后腹腔镜下肾部分切除术(附43例报告)

目的探讨后腹腔镜下肾部分切除术的安全性和临床疗效。方法回顾性分析43例行后腹腔镜下肾部分切除术的T1a期肾癌患者的临床资料,其中男23例,女20例,平均年龄51岁,平均肿瘤直径3.1cm,分析术中、术后情况。结果 43例手术均获成功,无中转开放手术。术中平均热缺血时间21min,平均手术时间100min,平均出血量70ml,平均术后住院时间8d。围手术期无并发症。平均随访29个月,无局部复发和远处转移。结论后腹腔镜下肾部分切除术安全可行,创伤小,恢复快,值得临床有选择地推广使用。     

Prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy

PURPOSE: We report on a prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy for renal tumor. MATERIALS AND METHODS: Between June 1999 and June 2001, 102 consecutive eligible patients with a computerized tomography identified renal tumor were prospectively randomized to undergo either a transperitoneal (group 1, 50 patients) or retroperitoneal (group 2, 52 patients) laparoscopic radical nephrectomy with intact specimen extraction. Exclusion criteria for the study included body mass index greater than 35 or a history of prior major abdominal surgery in the quadrant of interest. Both groups were matched regarding age (63 versus 65 years, p = 0.69), BMI (29 versus 28, p = 0.89), American Society of Anesthesiologists class (2.7 versus 2.8, p = 0.37), laterality (right side 46% versus 48%, p = 0.85) and mean tumor size (5.3 versus 5.0 cm, p = 0.73). RESULTS: All 102 procedures were technically successful without the need for open conversion. Compared to the transperitoneal approach, the retroperitoneal approach was associated with a shorter time to renal artery control (91 versus 34 minutes, p <0.0001), shorter time to renal vein control (98 versus 45 minutes, p <0.0001) and shorter total operative time (207 versus 150 minutes, p = 0.001). However, the transperitoneal and retroperitoneal approaches were similar in terms of estimated blood loss (180 versus 242 cc, p = 0.13), hospital stay (43 versus 45 hours, p = 0.55), intraoperative complications (10% versus 7.7%, p = 0.30), postoperative complications (20% versus 13.5%, p = 0.14) and postoperative analgesia requirements (27 versus 26 mg MSO4 equivalent p = 0.13). Pathology revealed renal cell carcinoma in 84% and 75% of cases, respectively, with no positive surgical margin in any case. CONCLUSIONS: Laparoscopic radical nephrectomy can be performed efficiently and effectively with the transperitoneal or the retroperitoneal approach. While renal hilar control and total operative time may be quicker with retroperitoneoscopy, the approaches are similar in terms of other patient outcomes evaluated.     

Comparison of laparoscopic and open partial nephrectomy in clinical T1a renal tumors

PURPOSE: Partial nephrectomy has been established as a standard of care for T(1a) renal tumors. Laparoscopic partial nephrectomy (LPN) has been described as more difficult to perform than open partial nephrectomy (OPN). We compare our series of LPN and OPN. PATIENTS AND METHODS: From October 2002 to January 2006, 76 LPNs were performed for patients with clinical T(1a) tumors. These patients were matched with a cohort of patients who underwent OPN for solitary tumors of 4 cm or smaller in diameter. The cohorts were compared with regard to demographics, perioperative data, and outcomes. RESULTS: The patient populations were demographically similar. Although mean tumor size was smaller in the laparoscopic cohort (2.5 v 2.9 cm, P=0.002), the OPN cohort demonstrated shorter operative (193 v 225 min, P=0.004) and ischemia times (20.5 v 32.8 min). LPN was associated with less blood loss (212 v 385 mL, P<0.001) and shorter hospital stay (2.5 v 5.6 days, P<0.001), however. One positive margin occurred in each of the LPN and OPN cohorts. Intraoperative complications were similar, although LPN was associated with fewer postoperative complications. Of note, two LPN (2.6%) patients had emergent reoperation and complete nephrectomy because of postoperative hemorrhage. CONCLUSIONS: Despite increased operative and ischemia times, LPN patients demonstrated quicker recovery and fewer postoperative complications. Two patients in the LPN group, however, had emergent complete nephrectomy because of hemorrhage. We conclude that LPN is still an evolving alternative to OPN in patients with small renal tumors.     

