Partial nephrectomy for renal tumors using selective parenchymal clamping

Purpose To describe our experience with partial nephrectomy using selective parenchymal clamping for the treatment of renal tumors. Patients and methods Between 2003 and 2005, seven patients with solid renal tumors underwent partial nephrectomy with selective parenchymal clamping at our Institution. In five, the tumor was in the right kidney and in two the tumor was in the left. Only one patient had a tumor within a solitary kidney. The tumor was located in the upper pole in 2 patients and in the lower pole in 5. Partial nephrectomy was performed with the DeBakey aortic clamp without occlusion of renal vessels. Results Mean operative time was 236 min (range 175–298 min). Mean intraoperative blood loss was 485 ml with only one patient requiring blood transfusion. There were no major complications. Mean preoperative serum creatinine level was 0.74 mg/dl (range 0.58–1.26 mg/dl) and mean postoperative serum creatinine level was 0.81 mg/dl (range 0.69–1.21 mg/dl) with no patient requiring dialysis. Mean hospital postoperative stay was 5 days (range 4–7 days). Mean tumor size was 2.9 cm (range 1.3–4.0 cm). Pathologic analysis detected renal cell carcinoma in 5 patients, angiomyolipoma in 1 and fibrosis with chronic hemorrhage in 1, all with negative surgical margins. After a mean follow-up of 18 months (range 3–32 months), all patients are free of disease recurrence. Conclusion Partial nephrectomy with selective parenchymal clamping allows resection of solid masses without damage to normal renal tissue, avoids the risk of renal failure and offers an excellent local cancer control.     

后腹腔镜下肾肿瘤剜除术的临床疗效观察(附5例报告)

目的：探讨后腹腔镜下肾肿瘤剜除术的操作要点及临床价值。方法：采用后腹腔镜下肾肿瘤剜除术治疗肾肿瘤5例,其中肾癌3例,肾错钩瘤2例,瘤体直径1．5～4．0cm。具体方法是：①暴露瘤体和肾动脉;②采用硅胶管牵拉肾动脉,必要时可暂时阻断肾动脉;③于瘤体1cm正常肾组织处用电钩切除瘤体;④采用生物蛋白胶、止血纱布缝合加压处理创面出血。结果：手术均获成功。手术时间150～210min,术中出血80～350ml。术后1～2天肠道功能恢复并可床上活动,1～4天可下床活动。术后住院5～9天,平均7天。结论：后腹腔镜下肾肿瘤剜除术具有创伤小、康复快、安全、住院时间短等优点;对外生性生长、直径小于4cm瘤体,该法可作为首选手术方法。     

肾癌肾部分切除术的临床价值及合适的手术切缘的探讨

目的：探讨肾癌肾部分切除术(保留肾单位手术)的临床价值及合适的手术切缘。方法：回顾性分析15例行肾部分切除术的肾癌患者临床资料．其中双侧异时性肾癌且一侧为多发肿瘤2例,单发肿瘤13例。肿瘤直径2～6cm．均为T1期(1997年TNM分期标准)。对15例肾癌患者行肾部分切除术．手术切缘位于肿瘤外1cm。另取肾癌根治性手术标本21例．于体外沿假包膜行肾肿瘤剜除术．并随机切取肿瘤边缘0．3cm、0．5cm及1cm处肾实质及肾蒂处淋巴脂肪组织行病理检查。结果：15冽患者随访12～72个月．平均41个月．未见并发症及残肾内肿瘤复发。21例标本于体外行肿瘤剜除后肉眼下均无肿瘤组织残留,送检组织均无肿瘤细胞浸润。结论：肾部分切除术能安全有效地治疗局限的早期肾癌患者．而手术切缘为肿瘤边缘1cm处较为合适。     

Nephron-sparing surgery is superior to radical nephrectomy in preserving renal function benefit even when expanding indications beyond the traditional 4-cm cutoff

