谨慎选择肾部分切除术

随着微创手术概念的推广普及和手术器械的更新换代,肾部分切除术(PN)以其对肾功能的保护及其与根治性肾切除术(RN)类似的肿瘤学效果,使得适应证逐渐扩大。但几乎所有支持PN优于RN的数据均来自证据等级较弱的回顾性分析研究,即使存在更利于PN的选择偏倚,大多数文献也不得不承认RN更安全,围手术期并发症更少。因此,如何平衡好肾功能保存和肿瘤控制、谨慎选择PN值得进一步探讨。     

Indications for and results of nephrectomy for metastatic renal cell carcinoma

We find that, when metastases are present, a nephrectomy for renal cell carcinoma is not justified in the vast majority of cases. The only noncontroversial indication is for palliative nephrectomy which is performed to relieve intractable symptoms in the properly chosen patient. However, it is unusual to see a patient with tumor-related symptoms that cannot be conservatively managed. A relative indication for nephrectomy is found in the patient with osseous metastases only, as some studies have demonstrated a prolongation of survival by adjunctive nephrectomy in this setting. Another relative indication is in the patient with limited metastases that are amenable to surgical or radiation ablation coupled with nephrectomy; patients in whom the metastasis appears years after the nephrectomy have the best chance for a successful outcome. When therapy that is effective against metastatic tumor is eventually found, adjunctive nephrectomy as a debulking procedure may become indicated; until then, surgery is not justified. On the basis of data presently available, adjunctive nephrectomy in the hope of inducing spontaneous regression of metastases is never indicated.     

Therapeutic living donor nephrectomy

Therapeutic living donor nephrectomy is defined as a nephrectomy that is performed as therapy for an underlying medical condition. The patient directly benefits from having their kidney removed, but the kidney is deemed transplantable. The kidney is subsequently used as an allograft for an individual with advanced renal disease. Therapeutic donor nephrectomy can be successfully utilized for a heterogenous cohort of disease processes as both treatment for the donor and to increase the number of suitable organs available for transplantation. We describe four cases of therapeutic donor nephrectomy that were performed at our institution. Of the four cases, two patients elected to undergo therapeutic donor nephrectomy as treatment for loin pain hematuria syndrome; one after blunt abdominal trauma that resulted in complete proximal ureteral avulsion; and the fourth after being diagnosed with a small renal mass. Based on our data presented to the United Network for Organ Sharing Board of Directors (UNOS) in December 2015, living donor evaluation has been made simpler for patients electing to undergo therapeutic donor nephrectomy. UNOS eliminated the requirement for a psychosocial evaluation for these patients. As the organ shortage continues to limit transplantation, therapeutic donor nephrectomy should be considered when appropriate.     

Race affects access to nephrectomy but not survival in renal cell carcinoma

OBJECTIVES

To assess whether, in contemporary patients with renal cell carcinoma (RCC), access to nephrectomy is the same between the Blacks and Whites, and that there is no difference in mortality after stratification for treatment type.

PATIENTS AND METHODS

The effect of race has received little attention in RCC; only two reports have addressed and suggested the presence of racial disparities, including access to nephrectomy and survival after nephrectomy, where Black patients were disadvantaged relative to Whites. We used the Surveillance, Epidemiology and End Results data from 12 516 patients of all stages diagnosed and treated for RCC between 2000 and 2004. The effect of race (Black vs White) on nephrectomy rate was addressed in logistic regression and binomial regression models, and Cox regression models tested the effect of race on overall survival.

RESULTS

Black patients were 50% less likely to have a nephrectomy than their White counterparts. However, race had no effect on overall survival when the entire cohort was assessed, as well as in subgroups of patients with or without nephrectomy.

CONCLUSIONS

Although race is a determinant of access to nephrectomy, it should not be interpreted as a barrier to care, as survival was unaffected by race in patients having a nephrectomy or not. Instead, race might represent a proxy of comorbidity and life‐expectancy, which represent surgical selection criteria for nephrectomy.     

