgery is currently the standard of care for the management of small renal masses. While both neoadjuvant and adjuvant conventional external beam radiotherapy have failed to demonstrate an oncologic benefit for the treatment of renal cell carcinoma, more recent work aims to explore the utility of stereotactic radiotherapy. We present the case of a 70-year-old woman who failed primary treatment of a small renal mass with the CyberKnife radiotherapy system and describe her successful salvage treatment with robot-assisted partial nephrectomy. This case demonstrates the safety of robotic surgery for the management of renal tumors following failed stereotactic radiotherapy.     

后腹腔镜肾部分切除术治疗肾脏小肿瘤的疗效及安全性评价

目的 探讨后腹腔镜肾部分切除术治疗肾脏小肿瘤的有效性和安全性.方法 回顾性分析28例后腹腔镜肾部分切除术及24例同期行开放性肾部分切除术患者的临床资料,比较两种术式在手术时间、术中估计出血量、术后镇痛药物使用剂量、胃肠道功能恢复时间、术后住院时间、并发症发生率及肿瘤学效果等方面的差异.结果 后腹腔镜组与开放手术组患者在性别、年龄、肿瘤位置及肿瘤大小上的差别无统计学意义.后腹腔镜组1例因动脉分支出血中转开放手术,其他手术均获成功.后腹腔镜组平均手术时间118.4±16.2 min较开放组手术时间102.3±22.4 min长,但二者之间差异无统计学意义.开放组术中估计出血量142±12 ml,后腹腔镜组估计出血量126±14 ml,二者差异无统计学意义.后腹腔镜组热缺血时间26.6±4.2 min,开放组16.5±1.8 min,组间差异显著.后腹腔镜组在镇痛药用量、胃肠道功能恢复时间、及术后住院日等方面明显均优于开放组(P<0.05).所有患者术后血肌酐均在正常水平.两组患者术后并发症的发生率相当(25.9%vs 16.7%),无术后大出血、尿瘘等严重并发症出现.平均随访时间17(1～30)个月,两组患者均未见肿瘤复发及转移.结论 与传统开放手术相比,后腹腔镜下肾部分切除术具有一定的技术难度,但仍是一种安全、有效的手术方式,而且具有创伤小、患者痛苦少、恢复快、住院时间短等优点.     

Predicting morbidity after robotic partial nephrectomy: The effect of tumor,environment, and patient-related factors

Purpose

To investigate the effect of tumor and nontumor related parameters on perioperative outcomes of robotic partial nephrectomy (RPN).

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.     

Imaging strategy and outcome following partial nephrectomy

Objectives

The aim of this study was to analyze the outcomes of surveillance after partial nephrectomy (PN) in a single institution and the relevance of imaging studies in detecting recurrence.

Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy

Background

Robot-assisted and laparoscopic partial nephrectomies (PNs) for medial tumors are technically challenging even with the hilum clamped and, until now, were impossible to perform with the hilum unclamped.

Objective

Evaluate whether targeted vascular microdissection (VMD) of renal artery branches allows zero-ischemia PN to be performed even for challenging medial tumors.

Design, setting, and participants

A prospective cohort evaluation of 44 patients with renal masses who underwent robot-assisted or laparoscopic zero-ischemia PN either with anatomic VMD (group 1; n = 22) or without anatomic VMD (group 2; n = 22) performed by a single surgeon from April 2010 to January 2011.

Intervention

Zero-ischemia PN with VMD incorporates four maneuvers: (1) preoperative computed tomographic reconstruction of renal arterial branch anatomy, (2) anatomic dissection of targeted, tumor-specific tertiary or higher-order renal arterial branches, (3) neurosurgical aneurysm microsurgical bulldog clamp(s) for superselective tumor devascularization, and (4) transient, controlled reduction of blood pressure, if necessary.

Measurements

Baseline, perioperative, and postoperative data were collected prospectively.

