腹腔镜下肾部分切除术减少热缺血时间的研究进展

传统的腹腔镜肾部分切除术(LPN)为了减少术中出血、维持手术视野清晰是以夹闭肾蒂血管为标准的手术方式,由此导致的肾暂时缺血和再灌注损伤将不可避免的导致术后肾功能损害.随着外科技术的不断发展和各种新型止血材料的应用,腹腔镜下肾部分切除术正在不断的缩短热缺血时间,并向最终的目标“零缺血”迈进.本文就LPN在减少热缺血时间上应用的新技术予以综述.     

Transition from laparoscopic to robotic partial nephrectomy: the learning curve for an experienced laparoscopic surgeon

Background:

The complexity of laparoscopic partial nephrectomy (LPN) has prompted many laparoscopic surgeons to adopt robotic partial nephrectomy (RPN) for the treatment of small renal masses. We assessed the learning curve for an experienced laparoscopic surgeon during the transition from LPN to RPN.

Methods:

We compared perioperative outcomes of the first 20 patients who underwent RPN to the last 18 patients who underwent LPN by the same surgeon (MAP). Surgical technique was consistent across platforms. The learning curve was defined as the number of cases required to consistently perform RPN with shorter average operative times (OT) and warm ischemia times (WIT), as compared to the last 18 LPN. A line of best fit aided graphical interpretation of the learning curve on a scatter diagram of OT versus procedure date.

Results:

The 2 groups had comparable preoperative demographics and tumor histopathology. No patients in either group had a positive surgical margin. There was a downward trend in both OT and WIT during the RPN learning curve. After the first 5 RPN cases, the average OT reached the average OT of the last 18 LPN cases. The average OT of the first 5 RPN patients was 242.8 minutes, compared with the average OT of the last 15 RPN patients of 171.3 minutes (P=0.011).

Conclusion:

The transition from LPN to RPN is rapid in an experienced laparoscopic surgeon. There were no significant differences in WIT, estimated blood loss, or length of hospital stay between LPN and RPN. RPN achieved a similar OT as LPN after 5 procedures.     

Multivariate analysis of the factors involved in loss of renal differential function after laparoscopic partial nephrectomy: a role for warm ischemia time

Background:

Partial nephrectomy (PN) is now the gold standard for the surgical treatment of small renal masses. We evaluated the effect of WIT and other factors on RDF assessed by preoperative and postoperative renal scintigraphy.

Methods:

Between 2003 and 2008, 182 consecutive laparoscopic PN (LPN) were performed in an academic centre. Among those, 56 had mercaptoacetyl triglycine (MAG3) lasix renal scintigraphy preoperatively and postoperatively.

Results:

Medians for age, preoperative estimated glomerular filtration rate and computed tomography scan tumour size were 62 years, 82 mL/min/1.73m² and 26 mm, respectively. Median WIT and preoperative RDF were 30 minutes and 50%, respectively. Median loss of RDF after surgery was 14%. Linear regression curves showed that loss in RDF rate was 0.2% per minute when WIT was <30 minutes and 0.7% per minute when WIT was ≥30 minutes. In multivariate analysis, length of WIT and endophytic tumour location were associated with a statistically significant loss of RDF (p < 0.05), but only in the group who experienced >30 minutes of WIT.

Interpretation:

Our results suggest that the factors associated with loss of RDF are not the same before and after 30 minutes of WIT and that the rate of loss in RDF increases after 30 minutes. Since, the effect of WIT is small up to 30 minutes, we believe that surgery should focus on limiting the resection of normal parenchyma and to ensure negative margins and hemostasis, rather than on premature unclamping.     

Robotic partial nephrectomy: a multi-institutional analysis

Laparoscopic partial nephrectomy for kidney tumors has demonstrated durable oncologic and functional outcomes. The feasibility of robotic partial nephrectomy (RPN) has been demonstrated in several small, single-institution studies. We performed a large, multi-institutional analysis to determine early oncologic results and perioperative outcomes after RPN. Between October, 2002 and September, 2007, 148 patients underwent RPN at six different centers by nine different primary surgeons for localized renal tumors. Medical and operative records were reviewed for clinical characteristics, pathologic findings, and follow-up information. A total of 148 patients underwent RPN. Mean tumor size was 2.8 cm. Renal hilar clamping was utilized in 120 patients, with a mean warm ischemia time of 27.8 min. Positive surgical margins were identified in six patients (4%), of which two had cautery artifact obscuring the margin after off-clamp cautery excision and one underwent completion radical nephrectomy with no evidence of cancer. There is no evidence of tumor recurrence at mean follow-up of 7.2 months (range 2–54 months) overall, and mean follow-up of 18 months (range 12–23 months) for patients with positive surgical margin. Complications occurred in nine patients (6.1%), including hematoma requiring drainage (n = 1), prolonged ileus (n = 3), pulmonary embolus (n = 2), prolonged urine leak (n = 2), and rhabdomyolysis (n = 1). Two patients underwent open conversion for failure to progress, one patient with morbid obesity and one patient with adhesions from prior ureterolithotomy. Mean hospital stay was 1.9 days. In this multi-institutional series of surgeons beginning their initial experience in RPN, the procedure is a feasible option for minimally invasive, nephron-sparing surgery, with immediate oncologic results and perioperative outcomes comparable with more mature laparoscopic series.     