Comparative analysis of laparoscopic versus open partial nephrectomy for renal tumors in 200 patients

PURPOSE: Laparoscopic partial nephrectomy is an emerging minimally invasive, nephron sparing approach for renal cell carcinoma. We compared perioperative outcomes after laparoscopic and open nephron sparing surgery (NSS) for patients with a solitary renal tumor of 7 cm or less at a single institution. MATERIALS AND METHODS: Since September 1999, 100 consecutive patients have undergone laparoscopic partial nephrectomy for a sporadic single renal tumor of 7 cm or less at our institution. A contemporary cohort of 100 consecutive patients with similar inclusion criteria have undergone open NSS since April 1998. Since our laparoscopic technique was based on our established open surgical principles, the 2 approaches were similar, including transient renal vascular control, sharp tumor excision in a bloodless field, pelvicaliceal repair when necessary, suture ligation of transected intrarenal blood vessels and suture repair of the renal parenchymal defect over a bolster. Demographic, intraoperative, postoperative and short-term followup data were retrospectively compared between the 2 groups. RESULTS: Median tumor size was 2.8 cm in the laparoscopic group and 3.3 cm in the open group (p = 0.005). There were significantly more tumors greater than 4 cm in the open group (p <0.001). There were more patients with a solitary kidney in the open surgical group (p = 0.002). More patients in the open group underwent NSS for a malignant tumor (p = 002). Comparing the laparoscopic versus open groups, median surgical time was 3 vs 3.9 hours (p <0.001), blood loss was 125 vs 250 ml (p <0.001) and mean warm ischemia time was 27.8 vs 17.5 minutes (p <0.001), respectively. In the laparoscopic and open groups median analgesic requirement was 20.2 vs 252.5 mg morphine sulfate equivalents (p <0.001), hospital stay was 2 vs 5 days (p <0.001) and average convalescence was 4 vs 6 weeks (p <0.001). Median preoperative serum creatinine (1.0 vs 1.0 mg/dl, p = 0.52) and postoperative serum creatinine (1.1 vs 1.2 mg/dl, p = 0.65) were similar in the 2 groups. No kidney was lost due to warm ischemic injury. Three patients in the laparoscopic group had a positive surgical margin compared to none in the open groups (3% vs 0%, p = 0.1). Laparoscopic NSS was associated with a higher rate of major intraoperative complications (5% vs 0%, p = 0.02). There were no significant differences in overall postoperative complications, although renal/urological complications were more common in the laparoscopic group (11% vs 2%, p = 0.01). CONCLUSIONS: Open surgical partial nephrectomy remains the established standard for nephron sparing treatment of renal tumors. When applied to small renal tumors, the laparoscopic approach is associated with longer warm renal ischemia time, more major intraoperative complications and more postoperative urological complications. Our data also suggest that more deliberate efforts to achieve a wider surgical margin are necessary with the laparoscopic approach. Nevertheless, our data suggest that laparoscopic NSS is emerging as an effective, minimally invasive therapeutic approach with respect to renal functional outcome with the additional advantages of decreased postoperative narcotic use, earlier hospital discharge and a more rapid convalescence. Continued efforts are required to develop laparoscopic renal hypothermia techniques and facilitate intrarenal suturing, while minimizing warm ischemia time.     

后腹腔镜保留肾单位术治疗肾肿瘤

目的:探讨后腹腔镜保留肾单位术治疗肾肿瘤的手术技巧。方法:采用后腹腔镜技术对9例肾错构瘤和2例局限性肾癌患者分别行肿瘤剜除术和肾楔形切除术。肿瘤直径1.5~3.0cm,平均2.5cm。观察手术时间、术中出血量、术后住院天数和围手术期并发症及手术效果。结果:11例手术均获得成功。平均手术时间110min,平均出血量70ml,平均术后住院时间5天。围手术期无并发症。病理检查2例恶性肿瘤切缘阴性,平均随访10个月无局部复发。结论:后腹腔镜保留肾单位术治疗肾肿瘤安全可行,创伤小,恢复快,能有效切除肿瘤和保留肾功能。     