Results and limitations

Group 1 tumors were larger (4.3 vs 2.6 cm; p = 0.011), were more often hilar (41% vs 9%; p = 0.09), were medial (59% and 23%; p = 0.017), were closer to the hilum (1.46 vs 3.26 cm; p = 0.0002), and had a lower C index score (2.1 vs 3.9; p = 0.004) and higher RENAL nephrometry scores (7.7 vs 6.2; p = 0.013). Despite greater complexity, no group 1 tumor required hilar clamping, and perioperative outcomes were similar to those of group 2: operating room time (4.7 and 4.1 h), median blood loss (200 and 100 ml), surgical margins for cancer (all negative), major complications (0% and 9%), and minor complications (18% and 14%). The median serum creatinine level was similar 2 mo postoperatively (1.2 and 1.3 mg/dl). The study was limited by the relatively small sample size.

Conclusions

Anatomic targeted dissection and superselective control of tumor-specific renal arterial branches facilitate zero-ischemia PN. Even challenging medial and hilar tumors can be excised without hilar clamping. Global surgical renal ischemia has been eliminated for most patients undergoing PN at our institution.     

da Vinci robotic partial nephrectomy for renal cell carcinoma: an atlas of the four-arm technique

da Vinci robotic surgery is becoming a standard alternative to open and laparoscopic surgical techniques. Robotic partial nephrectomy has been described in limited numbers. In this article, a surgical atlas of the transperitoneal four-arm approach to robotic partial nephrectomy is outlined. Surgical pearls, pitfalls, and limitations are reviewed.     

后腹腔镜下肾部分切除术治疗肾肿瘤的疗效评价

目的 探讨后腹腔镜下肾部分切除术治疗肾肿瘤的手术方式和临床效果. 方法 2002年6月至2009年12月对113例肾癌患者行后腹腔镜下肾部分切除术.患者平均年龄52(26～73)岁.肿瘤位于左肾51例,右肾62例.肿瘤直径平均3.7(1.2～6.3)cm.临床分期T1a 98例,T1b15例.腔镜下阻断肾动脉,以冷刀切开肾实质完整切除肿瘤.行肾楔形切除84例,肾极切除22例,半肾切除7例.腔镜下重建肾盂肾盏,2-0可吸收线间断或连续缝合关闭肾实质.开放肾动脉后取出标本.术后卧床10～14 d. 结果 113例手术均顺利完成,无中转开放及腹腔脏器损伤病例.平均手术时间85(60～125)min,平均热缺血时间24(19～43)min,术中平均出血150(50～350)ml,无术中输血患者.术后病理确诊肾透明细胞癌87例、乳头状肾细胞癌9例、嫌色细胞癌7例、肾血管周细胞瘤6例、嗜酸细胞瘤4例,肿瘤切缘均阴性.术后未出现尿漏,发生肉眼血尿2例,其中行肾切除术1例、血尿自行消失1例.随访3～41个月,未见肿瘤局部复发.结论 后腹腔镜下肾部分切除术治疗肾肿瘤安全有效,手术创伤小,有可能替代开放手术.     

机器人辅助腹腔镜与腹腔镜肾部分切除术治疗巨大肾血管平滑肌脂肪瘤的疗效比较

目的:比较机器人辅助腹腔镜肾部分切除术(RAPN)与腹腔镜肾部分切除术(LPN)对巨大肾血管平滑肌脂肪瘤(RAML)的疗效。方法:回顾性分析浙江省人民医院2014年10月至2020年5月行手术治疗的43例巨大RAML(直径>7cm)患者的临床资料,其中23例行RAPN,20例行LPN。RAPN组男4例,女19例;中位年...     

后腹腔镜下肾部分切除术23例报告

目的 探索后腹腔镜下肾部分切除术的应用范围和经验。方法 2001年12月至2005年10月，对23例患者施行后腹腔镜下肾部分切除术，其中肾细胞癌14例、错构瘤5例、重复肾4例，孤立肾1例。结果22例手术顺利完成，1例肾肿瘤因仅阻断肾动脉前支时出血而行腹腔镜肾切除．手术时间60～240min，平均121min。肾动脉阻断时间20～55min，平均32min。术中出血量100～300ml，均未输血。病理报告肾细胞癌14例，切缘均阴性；错构瘤5例。1例重复肾因切除不彻底，术后发现肾上极囊性肿块而再次开放手术行肾部分切除。结论 后腹腔镜下肾部分切除术对选择性的肾脏病变是一种有效和微创的治疗方法，远期效果有待进一步观察。     