ObjectivesTo analyze to what extent partial nephrectomy (PN) is superior to radical nephrectomy (RN) in preserving renal function outcome in relation to tumor size indication.Methods and materialsClinical data from 973 patients operated at 9 academic institutions were retrospectively analyzed. Glomerular filtration rate (GFR) before and after surgery was calculated with the abbreviated Modification of the Diet in Renal Disease equation. For a fair comparison between the 2 techniques, all imperative indications for PN were excluded. A shift to a less favorable GFR group following surgery was considered clinically significant.ResultsMedian age at diagnosis was 60 years (19–91). Tumor size was smaller than 4 cm in 665 (68.3%) cases and larger than 4 cm in 308 (31.7%) cases. PN and RN were performed in 663 (68.1%) and 310 (31.9%) patients, respectively. In univariate analysis, patients undergoing PN had a smaller risk for developing significant GFR change following surgery than those undergoing RN did. This was true for tumors≤4 cm (P = 0.0001) and for tumors>4 cm (P = 0.0001). In multivariate analysis, the following criteria were independent predictive factors for developing significant postoperative GFR loss: the use of RN (P = 0.0001), preoperative GFR<60 ml/min (P = 0.0001), tumor size≥4 cm (P = 0.0001), and older age at diagnosis (P = 0.0001).ConclusionsThe renal function benefit carried out by elective PN over RN persists even when expanding nephron-sparing surgery indications beyond the traditional 4-cm cutoff.     

Partial nephrectomy: contemporary outcomes, candidate selection, and surgical approach

Localized kidney cancer is ideally managed with surgical extirpation. Historically renal cell carcinoma has been treated with radical nephrectomy, but partial nephrectomy has become increasingly used because of a growing body of evidence demonstrating equivalent oncologic control and a potential benefit in overall survival. In this article, the authors demonstrate that partial nephrectomy carries excellent oncologic efficacy. They additionally review the growing indications for partial nephrectomy and factors influencing candidate selection. The authors also compare the relative outcomes of open and minimally invasive techniques. Several factors influence outcome, and surgeon experience should dictate the choice of technique.     

Perioperative efficacy of laparoscopic partial nephrectomy for tumors larger than 4 cm

Background

Laparoscopic partial nephrectomy (LPN) is typically reserved for kidney tumors ≤4 cm in size. The use of LPN in patients with larger tumors (>4 cm) has not been systematically evaluated.

Objective

To examine technical feasibility and perioperative safety and efficacy of LPN for clinical stage pT1b–T2 tumors >4 cm.

Design, setting, and participants

This is a retrospective review of data from an Institutional Review Board–approved, prospectively maintained database of 425 LPN procedures over a 6-yr period (September 1999 through December 2005). Patients were grouped according to tumor size: control group1: <2 cm (n = 89; 21% of patients); control group 2: 2–4 cm (n = 278; 65% of patients); and study group 3: >4 cm (n = 58; 14% of patients).

Intervention

Retroperitoneal and transperitoneal LPN.

Measurements

Serum creatinine levels, estimated glomerular filtration rates.

Results and limitations

For groups 1, 2, and 3, mean tumor size was 1.5 cm, 2.9 cm, and 6 cm in diameter, respectively (p < 0.001). Study group 3 patients more often had an American Society of Anesthesiologists score ≥3 (p < 0.05), central tumors (p < 0.001), pelvicalyceal repair (p = 0.004), and heminephrectomy (p < 0.001). Total operative time, estimated blood loss, and duration of hospital stay were equivalent. Mean warm ischemia time was 30 min, 32 min, and 38 min in groups 1, 2, and 3, respectively (p = 0.007). Tumor size >4 cm did not increase significant risk for positive tumor margins, intraoperative complications, or postoperative genitourinary complications. In each group preoperative stage ≥3 chronic kidney disease (CKD) was present in 31%, 35%, and 44% of patients in groups 1, 2, and 3, respectively (p = 0.15); postoperatively, stage 3–5 CKD incidence increased to 52%, 52%, and 63% in groups 1, 2, and 3, respectively (p = 0.20). Patients with tumor size >4 cm and preoperative stage 3–5 CKD had an 8-fold increase in risk for CKD stage progression. Limitations of the study include retrospective analysis and a relatively low number of patients in group 3.

Conclusions

Given laparoscopic expertise and appropriate patient selection, LPN is feasible and efficacious for kidney tumors >4 cm. Indications for LPN should be expanded to include patients with amenable tumors >4 cm in order to maximally preserve kidney function in these patients.     

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.     