Long-term oncological outcomes of laparoscopic partial nephrectomy

PURPOSE OF REVIEW: Widespread applicability of laparoscopic partial nephrectomy will only occur when oncologic outcomes are critically analyzed in the context of published open partial nephrectomy series. The most recent oncologic outcomes of laparoscopic partial nephrectomy are reviewed. RECENT FINDINGS: Oncologic outcomes at 5 years of follow-up have recently been published for laparoscopic partial nephrectomy. The low margin positivity demonstrated by earlier series has translated into cancer-specific survival rates comparable to open partial nephrectomy. Local and distant recurrence rates are acceptably low, and in line with both contemporary and historical open partial nephrectomy pT1 controls. SUMMARY: Laparoscopic partial nephrectomy is becoming a standard of care for selected small renal tumors at high volume centers. While the goal of minimizing morbidity is laudable, ultimately its effectiveness as a cancer operation is the most important criterion. At high volume centers, in expert hands this technically advanced procedure has been shown to duplicate the oncologic outcomes of open surgery. The indolent natural history of small renal masses mandates that we await 10-year data, as well as corroboration of these favorable results at multiple institutions.     

Robot‐assisted partial nephrectomy: Superiority over laparoscopic partial nephrectomy

Nephron‐sparing surgery has been proven to positively impact the postoperative quality of life for the treatment of small renal tumors, possibly leading to functional improvements. Laparoscopic partial nephrectomy is still one of the most demanding procedures in urological surgery. Laparoscopic partial nephrectomy sometimes results in extended warm ischemic time and severe complications, such as open conversion, postoperative hemorrhage and urine leakage. Robot‐assisted partial nephrectomy exploits the advantages offered by the da Vinci Surgical System to laparoscopic partial nephrectomy, equipped with 3‐D vision and a better degree in the freedom of surgical instruments. The introduction of the da Vinci Surgical System made nephron‐sparing surgery, specifically robot‐assisted partial nephrectomy, safe with promising results, leading to the shortening of warm ischemic time and a reduction in perioperative complications. Even for complex and challenging tumors, robotic assistance is expected to provide the benefit of minimally‐invasive surgery with safe and satisfactory renal function. Warm ischemic time is the modifiable factor during robot‐assisted partial nephrectomy to affect postoperative kidney function. We analyzed the predictive factors for extended warm ischemic time from our robot‐assisted partial nephrectomy series. The surface area of the tumor attached to the kidney parenchyma was shown to significantly affect the extended warm ischemic time during robot‐assisted partial nephrectomy. In cases with tumor‐attached surface area more than 15 cm², we should consider switching robot‐assisted partial nephrectomy to open partial nephrectomy under cold ischemia if it is imperative. In Japan, a nationwide prospective study has been carried out to show the superiority of robot‐assisted partial nephrectomy to laparoscopic partial nephrectomy in improving warm ischemic time and complications. By facilitating robotic technology, robot‐assisted partial nephrectomy will be more frequently carried out as a safe, effective and minimally‐invasive nephron‐sparing surgery procedure.     

The role of nephrectomy in the acutely injured

HYPOTHESIS: The high mortality in patients who undergo nephrectomy after trauma is not secondary to the nephrectomy itself but is the consequence of a more severe constellation of injuries associated with renal injuries that require operative intervention. DESIGN: A retrospective review of all patients identified using International Classification of Diseases, Ninth Revision codes as having sustained renal injuries over a 62-month period. PATIENTS: Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. METHODS: All medical records were reviewed for patient management, definitive care, and outcome. Based on outcome, patients were assigned to either the survivor or nonsurvivor group. For patients who underwent nephrectomy, intraoperative core temperature changes, estimated blood loss, and operative time were also reviewed. RESULTS: Seventy-eight patients with renal injuries who underwent exploratory laparotomy were identified. Twenty-nine patients underwent laparotomy with conservative management of the renal injury, of whom 5 (17.2%) died. Twelve patients had renal injuries repaired and all survived. Thirty-seven patients underwent nephrectomy, of whom 16 (43.2%) died. Compared with nephrectomy survivors, nephrectomy nonsurvivors had a significantly lower initial systolic blood pressure, higher Injury Severity Score, higher incidence of extra-abdominal injuries, shorter operative duration, and higher estimated operative blood loss. The nephrectomy survivors' core temperature increased a mean of 0.5 degrees C in the operating room, while the nephrectomy nonsurvivors' core temperature cooled a mean of 0.8 degrees C. CONCLUSIONS: Patients who undergo trauma nephrectomy tend to be severely injured and hemodynamically unstable and warrant nephrectomy as part of the damage control paradigm. That a high percentage of patients die after nephrectomy for trauma demonstrates the severity of the overall constellation of injury and is not a consequence of the nephrectomy itself.     