Complications of laparoscopic partial nephrectomy

OBJECTIVES: To review the current evidence about laparoscopic partial nephrectomy (LPN) and its complications to define the role of this technique and to demonstrate specific operative modifications developed in a high volume laparoscopy centre. METHODS: The most recent literature was reviewed based on a PubMed search to evaluate the current types and rates of surgical complications following laparoscopic partial nephrectomy. Own data and experiences were added. Particular alert was dedicated to detailed operative knowledge to avoid typical pitfalls. RESULTS: LPN is still a challenging option for treatment of small renal cell cancer (RCC) and the technique is under development. The intermediate-term functional and oncological results of LPN can compete with the standard options at least in laparoscopy dedicated centres. The learning curve has to be considered because of its great impact on the reduction of the risk of complications. Advantages of LPN are less blood loss, shorter hospital stay and less blood loss. A careful case selection is required in reliance on the surgeons; experience. CONCLUSION: LPN is an additional but still challenging option for selected cases of RCC, which should be managed by the hands of experienced surgeons. Respecting these restrictions LPN has been shown to be equivalent to open partial nephrectomy. Distinctive attention has to be dedicated for improvement and standardization of operative techniques to decrease the learning curve of future users.     

后腹腔镜下肾部分切除术治疗早期肾癌

目的 探讨后腹腔镜下肾部分切除术治疗早期肾癌的可行性及安全性.方法 肾癌患者65例.男45例,女20例.平均年龄52岁.临床分期均为T_1N_0M_0.肿瘤直径1.8～4.0 cm,单发.行后腹腔镜下肾部分切除术.术中用bulldog血管夹阻断肾动脉,距肿瘤边缘0.5～1.0 cm处完整切除肿瘤.结果 中转开放手术3例,改为根治性肾切除术1例.手术时间平均120(70～210)min,肾动脉阻断时间平均32(21～55)min,术中出血量平均60(20～200)ml,平均住院10.5(7～15)d.术后发生肾周血肿1例,尿瘘1例,保守治疗后痊愈.62例患者随访3～56个月,未见肿瘤复发.残肾功能良好.结论 后腹腔镜下肾部分切除术是治疗直径≤4 cm、局限性单发肾癌的有效方法.     

Outlining the limits of partial nephrectomy

Amongst nephron-sparing modalities, partial nephrectomy (PN) is the standard of care in the treatment of renal cell carcinoma (RCC). Despite the increasing utilization of PN, particularly propagated by robot-assisted, minimally invasive approaches for small renal masses (SRMs), the limits of PN appear to be also evolving. In this review, we sought to address the tumour stage beyond which PN may be oncologically perilous. While the evidence supports PN in the treatment of tumours < pT2a, PN may have a role in advanced or metastatic RCC. Other scenarios wherein PN has limited utility are also explored, including anatomical or surgical factors that dictate the difficulty of the case, such as prior renal surgery. Lastly, we discuss the emerging role of molecular biomarkers, specifically epigenetics, to aid in the risk stratification of SRMs and to select tumours optimally suited for PN.     

Long-term renal functional outcomes of minimally invasive partial nephrectomy for renal cell carcinoma