Indications and contraindications for the use of laparoscopic surgery for renal cell carcinoma

Surgery remains the only treatment with a chance of cure for renal cell carcinoma. Laparoscopic radical nephrectomy (LRN) has developed to be a standard treatment for the management of suspected renal malignancy in many centers worldwide, with oncologic efficacy equal to that of open radical nephrectomy. LRN has considerable advantages over open surgery, such as decreased postoperative morbidity, decreased analgesic requirements, and shorter hospital stay and convalescence. Current indications for LRN include all patients with localized stage T1-2 renal tumors. LRN for stage T3 renal tumors may be technically feasible in individual situations, but cannot be considered standard treatment. Open radical nephrectomy is reserved for advanced renal tumors, according to the surgeon's judgment. Partial nephrectomy is well established and considered to be the standard management for all organ-confined tumors of 相似文献   

经腹腔与腹膜后行腹腔镜肾癌根治术的比较

目的:比较经腹腔和腹膜后方式行腹腔镜肾癌根治术的优缺点。方法:随机将60例肾癌患者分别经腹腔或腹膜后方式行腹腔镜下肾癌根治术,比较两组术中、术后的情况。结果:与经腹腔方式比较,腹膜后方式处理肾动脉平均时间、处理肾静脉平均时间、总的手术平均时间较短。但经腹膜和腹膜后方式在估计出血量、术后住院时间、术中并发症和术后并发症发生率上无明显差异。结论:腹腔镜下经腹腔或腹膜后方式行肾癌根治术均有效,但后者在处理肾门和总的手术时间方面更快。     

Laparoscopic Radical Nephrectomy for Renal Tumor: The Washington University Experience

Purpose

We report our experience with laparoscopic radical nephrectomy in 17 consecutive patients with renal tumors.

Materials and Methods

The clinical data on 17 consecutive patients undergoing laparoscopic radical nephrectomy were reviewed. Of the patients 12 with stage pT1 or pT2 renal cell carcinoma 7 cm. in diameter or smaller undergoing laparoscopic radical nephrectomy were compared to 12 undergoing open radical nephrectomy for stage pT1 or pT2 renal cell carcinoma 6 cm. in diameter or smaller.

Results

Among the 17 patients undergoing laparoscopic radical nephrectomy average operative time was 6.9 hours (range 4.5 to 9) and average estimated blood loss was 105 cc (range 50 to 600). Average weight of the surgical specimen was 402 gm. (range 190 to 1,100). In 12 of 16 patients in whom laparoscopic radical nephrectomy was completed the specimen was removed intact. The patients required an average of 24 mg. morphine sulfate equivalent (range 2 to 220) for postoperative pain. Average hospital stay was 4.5 days (range 3 to 11) and average interval to resume normal activities was 3.5 weeks (range 2 to 4).The 12 patients in the open and laparoscopic radical nephrectomy groups were similar with respect to age, American Society of Anesthesiologists score and interval of surgery. Laparoscopic radical nephrectomy required significantly more operative time than open radical nephrectomy (6.9 versus 2.2 hours, respectively). However, the laparoscopic radical nephrectomy group compared to the open radical nephrectomy group had significantly less postoperative pain (24 versus 40 mg. morphine sulfate equivalent required for postoperative analgesia), shorter interval to resuming oral intake (1 versus 3 days), more rapid discharge from the hospital (4.5 versus 8.4 days) and more rapid return to normal activities (3.5 versus 5.1 weeks). The laparoscopic nephrectomy group also fully recovered more rapidly than the open surgical group (5.8 versus 39 weeks). To date, during a 4-year period there was no retroperitoneal recurrence or seeding of a port site.

Conclusions

Laparoscopic radical nephrectomy is a lengthy and demanding procedure. However, it affords patients with renal cell carcinoma a markedly improved postoperative course while accomplishing the necessary surgical goals.     