Laparoscopic radical nephrectomy

Laparoscopic radical nephrectomy has gained in popularity as an accepted treatment modality for localized renal cell carcinoma at many centers worldwide. Laparoscopic radical nephrectomy may be performed via a transperitoneal or retroperitoneal approach. Mostly, the transperitoneal approach is used. Current indications for laparoscopic radical nephrectomy include patients with T(1)-T(3a)N(0)M(0) renal tumors. Herein, transperitoneal as well as retroperitoneal laparoscopic approaches are described. Surgical outcomes and complications from published series are reviewed with comparison to open surgery. Special related concerns as oncologic principles, organ retrieval, lymphadenectomy, and concomitant adrenalectomy are addressed. In conclusion, laparoscopic radical nephrectomy is now established with considerable advantages; decreased postoperative morbidity, decreased analgesic requirements, improved cosmesis, shorter hospital stay and convalescence. Although no long-term follow-up is available, short and intermediate follow-up results confirm the effectiveness of laparoscopic radical nephrectomy.     

Laparoscopic total and partial nephrectomy

Laparoscopic radical nephrectomy has established its role as a standard of care for the management of renal neoplasms. Long term follow-up has demonstrated laparoscopic radical nephrectomy has shorter patient hospitalization and effective cancer control, with no significant difference in survival compared with open radical nephrectomy. For renal masses less than 4cm, partial nephrectomy is indicated for patients with a solitary kidney or who demonstrate impairment of contralateral renal function. The major technical issue for success of laparoscopic partial nephrectomy is bleeding control and several techniques have been developed to achieve better hemostatic control. Development of new laparoscopic techniques for partial nephrectomy can be divided into 2 categories: hilar control and warm ischemia vs. no hilar control. Development of a laparoscopic Satinsky clamp has achieved en bloc control of the renal hilum in order to allow cold knife excision of the mass, with laparoscopic repair of the collecting system, if needed. Combination of laparoscopic partial nephrectomy with ablative techniques has achieved successful excision of renal masses with adequate hemostasis without hilar clamping. Other techniques without hilar control have been investigated and included the use of a microwave tissue coagulator. In conclusion, laparoscopic radical nephrectomy for renal cell carcinoma has clearly demonstrated low morbidity and equivalent cancer control. The rates for local recurrences and metastatic spread are low and actuarial survival high. Furthermore, laparoscopic partial nephrectomy has demonstrated to be technically feasible, with low morbidity. With short term outcomes demonstrating laparoscopic partial nephrectomy as an efficacious procedure, the role of laparoscopic partial nephrectomy should continue to increase.     

Laparoscopic partial nephrectomy: integration of an advanced laparoscopic technique