No need for systemic heparinization during laparoscopic donor nephrectomy with short warm ischemia time

Purpose  

Systemic heparin administration during laparoscopic donor nephrectomy (LDN) may prevent microvascular thrombus formation following warm ischemia. We herein present our experience with and without systemic heparinization during LDN.     

T1期肾肿瘤个性化"缩短热缺血时间"技术辅助腹腔镜肾部分切除术的方案选择及临床应用研究

目的:目的:探讨个性化"缩短热缺血时间"技术辅助腹腔镜肾部分切除术治疗T_1期肾肿瘤的安全性及有效性。方法:回顾分析2014年1月至2018年1月接受腹腔镜下肾部分切除术的189例T_1期肾肿瘤患者的临床资料。其中男112例,女77例,平均(56.51±14.31)岁,肿瘤直径平均(3.80±1.68)cm,内生型78例,外生型111例,平均R.E.N.A.L评分(7.45±1.78)分。个性化"缩短热缺血时间"技术组分为:标准无阻断技术、预留缝线无阻断技术、术前DSA超选栓塞无阻断技术、早期序贯开放血流法、肾动脉全阻断(2+1缝合法)。结果:189例患者均顺利完成腹腔镜下肾部分切除术。97例个性化选择的患者中83例(85.6%)完成个性化手术方式,入选个性化组;92例肾癌患者入选传统组(全阻断)。两组患者术前临床资料差异无统计学意义。个性化组手术时间、术中出血量多于传统组(P0.001),两组术后血红蛋白改变、术后住院时间等差异无统计学意义。术后第6个月、第12个月,个性化组肾功能恢复情况占优势,差异有统计学意义。结论:个性化"缩短热缺血时间"技术利用肿瘤的特性选择合理的术式,尽可能保护患者术后肾功能,安全可行。     

Robotic and laparoscopic partial nephrectomy: a matched-pair comparison from a high-volume centre

OBJECTIVES

To evaluate the relative merits of robotically assisted partial nephrectomy (RPN), using a matched‐pair analysis, with laparoscopic PN (LPN).

PATIENTS AND METHODS

Between July 2006 and August 2007, 12 patients had RPN for tumour; the outcomes were compared retrospectively with 12 matched patients who had LPN. Patients were matched for age, gender, body mass index, American Society of Anesthesiologists score, tumour side, size and location, and the specific technique used (early vs conventional unclamping). Operative measures evaluated included operative time, estimated blood loss, warm ischaemia time (WIT), and number of ports used. Outcomes measured included serum creatinine and estimated glomerular filtration rate before and after surgery, length of hospital stay, transfusion rate, operative and 30‐day complication rate, and surgical margin status.

RESULTS

Overall there were no differences in perioperative variables (WIT, estimated blood loss, surgery time, length of stay) between the groups. Fewer ports were used during LPN. Renal functional outcomes, transfusion rate and complication rates were comparable. Two RPN cases required conversion to standard LPN. A subset analysis of six patients in each group who had early unclamping showed a 7‐min shorter WIT with LPN (14 vs 21 min, P = 0.05), despite larger tumours being treated with LPN (3 vs 2.4 cm, P < 0.01) in this subset.

CONCLUSIONS

RPN is a developing procedure, and is technically feasible and safe, albeit with a longer warm WIT than LPN. Further experience is necessary to determine the relative merits of RPN.     

Reducing warm ischaemia time during laparoscopic partial nephrectomy: a prospective comparison of two renal closure techniques

OBJECTIVE: To test the hypothesis that a modified technique for renal parenchymal closure during laparoscopic partial nephrectomy (LPN) enables a significant reduction in warm ischaemia (WIT). METHODS: Perioperative factors including WIT were prospectively recorded during 40 consecutive LPNs performed by a single experienced laparoscopist. In the first 20 (controls), renal parenchyma was closed by conventional technique (haemostasis and closure of the collecting system with interrupted sutures, then closure of the renal parenchyma over a Surgicel bolster before unclamping the renal artery). In the second consecutive 20 patients (group 1), a modified closure technique was used, which involved earlier arterial unclamping after two (group 1a) or one (group 1b) running suture on the tumour bed. Vascularised renal parenchyma was then closed over a surgical bolster. RESULTS: All LPNs were performed successfully without conversion. WIT was significantly less in group 1 compared with the control group (27.2+/-5 min vs. 13.7+/-4 min, respectively; p<0.01). WIT was 16.8+/-3.6 vs. 10.3+/-1.2 min in groups 1a and 1b (p<0.01); no other significant differences were observed in perioperative factors. All specimens had negative tumour margins histologically. Major complications and haemoglobin reduction were lower in group 1 compared with the control group. CONCLUSIONS: The described technique is effective and allows a significant reduction of WIT, even in challenging cases, without increasing perioperative bleeding or morbidity. Its use therefore reduces the need for hypothermic techniques, and allows more time for careful tumour resection and renal reconstruction.     