The experience of laparoscopic radical nephrectomy for renal tumors

We evaluate the safety and feasibility of laparoscopic radical nephrectomy for renal tumors. Between September 1993 and October 2001, 18 patients with renal tumors underwent laparoscopic radical nephrectomy. The mean patient age was 57.1 years ranging from 36 to 78. Clinical stage was T1N0 in all patients. The mean tumor diameter was 4.0 cm ranging from 1.8 to 7.0. Laparoscopic radical nephrectomy was performed by using the transperitoneal anterior approach on 11 patients and retroperitoneal approach on 7 patients. The specimen was removed through an extended stab wound after blunt segmentation of renal parenchyma in a specimen bag (LapSac). The mean operative time was 405 (270-550) and 453 (325-635) min for the transperitoneal approach and retroperitoneal approach respectively, and the mean blood loss was 281 (52-700) and 223 (10-850) ml, respectively. There was an intraoperative complication of minor splenic injury in 2 patients receiving the transperitoneal approach, which was conservatively managed. Histopathology revealed renal cell carcinoma in 17 patients and renal oncocytoma in one patient. There was no recurrence with a mean follow-up of 28.9 months. Compared with 13 patients who underwent open radical nephrectomy during the same period, laparoscopic nephrectomy has a longer operative time (424 versus 214 min, p < 0.001), equal blood loss (259 versus 210 ml, p = 0.59), quicker resumption of ambulation (1.8 versus 2.5 days, p = 0.016) and food intake (1.4 versus 2.2 days, p = 0.003), shorter postoperative hospital stay (10.9 versus 18 days, p = 0.0016), and a tendency of less frequent analgesic requirements (1.9 versus 4.7 times, p = 0.09). Laparoscopic radical nephrectomy is a safe and useful surgery for renal tumors providing minimal invasiveness.     

后腹腔镜肾切除的临床研究

目的通过与开放性肾切除比较,评估后腹腔镜肾切除的临床应用价值。方法从2003年2月至2006年10月,我科行后腹腔镜肾切除26例,其中巨大肾积水12例,肾性高血压8例（5例先天性肾发育不良、3例外伤性肾萎缩）,肾盂肿瘤6例。同期开放手术36例,其中巨大肾积水22例,肾性高血压7例,肾盂肿瘤7例。记录腹腔镜组及开放组的手术时间、术中失血量、术后恢复时间、住院时间及术后应用止痛剂次数。结果腹腔镜手术组除1例因出血改为开放外,其余均顺利完成肾切除,开放手术亦均顺利完成。与开放手术相比,后腹腔镜肾切除除手术时间长外,术中出血量、术后应用止痛剂次数、术后恢复时间和住院时间均显著优于开放手术组。结论巨大肾积水致肾功丧失及肾性高血压需肾切除者应首选腹腔镜肾切除,特别是后腹腔镜手术,其可避免腹腔内并发症。对于小的肾盂肿瘤,应首先考虑腹腔镜肾切除,其可避免腰部切口,减少相应并发症。与开放手术相比,后腹腔镜肾切除具有创伤小、恢复快、出血少等优点,具有一定的临床应用价值。     

Robot-assisted partial nephrectomy for complex renal masses

To determine whether the approach for partial nephrectomy is influenced by tumor complexity and if the introduction of robotic techniques has allowed us to treat more complex tumors minimally invasively. Data from 292 patients who underwent partial nephrectomy for renal masses from November 1999 to July 2013 at a tertiary referral center were retrospectively reviewed. Nephrometry scores and perioperative outcomes were stratified based on when robotic techniques were introduced. Mean follow-up time was 2.6 years. Preoperative RENAL nephrometry scores and perioperative outcomes were analyzed. Of the 292 patients, 31.5 % underwent robot-assisted partial nephrectomy, 46.2 % laparoscopic partial nephrectomy and 22.9 % open partial nephrectomy. Robot-assisted partial nephrectomy mean nephrometry score was significantly higher than laparoscopic and equivalent to open. Significant perioperative differences were estimated blood loss (p = 0.0001), length of stay (p = 0.0001) and Clavien score (p = 0.0069), all favoring robot-assisted partial nephrectomy. Limitations include retrospective design and single center data. Robot-assisted partial nephrectomy is a safe and effective surgical modality that allows for complex renal tumors that were previously reserved for open partial nephrectomy in the pure laparoscopic era to be managed with a minimally invasive approach.     