Background: Laparoscopic radical nephrectomy and open partial nephrectomy are now established methods of treatment for appropriate renal lesions suspicious for malignancy, Laparoscopic partial nephrectomy has undergone progressive evolution. The aim of this paper is to; (i) evaluate the current status of laparoscopic partial nephrectomy, and (ii) to place it in the Australian and New Zealand context by evaluating the necessary skill acquisition for advanced laparoscopic urology. Methods: The National Library of Medicine database (PubMed) was used to specifically search the available literature on laparoscopic partial nephrectomy, renal failure and nephrectomy, modular surgical training and laparoscopic training. Of the articles identified, selection was based on their contribution to the development of techniques, progressive clinical outcomes, as well as comparisons with current management. Results: The technique and outcomes of laparoscopic partial nephrectomy are now secure enough to treat anatomically complex tumours in laparoscopically experienced hands. For the appropriate patient with a small renal mass, the impact of radical nephrectomy and long‐term renal dysfunction needs to be considered, even in the presence of a normal contra‐lateral kidney. Robotic assisted laparoscopic surgery is expensive and may impair the acquisition of advanced iaparoscopic skills. Conclusion: Over the past 5 years, laparoscopic partial nephrectomy has developed to the stage where, with the necessary laparoscopic skill, it is now a standard of care at tertiary referral institutions. Widespread dissemination of advanced laparoscopic skills remains the next challenge.     

Trasplante renal y poliquistosis: consideraciones quirúrgicas

BackgroundThe indication and timing of nephrectomy in patients with autosomal dominant polycystic kidney disease (ADPKD) remain controversial, especially in patients who are candidates to renal transplantation (RT). The main surgical options such as unilateral vs. bilateral nephrectomy, nephrectomy before vs. after RT, or simultaneous nephrectomy and transplantation, are herein discussed.ObjectiveEvidence acquisition of the best surgical management available for ADPKD in the context of kidney transplantation.Acquisition of evidenceSystematic literature review in PubMed from 1978 to 2013 was conducted. Articles selected included:randomized controlled trials and cohort studies. Furthermore, well designed ADPKD reviews were considered for this study.Synthesis of evidenceLaparoscopic nephrectomy in ADPKD is a safe procedure with an acceptable complication rate. Unilateral nephrectomy has advantages over the bilateral one regarding theperioperative complication rate. Although the timing of nephrectomy is controversial, it seems that simultaneous nephrectomy and renal transplantation does not increase surgical morbidity neither affect graft survival.ConclusionsSimultaneous nephrectomy and RT appears to be an acceptable alternative to conventional two-stage procedure without any increased morbidity, in the context of ADPKD. Furthermore, laparoscopic nephrectomy performed in experienced centres is a safe alternative to conventional approach.     

The role of adjunctive nephrectomy in patients with metastatic renal cell carcinoma.

The results of therapy for 78 patients with disseminated renal cell carcinoma are evaluated. Symptoms related to the primary tumor were noted in only 28 per cent of the patients and were not difficult to manage in those patients not undergoing nephrectomy. Adjuctive nephrectomy, therefore, is a more appropriate term than palliative nephrectomy when referring to removal of the primary tumor as part of an aggresive combined therapeutic approach. Of patients receiving an adjunctive nephrectomy those with osseous metastases only had a better 1-year survival rate (36 per cent) than those with metastases to other sites (18 per cent). Complete regression of metastases was noted in 12 per cent of patients treated with medroxyprogesterone acetate and adjunctive nephrectomy. The role of adjunctive nephrectomy combined with embolic infarction, hormonal therapy, chemotherapy and/or immunotherapy is discussed.     

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   

Laparoscopic radical nephrectomy for renal cell carcinoma: the standard of care already?

PURPOSE OF REVIEW: Laparoscopic radical nephrectomy has been developed and applied for patients with renal cell carcinoma since 1992. The number of patients undergoing laparoscopic radical nephrectomy has increased explosively worldwide in recent years, and laparoscopy is now extended to patients with advanced disease. It is very important to clarify the present status of laparoscopic radical nephrectomy among the treatment modalities for patients with renal cell carcinoma. RECENT FINDINGS: Laparoscopic radical nephrectomy has a minimally invasive nature as well as comparable long-term cancer control in patients with pT1-3a renal cell carcinoma to open surgery. It is technically applicable for N1-2 disease and T3b disease if the tumor thrombus is within the renal vein. Also, it is feasible as a cytoreductive surgery for patients with M1 disease. SUMMARY: Laparoscopic radical nephrectomy is a standard treatment modality for T1-3a renal cell carcinoma patients. It is also available for treating patients with N1-2 disease, and for patients with M1 disease as a cytoreductive surgery.     