Contact fibre Nd: YAG laser for partial nephrectomy: experimental study in pigs

Summary Thirty-two partial nephrectomies were performed without renal cooling on 13 pigs with a contact fibre Nd: YAG laser (10 W) or a steel scalpel with or without a vascular pedicle clamp. Nine pigs had a 2-week follow-up with an abdominal ultrasound 1 week postoperatively. The time for haemostasis was 6.9±5.8 min (mean ±SD) with the laser and 9.1±5.8 min with the steel scalpel when the clamp was used (P=0.028). There was no significant difference in the total operating time (13.2±4.5 min with the laser vs 12.6±4.6 min with the steel scalpel, P=0.203). Intraoperative blood loss was similar in the two groups when the clamp was used. Clamping the renal pedicle decreased the blood loss by 61% in the laser group and 31% in the steel scalpel group. The number of ligatures used was significantly lower in the laser group (3.7±2.6) compared with the steel scalpel group (6.6±3.4) (P=0.013). Five urinomas developed on the laser side and four on the steel scalpel side. These results indicate that the contact fibre Nd:YAG laser method can be used in partial nephrectomy, but it offers no definitive advantage over the conventional technique.     

后腹腔镜下肾部分切除术(附4例报告)

目的 探讨腹腔镜肾部分切除术的可行性.方法 2005年8～11月对2例肾恶性肿瘤和2例肾错构瘤行腹腔镜肾部分切除术.先游离患肾,显露肾动、静脉及输尿管,棉带穿过肾动脉以备阻断患肾血流,行肾部分切除术,结果 4例手术均获成功,无中转开放手术.手术时间2例均为1.5h,1例2h,1例3h;术中出血50～180ml,均未输血.1例肾蒂阻断时间25min,余3例未完全阻断.结论 腹腔镜肾部分切除术技术可行.     

Assessment of Risk Factors for Complications of Laparoscopic Partial Nephrectomy

Objective

Laparoscopic partial nephrectomy (LPN) is a technique that is emerging as an attractive option for the treatment of renal tumors ≤4 cm. We retrospectively analyzed our experience with LPN to identify patient and tumor features that correlate with a higher risk of complications.

Material and methods

From January 2001 to May 2007, 90 patients underwent LPN at our institution for a clinically localized renal tumor. A retrospective chart review was carried out. Clinical and pathological information were collected for each patient, including patient age and body mass index, tumor size, location and pattern of growth (cortical vs. corticomedullar), surgical approach (transperitoneal vs. retroperitoneal), warm ischemia time, technique that was used to achieve hemostasis, maximum thickness of the margin of resection, and histology. Statistical analysis (chi-square test, Fisher exact test, Mann-Whitney U test, linear regression model) was performed to test the correlation between the above-mentioned variables and the occurrence of complications.

Results

Twenty-two patients (24.4%) had surgical and/or medical complications in our series. The only variable that was found to significantly correlate with a higher number of complications was a corticomedullar tumor growth pattern as opposed to a cortical growth pattern (p = 0.02).

Conclusions

LPN is an attractive alternative to open partial nephrectomy for the treatment of small renal tumors. On the basis of our experience, the selection of patients with cortical renal lesions seems to be required to reduce the risk of complications and therefore maximize the advantages of this minimally invasive but challenging procedure.     

R-LESS Partial Nephrectomy Trifecta Outcome Is Inferior to Multiport Robotic Partial Nephrectomy: Comparative Analysis

Background

Trifecta achievement in partial nephrectomy (PN) is defined as the combination of warm ischemia time ≤20 min, negative surgical margins, and no surgical complications.

Objective

To compare trifecta achievement between robotic, laparoendoscopic, single-site (R-LESS) PN and multiport robotic PN (RPN).

Design, setting, and participants

Data from 167 patients who underwent RPN from 2006 to 2012 were retrospectively analyzed.

Outcome measurements and statistical analysis

Primary outcome measurement was trifecta achievement; secondary outcome was the perioperative and postoperative comparison between groups. The measurements were estimated and analyzed with SPSS v.18 using univariable, multivariable, and subgroup analyses.

Results and limitations

Eighty-nine patients were treated with RPN and 78 were treated with R-LESS PN. Baseline characteristics of both groups were similar. Trifecta was achieved in 38 patients (42.7%) in the multiport RPN group and 20 patients (25.6%) in the R-LESS PN group (p = 0.021). Patients in the R-LESS PN group had longer mean operative time, warm ischemia time, and increased estimated glomerular filtration rate (eGFR) percentage change. No significant differences were found between the two groups in days of hospitalization, blood loss, postoperative eGFR, positive surgical margins, and surgical complications. Patients with increased PADUA and RENAL scores, infiltration of the collecting system, and renal sinus involvement had an increased probability of not achieving the trifecta. In regression analysis, the type of procedure and the tumor size could predict trifecta accomplishment (p = 0.019 and 0.043, respectively). The retrospective study, the low number of series, and the controversial definition of trifecta were the main limitations.