Laparoscopic and open partial nephrectomy: complication comparison using the Clavien system

Background and Objectives:

To compare postoperative complications in patients undergoing laparoscopic and open partial nephrectomy using a standardized complication-reporting system and a standardized tumor-scoring system.

Methods:

We conducted a retrospective analysis of 189 consecutive patients with nephrometry scores available who underwent elective partial nephrectomy for renal masses. Demographic, perioperative, and complication data were recorded. By using the modified Clavien scale, we graded 30- and 90-day complication rates.

Results:

107 patients underwent laparoscopic partial nephrectomy and 82 underwent open partial nephrectomy (N=189). Open partial nephrectomy patients had higher nephrometry scores than laparoscopic patients had (7.1±2.4 vs. 5.6±1.8, P<.001). Surgical and hospitalization times were shorter, and estimated blood loss was lower in the laparoscopic group (P<.001). At 30 days, there were more overall complications in the open group, but more major complications in the laparoscopic group (P>.05). After multivariable logistic regression analysis, only higher body mass index and higher estimated blood loss were predictors of more overall complications.

Conclusions:

Laparoscopic partial nephrectomy has the advantages of decreased operative time, lower blood loss, and shorter hospital stay. The complication rate in the laparoscopic group is similar to that in the open group, despite favorable tumor characteristics in the laparoscopic group.     

腹膜后腹腔镜肾部分切除术52例报告

目的：评价腹膜后腹腔镜肾部分切除术的可行性及临床价值。方法：52例肾占位患者,肿瘤直径2.0~4.0cm。经后腹腔途径施术,术后病理为47例肾脏透明细胞癌,3例嫌色性细胞癌,2例乳头状肾癌。结果：51例手术顺利完成,1例中转开放,手术时间40~100min,平均75min,术中出血50~400ml,平均150ml。术后恢复顺利,住院12~18d,平均14d,随访6~24个月无肿瘤复发。结论：腹膜后腹腔镜肾部分切除术患者创伤小,术后康复快,值得临床推广。     

Health-related quality of life after laparoscopic and open nephrectomy

BACKGROUND: Postoperative recovery often is assessed with parameters (pain and return to work) susceptible to bias. This study sought objectively to compare postoperative health-related quality of life (HRQL) after laparoscopic and open nephrectomy with the Postoperative Recovery (PRS) (a validated questionnaire designed to assess pain), activities of daily living (ADL), and HRQL in postoperative patients. METHODS: Patients undergoing contemporaneous laparoscopic and open nephrectomy received the PRS pre- and postoperatively. The results were analyzed with analysis of covariance (ANCOV) and survival analysis. RESULTS: The 33 open nephrectomy and 38 laparoscopic patients in this study were comparable in age, gender, body mass index (BMI) and employment. Laparoscopic operative time was longer (p = 0.015), and the hospital stay was shorter (p<0.001). Laparoscopic patients had higher HRQL scores from postoperative days 3 to 365 (p<0.001), and they returned to preoperative HRQL faster (p<0.001). CONCLUSIONS: An objective HRQL instrument confirms that laparoscopic nephrectomy patients recover faster and with a higher HRQL than open surgery patients. The PRS can be modified for use after other abdominal procedures, and may prove useful for comparisons of other minimally invasive surgical techniques.     

腹腔镜肾部分切除术(附15例报告)

目的 评价腹腔镜肾部分切除术治疗肾脏肿痛的临床效果。方法 2004年1月至2005年4月采用腹腔镜经腹腔或后腹腔途径对15例肾肿瘤患者行肾部分切除术。男11例，女4例。平均年龄52岁（29～70岁）。局限性肾透明细胞癌12例，平均肿瘤直径3．0cm（2．0～4，0cm）；肾血管平滑肌脂肪瘤3例，平均肿瘤直径4．5cm（3．5～6．0cm）。观察手术时间、术中出血量、住院天数、并发症及手术效果。结果 15例手术顺利。平均手术时间120min（80～150min），术中平均出血量150ml（100～220ml），无输血、中转开放手术病例。术后无并发症，平均住院时间8d（7～9d）。随访2～16个月肿瘤无复发。结论 腹腔镜肾部分切除术安全有效，但需长期随访以确定其远期疗效。     