ObjectivePreservation of renal function is the major benefit of partial over radical nephrectomy. We evaluated patients undergoing minimally invasive partial nephrectomy (MIPN) to better understand factors predicting long-term renal function.MethodsWe identified 358 patients who underwent MIPN for confirmed renal cell carcinoma between 1998 and 2011 with a serum creatinine level at least 1 year postoperatively. Exposure variables included demographic, clinical, and perioperative information. The primary outcome was clinically significant progression of chronic kidney disease (CKD) class, defined as estimated glomerular filtration rate (eGFR) decreasing from >60 to<60, from 30 to 60 to <30, or from 15 to 30 to<15. Bivariate and multivariate analyses were performed.ResultsMedian follow-up was 39 months. Only 7 patients had a solitary kidney. A total of 47 patients (13%) had CKD class progression. The estimates for remaining free of CKD class progression at 5, 7, and 10 years were 86.98%, 75.45%, and 53.54%, respectively. On multivariate analysis, lower preoperative eGFR (odds ratio [OR] = 0.97, 95% CI: 0.96–0.98), larger tumor size (OR = 1.22, 95% CI: 1.01–1.48), and longer ischemia time (OR = 1.03, 95% CI: 1.01–1.05) were associated with CKD class progression.ConclusionsClinically significant progression of CKD occurs in a minority of patients 5 years after MIPN, but in almost one-half, it occurs 10 years after surgery. Lower preoperative eGFR and larger tumor size are associated with greater incidence of CKD progression. Longer ischemia time, even when most patients had 2 kidneys and when controlling for other factors, nonetheless increased the risk of CKD progression, although this may be a marker of other unmeasured variables.     

Analysis of complications following partial and total nephrectomy for renal cancer in a population based sample

PURPOSE: We determined the frequency and predictors of complications of partial and total nephrectomy in a population based sample. MATERIALS AND METHODS: There were 3,019 partial and 18,575 total nephrectomies identified from the Nationwide Inpatient Sample data set of the Healthcare Cost and Utilization Project (2000 to 2003). The prevalence of International Classification of Diseases, 9th Revision coded complications following nephrectomy was determined. Hospital and patient related factors associated with the occurrence of a complication were determined by logistic regression analysis. We evaluated the impact of complications on in-hospital mortality, length of stay and hospital charges. RESULTS: Respiratory, digestive and bleeding complications were the most common, with similar patterns for partial nephrectomy and total nephrectomy. Significant predictors of complications after total nephrectomy included age, male sex, comorbidity severity index and hospital location (rural vs urban), while comorbidity was the only significant predictor for partial nephrectomy complications. Any complication had a significant impact on in-hospital mortality, total charges and length of stay. Digestive and urinary complications, hemorrhage, and postoperative infections had a significant impact on in-hospital mortality after partial nephrectomy, while these same complications, in addition to respiratory and cardiac complications, had a significant impact on total charges and length of stay. All except digestive complications had a significant impact on mortality, hospital charges and length of stay for patients undergoing total nephrectomy. CONCLUSIONS: In a population based cohort partial nephrectomy and total nephrectomy are associated with low morbidity and mortality profiles, and all complications affect mortality, length of hospital stay and charges.     

后腹腔镜肾部分切除术与肾癌根治术治疗复杂性T1b期肾肿瘤的比较 #br#

目的对比分析后腹腔镜肾部分切除术（RLPN）与后腹腔镜肾癌根治术（RLRN）治疗复杂性T_1b期肾肿瘤的疗效。 方法回顾性纳入2014年11月至2015年11月西安市人民医院收治的68例复杂性T_1b期肾脏肿瘤患者的临床资料,根据手术方法将患者分为RLPN组和RLRN组,每组34例。RLPN组行后腹腔镜肾部分切除术,RLRN组行后腹腔镜肾癌根治术。比较两组患者的围术期相关指标、肾功能情况及生存情况。 结果两组患者手术时间、术中出血量、引流管留置时间、术后住院时间及术后并发症情况比较,差异均无统计学意义（P>0.05）;时间与方法在肾小球滤过率估算值上不存在交互作用（P>0.05）,时间与方法在eGFR上主效应均显著（P<0.05）;RLPN组患者术后6个月时eGFR水平高于RLRN组;随访期间,Kaplan-Meier分析显示,RLRN组患者5年总生存率为88.2%,无病生存率为85.3%;RLPN组患者5年总生存率为91.2%,无病生存率为82.4%,两组患者总生存率与无病生存率比较差异无统计学意义（χ²=0.188、0.082,P=0.664、0.774）。 结论RLPN安全有效,可以最大限度地保留正常肾组织,保护肾功能,提高了术后生活质量,且具有与RLRN相当的远期疗效,值得临床推广应用。