Laparoscopic Living Donor Nephrectomy: Low Surgical Risk for High-quality Grafts

Renal transplantation is most important for patients with end-stage renal disease to preserve their survival and quality of life. Living donation has decisive advantages over deceased donor kidney transplantation, and with the continuing organ shortage, it also can reduce the number of patients waiting for an organ. The major problem with living kidney donation is that a healthy person has to undergo a substantial surgical procedure to provide the organ for transplantation; therefore, a nephrectomy technique that is associated with the lowest surgical risk for the donor and the best organ quality for the recipient should be used. Since its introduction by Ratner and colleagues in 1995, laparoscopic donor nephrectomy has become the technique of choice at many major transplant centres. The aim is to achieve less postoperative pain, shorter hospitalisation time, more rapid return to normal activities, a more cosmetically acceptable incision, and, in particular, a greater patient acceptance. All techniques for living donor nephrectomy (open donor nephrectomy, “pure” laparoscopic donor nephrectomy, hand-assisted laparoscopic donor nephrectomy, robot-assisted laparoscopic donor nephrectomy, laparoscopic donor nephrectomy via natural orifice transluminal endoscopic surgery or laparoendoscopic single-site surgery, and retroperitoneoscopic donor nephrectomy) achieve good results, in so far as they are performed at specialised centres. Perioperative complications are rare, and the quality of the grafts is excellent. Renal graft function is specified at up to 96% at 1 yr and 85% at 5 yr after living donor kidney transplantation.Patient summaryLiving donation has decisive advantages over deceased donor kidney transplantation. When performed at specialised centres, living donor nephrectomy achieves good results, with few perioperative complications and excellent graft quality.     

Synchronous bilateral renal tumour: a case report

We report a case of synchronous bilateral renal carcinoma treated by partial nephrectomy on the right and total nephrectomy on the left. Follow-up at 42 months after surgery showed no recurrence of the disease. The increasing use of diagnostic imaging techniques such as ultrasound tomography, computerised tomography and nuclear magnetic resonance now allows even small-sized renal formations to be identified. Synchronous bilateral renal tumour has a favourable prognosis, especially when compared with single or asynchronous renal tumours. The recommended intervention is total monolateral nephrectomy combined with partial nephrectomy. The treatment of neoplasms at a more advanced stage, of such a nature as to necessitate bilateral nephrectomy or chemotherapy, results in a significant increase in mortality. Recently, biological therapy has been proposed as a more promising short-term option using interferon-alpha (IFN-alpha) and gamma.     

Retrograde renal hilar dissection and segmental arterial clamping: a simple modification to achieve super-selective robotic partial nephrectomy

Super-selective vascular control prior to robotic partial nephrectomy (also known as ‘zero-ischemia’) is a novel surgical technique that promises to reduce warm ischemia time. The technique has been shown to be feasible but adds substantial technical complexity and cost to the procedure. We present a simplified retrograde dissection of the renal hilum to achieve selective vascular control during robotic partial nephrectomy. Consecutive patients with stage 1 solid and complex cystic renal masses underwent robotic partial nephrectomies with selective vascular control using a modification to previously described super-selective robotic partial nephrectomy. In each case, the renal arterial branch supplying the mass and surrounding parenchyma was dissected in a retrograde fashion from the tumor. Intra-renal dissection of the interlobular artery was not performed. Intra-operative immunofluorescence was not utilized as assessment of parenchymal ischemia was documented before partial nephrectomy. Data was prospectively collected in an IRB-approved partial nephrectomy database. Operative variables between patients undergoing super-selective versus standard robotic partial nephrectomy were compared. Super-selective partial nephrectomy with retrograde hilar dissection was successfully completed in five consecutive patients. There were no complications or conversions to traditional partial nephrectomy. All were diagnosed with renal cell carcinoma and surgical margins were all negative. Estimated blood loss, warm ischemia time, operative time and length of stay were all comparable between patients undergoing super-selective and standard robotic partial nephrectomy. Retrograde hilar dissection appears to be a feasible and safe approach to super-selective partial nephrectomy without adding complex renovascular surgical techniques or cost to the procedure.     