Laparoscopic cytoreductive nephrectomy as preparation for administration of systemic interleukin-2 in the treatment of metastatic renal cell carcinoma: a pilot study

OBJECTIVES: Cytoreductive nephrectomy is commonly performed in patients with metastatic renal cell carcinoma before systemic interleukin-2 (IL-2) therapy. Open nephrectomy is associated with prolonged recovery during which metastatic disease can progress. The feasibility of laparoscopic cytoreductive surgery in these patients with large renal tumors was examined. The role of tumor morcellation in reducing the recovery period and allowing earlier treatment with IL-2 was investigated. METHODS: Patients with metastatic renal cancer underwent either open nephrectomy (group 1, n = 19) or laparoscopic cytoreductive nephrectomy (n = 11; 6 with tumor morcellation [group 2], 5 with removal of the tumor through a small incision [group 3]). The three groups were compared to evaluate relative recovery, suitability for treatment with IL-2, and laparoscopic port site seeding. RESULTS: A group of 19 patients underwent open nephrectomy (group 1). Eleven patients with a median tumor volume of 377 cm3 (median tumor diameter 9 cm) underwent laparoscopic cytoreductive nephrectomy. Six of these patients underwent tumor morcellation (group 2) and 5 underwent laparoscopic assisted nephrectomy (group 3). There was no difference in patient age, sex, sites of metastatic disease, ECOG status, size of renal tumor, or surgical complication rates among groups. Patients whose tumor was morcellated had reduced postoperative parenteral narcotic requirements and were discharged sooner than patients undergoing open cytoreductive nephrectomy. Time to treatment with IL-2 was shortest in the morcellation group (median time to treatment 37 days). No port site seeding was observed. CONCLUSIONS: Laparoscopic cytoreductive nephrectomy in patients with bulky renal disease is a safe procedure in selected patients. This pilot study demonstrated a significant association of laparoscopic tumor morcellation with less postoperative pain, faster time to discharge, and shorter time to treatment with IL-2. A randomized study is warranted to determine the role of laparoscopic cytoreductive nephrectomy with tumor morcellation.     

后腹腔镜保留肾单位手术治疗副肾动脉供血的肾肿瘤

目的：探讨后腹腔镜保留肾单位手术中使用三套管自制套索法控制副肾动脉供血的手术方法和临床效果。方法：采用后腹腔镜技术对5例副肾动脉供血的肾肿瘤患者行肾部分切除术。男4例,女1例,年龄22～60岁,平均45岁。其中肾透明细胞癌3例,肾错构瘤2例。肿瘤大小2．2～7．0cm,平均3．2cm。结果：5例手术均获得成功。手术时间120～180min,平均150min。副肾动脉阻断时间18～38min,平均22min。术中出血量50～100ml,平均70ml。平均术后住院时间8天,无围手术期并发症。病理检查3例肾透明细胞癌切缘阴性,随访4～28个月未见复发。结论：后腹腔镜肾部分切除术安全可行,在其中采用三套管自制套索法控制副肾动脉供血具有操作简便、干扰少等优点,值得进一步推广应用。     

Complications of Laparoscopic Surgery for Renal Masses: Prevention,Management, and Comparison with the Open Experience

Context

The initial excitement about the laparoscopic treatment of renal masses has been tempered by concerns related to increased operative time, technical complexity, and the suitability of laparoscopic approaches to oncologic surgery.

Objective

To provide a comprehensive review of intraoperative and postoperative complications and their prevention and management during laparoscopic surgery of renal tumors.

Evidence acquisition

A literature review of the Medline and Google Scholar databases was performed, searching for renal cell carcinoma, renal mass, laparoscopy, laparoscopic radical nephrectomy, open radical nephrectomy, laparoscopic partial nephrectomy, open partial nephrectomy, laparoscopic cryoablation, laparoscopic radiofrequency ablation, complications, intra-operative, and post-operative. English-language articles published between 1990 and 2008 were reviewed.