Predictors of warm ischemia time and perioperative complications in a multicenter, international series of robot-assisted partial nephrectomy

Background

Warm ischemia time (WIT) and complication rates are two important parameters for evaluating the perioperative results of robot-assisted partial nephrectomy (RAPN). Few data are available about the clinical predictors of WIT and overall complications.

Objective

To identify clinical predictors of WIT and perioperative complications.

Design, setting, and participants

This is a retrospective study including 347 patients who underwent RAPN for suspicious renal cell carcinoma (RCC) at four referral centers from September 2008 to September 2010.

Intervention

All patients underwent RAPN using the da Vinci S Surgical System with hilar clamping.

Measurements

WIT >20 min and overall complication rates were the main outcomes. Postoperative complications were classified according to the Clavien/Dindo system. Moreover, the following perioperative variables were considered: clinical tumor size, anatomical tumor characteristics according to Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification score, surgeon experience, console time, blood loss, and upper collecting system (UCS) repair.

Results and limitations

WIT >20 min was reported in 125 (36%) cases. Intraoperative and postoperative complications were observed in 10 (2.9%) and 41 (11.8%) cases, respectively. Surgeon experience (odds ratio [OR]: 6.381; 95% confidence interval [CI], 3.687-11.042; p < 0.001), clinical tumor size (OR: 1.022; 95% CI, 1.002-1.044; p = 0.03), the other anatomic characteristics determined by the PADUA classification score (OR: 1.294; 95% CI, 1.080-1.549; p = 0.005), and the UCS repair (OR: 2.987; 95% CI, 1.728-5.165; p < 0.001) turned out to be independent predictors of WIT >20 min. Similarly, surgeon experience (OR: 3.937; 95% CI, 2.011-7.705; p < 0.001), clinical tumor size (OR: 1.033; 95% CI, 1.009-1.058; p = 0.007), and the other anatomical characteristics determined by the PADUA classification score (OR: 1.427; 95% CI, 1.149-1.773; p < 0.001) turned out to be independent predictors of overall complication rates. The retrospective design is the main limitation of this multicenter, international study. Therefore, some patient characteristics and comorbidities were not recorded.

Conclusions

Anatomic tumor characteristics as determined by the PADUA classification score were independent predictors of WIT and overall complications, once adjusted for the effects of surgeon experience and clinical tumor size.     

Robotic versus laparoscopic partial nephrectomy for complex tumors: comparison of perioperative outcomes

Background

Recent studies showed that robotic partial nephrectomy (RPN) offered outcomes at least comparable to those of laparoscopic partial nephrectomy (LPN). LPN can be particularly challenging for more complex tumors.

Objective

To compare the perioperative outcomes of patients undergoing LPN or RPN for a single renal mass of moderate or high complexity.

Design, setting, and participants

A retrospective analysis was performed for 381 consecutive patients who underwent either LPN (n = 182) or RPN (n = 199) between 2005 and 2011 for a complex renal mass (RENAL score ≥7). Perioperative outcomes were compared. Predictors of postoperative renal function were assessed using multivariable linear regression analysis.

Intervention

LPN or RPN.

Outcome measurements and statistical analysis

Perioperative outcomes were compared. Predictors of postoperative renal function were assessed using multivariable linear regression analysis.

Results and limitations

There was no significant difference between the two groups with respect to patient age, gender, side, American Society of Anesthesiologists score, Charlson comorbidity index (CCI), or tumor size. Patients undergoing LPN had a slightly lower body mass index (29.2 kg/m² compared with 30.7 kg/m², p = 0.02) and preoperative estimated glomerular filtration rate (eGFR) (81.1 compared with 86.0 ml/min per 1.73 m², p = 0.02). LPN was associated with an increased rate of conversion to radical nephrectomy (RN) (11.5% compared with 1%, p < 0.001) and a higher decrease in percentage of eGFR (−16.0% compared with −12.6%, p = 0.03). There were no significant differences with respect to warm ischemia time (WIT), estimated blood loss, transfusion rate, or postoperative complications. WIT, preoperative eGFR, and CCI were found to be predictors of postoperative eGFR in multivariable analysis. No difference in perioperative outcomes was found between moderate and high RENAL score subgroups. The retrospective study design was the main limitation of this study.

Conclusions

RPN provides functional outcomes comparable to those of LPN for moderate- to high-complexity tumors, but with a significantly lower risk of conversion to RN. This situation is likely because of the technical advantages offered by the articulated robotic instruments. A prospective randomized study is needed to confirm these findings.