Renal parenchymal histopathology predicts life‐threatening chronic kidney disease as a result of radical nephrectomy

The preoperative prediction of post‐radical nephrectomy renal insufficiency plays an important role in the decision‐making process regarding renal surgery options. Furthermore, the prediction of both postoperative renal insufficiency and postoperative cardiovascular disease occurrence, which is suggested to be an adverse consequence caused by renal insufficiency, contributes to the preoperative policy decision as well as the precise informed consent for a renal cell carcinoma patient. Preoperative nomograms for the prediction of post‐radical nephrectomy renal insufficiency, calculated using patient backgrounds, are advocated. The use of these nomograms together with other types of nomograms predicting oncological outcome is beneficial. Post‐radical nephrectomy attending physicians can predict renal insufficiency based on the normal renal parenchymal pathology in addition to preoperative patient characteristics. It is suggested that a high level of global glomerulosclerosis in nephrectomized normal renal parenchyma is closely associated with severe renal insufficiency. Some studies showed that post‐radical nephrectomy severe renal insufficiency might have an association with increased mortality as a result of cardiovascular disease. Therefore, such pathophysiology should be recognized as life‐threatening, surgically‐related chronic kidney disease. On the contrary, the investigation of the prediction of mild post‐radical nephrectomy renal insufficiency, which is not related to adverse consequences in the postoperative long‐term period, is also promising because the prediction of mild renal insufficiency might be the basis for the substitution of radical nephrectomy for nephron‐sparing surgery in technically difficult or compromised cases. The deterioration of quality of life caused by post‐radical nephrectomy renal insufficiency should be investigated in conjunction with life‐threatening matters.     

Early and late residual renal function and surgical complications in living donors: a 15-year experience at a single institution

Living donation in the field of renal transplantation has increased over time as well as the use of laparoscopic nephrectomy. We present a 15-year experience on 162 living donors (105 women, 57 men; mean age, 46.7 years; range, 31-74 years) who underwent nephrectomy using different surgical approaches as open lombotomic nephrectomy (OLN), open transperitoneal nephrectomy (OTN), and laparoscopic hand-assisted nephrectomy (LHAN). We collected data on residual donor and recipient renal function, as well as early versus late medical and surgical complications. With a mean follow-up of about 8 years, we observed normal residual renal function in all donors and similar results of early and late graft function independent of the surgical procedure. Long-term incidence of hypertension and noninsulin-dependent diabetes in living donors was similar to the general population. OLN and OTN donors showed higher incidences of early and late complications, readmissions, and reoperations than LHAN donors. Our results confirmed that living donor nephrectomy is a safe procedure without serious side effects in terms of renal function and long-term quality of life. LHAN should be the preferred technique because of a lower incidence of early and late complications.     

Diabetic glomerulopathy following unilateral nephrectomy in the rat.

One month following induction of diabetes with streptozotocin, one half of diabetic and control rats underwent unilateral nephrectomy. Subsequently, all animals were studied with respect to renal function and glomerular alterations of diabetes. Blood pressure levels were similar in all animals. Diabetic and control animals with unilateral nephrectomy had similar but elevated serum creatinine levels and lower creatinine clearance values as compared with the intact rats. However, on a per kidney basis the creatinine clearance levels were higher in the animals with unilateral nephrectomy. At both three and six months following nephrectomy, markedly increased mesangial matrix thickening and mesangial deposition of IgG and C3 were observed in diabetic rats with unilateral nephrectomy as compared with intact diabetic animals. Nephrectomy had no detectable effects on glomerular morphology or immunohistochemistry of nondiabetic rats. Thus, unilateral nephrectomy in the rat increases, at as early as three months, the severity of diabetic glomerular lesions.