Evidence synthesis

Laparoscopic radical nephrectomy (LRN), whether transperitoneal or retroperitoneal, can be performed safely. The overall complication rate is low and does not significantly differ from that of the open experience. Laparoscopic partial nephrectomy (LPN), in contrast, is a technically challenging procedure. Although the intermediate oncologic outcomes are comparable to those of the open experience, there are concerns related to warm ischemia time, and there is a risk of major complications such as urinary leakage and hemorrhage requiring transfusion. Laparoscopic-assisted ablative therapies (cryotherapy and radiofrequency) are being performed more commonly for the treatment of small exophytic renal lesions with a low complication rate and intermediate oncologic outcomes similar to LRN and LPN.

Conclusions

Complications associated with the laparoscopic management of renal masses vary among the different procedures and with surgeon experience. The rate of complication appears to be similar to that of open surgery.     

后腹腔镜保留肾脏手术治疗肾肿瘤

目的探讨后腹腔镜保留肾脏手术治疗肾肿瘤的手术方法和临床效果。方法采用后腹腔镜技术使用超声刀对13例肾良性肿瘤和5例肾恶性肿瘤患者分别行肿瘤剜除术和肾楔形切除术。男7例，女11例。平均年龄51岁。肿瘤直径1．5～4．0cm，平均2．8cm。观察手术时间、术中出血量、术后住院天数和术中术后并发症及手术效果。结果18例手术均获得成功。平均手术时间87min，平均出血量55ml，平均术后住院时间5．8d。围手术期无并发症。病理检查5例恶性肿瘤切缘阴性，平均随访10个月无局部复发。结论后腹腔镜肾部分切除术安全可行，切除肿瘤精确彻底，创伤小，恢复快，值得临床有选择地推广使用。     

Costs analysis of laparoendoscopic,single-site laparoscopic and open surgery for cT1 renal masses in a European high-volume centre

Objective

To analyse intraoperative costs and healthcare reimbursements of partial/radical nephrectomy in open and minimal invasive surgery (MIS), as laparoscopy and laparoendoscopic single-site surgery (LESS), for the treatment of renal tumour.

Materials and methods

In a non-randomized retrospective study, we selected 90 patients who underwent (01/2010–12/2011) partial and radical nephrectomy for clinical renal masses ≤7 cm (cT1N0M0) and divided them into laparoscopic [laparoscopic partial nephrectomy (LPN), laparoscopic radical nephrectomy (LRN)], LESS [laparoendoscopic single-site partial nephrectomy (LESS-PN), laparoendoscopic single-site radical nephrectomy (LESS-RN)] and open groups [open partial nephrectomy (OPN), open radical nephrectomy (ORN)]. Patients were matched for age, sex, body mass index, ASA score and tumour side. Primary endpoints were evaluation of intraoperative costs (general, laparoscopic, sutures, haemostatic agents, anaesthesia, and surgeon/nurses fee), total insurance and estimated daily reimbursement.

Results

MIS showed longer operative time (p ≤ .02) and shorter hospital stay (p ≤ .04). Total costs were higher (p ≤ .03) in MIS (LRN: 4,091.5 €; LPN: 4,390.4 €; LESS-RN: 3,866 €; and LESS-PN: 3,450 €) if compared with open (OPN: 2,216.8.8 €, ORN: 1,606.4 €). Laparoscopic materials incised mainly in total costs of MIS (38–58.1 %). Reusable instruments reduced LESS laparoscopic costs (LESS-PN: 1,312.2 € vs. LRN: 2,212.2 €, p < .0001). Intraoperative frozen section and DJ ureteric stenting (general costs) (p ≤ .008) and haemostatic agents use (p ≤ .01) were higher in nephron sparing surgery (NSS), due to more frequent use of ancillary procedures necessary for a safe management of such an approach. Estimated anaesthesia costs and doctor/nurses fee were higher in MIS (p ≤ .02). Whereas total final reimbursements were comparable (p ≥ .8), estimated daily reimbursements were lower in MIS (p < .001) due to higher intraoperative costs and longer operative time.

Conclusion

Well-known advantages offered by MIS/NSS face higher total intraoperative costs and ‘paradoxical’ reduced healthcare reimbursement. We believe that local health systems should consider a subclassification with different compensations, which will incentive NSS and MIS approaches.