Conclusions

The trifecta was achieved in significantly more patients who underwent multiport RPN than those who underwent R-LESS PN. R-LESS PN could be an alternative option for patients with decreased tumor size, low PADUA and RENAL scores, and without renal sinus or collecting system involvement.

Patient summary

In this study, we looked at the outcomes of patients who had undergone robotic partial nephrectomy. We found that conventional robotic partial nephrectomy is superior to R-LESS partial nephrectomy with regard to the accomplishment of negative margins, reduced warm ischemia time, and minimal surgical complications.     

Intravenous Mannitol Versus Placebo During Partial Nephrectomy in Patients with Normal Kidney Function: A Double-blind,Clinically-integrated,Randomized Trial

Background

Mannitol is currently used as a renal protective agent to mitigate the effects of renal ischemia during nephron-sparing surgery (NSS). This routine practice lacks rigorous methodological study.

The Expanding Role of Partial Nephrectomy: A Critical Analysis of Indications,Results, and Complications

Context

The gained expertise in the surgical technique of partial nephrectomy (PN) with excellent oncologic outcome and reduced morbidity has contributed to more frequent use of PN in many centres of reference, and the recent evidence favouring PN over radical nephrectomy (RN) in the prevention of chronic kidney disease and possibly linking it to a better overall survival (OS) will constitute a strong argument for wider use of PN.

Objective

To objectively analyse the advantages of PN over RN and to evaluate the risk–benefit ratio of expanding the indications of PN T1b renal cortical tumours.

Evidence acquisition

Literature searches on English-language publications were performed using the National Library of Medicine database. The queries included the keywords partial nephrectomy and nephron sparing surgery. Eight hundred four references were scrutinised, and 175 publications were identified and reviewed. Sixty-nine articles were selected for this review. These references formed the basis for this analysis and were selected based on their relevance and the importance of their content.

Evidence synthesis

The use of PN has been steadily increasing, particularly in tertiary care centres. This trend is now strengthened by evidence supporting the role of PN in reducing the risk of chronic kidney disease in patients with renal masses ≤4 cm. A wider use of PN for larger tumours, granted technical feasibility, is supported by the preliminary evidence, suggesting an OS advantage favouring PN over RN. However, the potential for selection bias and residual confounding factors may contribute to the observed difference. In the carefully selected patients with tumours >4 cm, PN obtained equivalent oncologic outcome to that achieved after RN. Although higher morbidity rates were seen after PN, the complication type and severity were not prohibitive.

Conclusions

The available evidence supports elective PN as the standard surgical treatment for renal cortical tumours ≤4 cm. For larger tumours, PN has demonstrated feasibility and oncologic safety in the carefully selected patient population studied.     

Cryoablation versus Partial Nephrectomy for Clinical T1b Renal Tumors: A Matched Group Comparative Analysis

Background

The traditional treatment for a cT1b renal tumor has been radical nephrectomy. However, recent guidelines have shifted towards partial nephrectomy (PN) in selected patients with cT1b renal tumors. Furthermore, practitioners have extended the role of cryoablation (CA) to treat cT1b tumors in selected patients.

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。     

Laparoscopic partial nephrectomy for hilar tumors: technique and results

BACKGROUND: Laparoscopic partial nephrectomy for hilar tumors is a cutting edge procedure for which little data is available in the current literature. OBJECTIVE: To describe our technique and results of laparoscopic partial nephrectomy for renal hilar tumors. DESIGN, SETTING, AND PARTICIPANTS: Between April 2000 and September 2006, 94 partial laparoscopic nephrectomies were performed at our institution. A total of 18 (19.1%) patients had hilar tumors. A hilar tumor was defined as a lesion suspicious for renal cell carcinoma in contact with a major renal vessel on preoperative cross-sectional imaging. In 3 (16.7%) of the patients, the indication for nephron-sparing surgery was imperative. Mean tumor size was 3cm (range, 2-4.5). Eight (44.4%) surgeries were performed with renal artery perfusion for cold ischemia; the remaining surgeries were performed under warm ischemia. INTERVENTION(S): After occluding the renal artery and controlling the renal vein by using separate rubber band tourniquets, we excised the tumor mass including delicate mobilization away from the blood vessels. Although we used to insert a ureteral stent at the beginning of our experience with laparoscopic partial nephrectomies, we no longer do so. All surgeries were performed by a single urologist (G.J.). MEASUREMENTS: Operative time, ischemia time, blood loss, renal function using the Cockroft formula as well as renal scans, operative and post-operative complications, pathology parameters. RESULTS AND LIMITATIONS: All surgeries were completed laparoscopically. Mean surgical time was 238min (range, 150-420). Mean ischemia times were 42.5min (range, 27-63) and 34.1min (range, 24-56) for the cold and warm ischemia groups, respectively. Estimated intraoperative blood loss was 165ml (range, 50-500). There were two (11%) entries into major vessels during tumor excision, namely a segmental renal artery in one patient and a segmental renal vein in another. Both of these occurrences were managed laparoscopically. One patient necessitated laparoscopic reexploration for urine extravasation in the immediate postoperative period. All postoperative nuclear scans (available in 12 of 18 patients) showed functional kidney moiety. Mean split renal function was 38.6% (range, 24-50) on the operated side. Histopathological examination confirmed renal cell carcinoma in 14 (77.8%) of the patients. One (7.1%) patient had a positive surgical margin on the surface that was adjacent to the renal artery. In a median follow-up of 26 mo (range, 1-59), no local recurrence or systemic progression occurred. CONCLUSION: Laparoscopic partial nephrectomy for hilar tumors is a feasible and safe procedure in the hands of experienced laparoscopic surgeons. Oncological results seem excellent, but further follow-up is needed for accurate long-term assessment of this surgical approach.     

Multi-institutional analysis of robotic partial nephrectomy for hilar versus nonhilar lesions in 446 consecutive cases

Background

Minimally invasive approaches to partial nephrectomy have been rapidly gaining popularity but require advanced laparoscopic surgical skills. Renal hilar tumors, due to their anatomic location, pose additional technical challenges to the operating surgeon.

Objective

We compared the outcomes of robot-assisted partial nephrectomy (RPN) for hilar and nonhilar tumors in our large multicenter contemporary series of patients.

Design, setting, and participants

We retrospectively reviewed prospectively collected data on 446 consecutive patients who underwent RPN by renal surgeons experienced in minimally invasive techniques at four academic institutions from June 2006 to March 2010. Patients were stratified into two groups: those with hilar lesions and those with nonhilar lesions.

Measurements

Patient demographics, operative outcomes, and postoperative outcomes, including oncologic outcomes, were recorded.

Results and limitations

Forty-one patients (9%) had hilar renal masses; 405 patients (91%) had nonhilar masses. There was no statistical differences in patient demographics except for larger median tumor size in the hilar cohort (3.2 cm vs 2.6 cm; p = 0.001). The only significant difference in operative outcomes was an increase in warm ischemia times for the hilar group versus the nonhilar group (26.3 ± 7.4 min vs 19.6 ± 10.0 min; p = <0.0001). There were no differences in postoperative outcomes; however, there was a trend for increased risk of malignancy and higher stage tumors in the hilar lesion group. Final pathologic margin status was similar in both groups. Only one patient in the nonhilar group had evidence of recurrence at 21 mo. The study was limited by the lack of standard anatomic classification of renal tumors and the potential influence of the surgeons’ prior robotic experience.

Conclusions

The data represent the largest series of its kind and strongly suggest that RPN is a safe, effective, and feasible option for the minimally invasive approach to renal hilar tumors with no increased risk of adverse outcomes compared with nonhilar tumors in the hands of experienced robotic surgeons.     

后腹腔镜下肾部分切除术(附45例报告)

目的:评价后腹腔镜技术进行肾部分切除术的可行性及临床价值。方法:对45例肾占位患者(其中10例为肾癌,35例为错构瘤)术前均行B超、CT和(或)KUB加IVU确诊。入院后经积极术前准备,在全麻腹腔镜下、后腹腔径路肾部分切除术,先用超声刀将肾脏充分游离,游离出肾动脉并用8号导尿管贯穿,预备阻断,用超声刀切除肾占位(切缘0.5～1.0cm),彻底止血,严密缝合切缘。结果:所有患者均成功完成手术,手术时间时间60～150min,平均90min,术中出血量200～600ml,平均350ml,术后恢复顺利,住院7～10天,平均8天随访6～24个月,无肿瘤复发。结论:腹腔镜下后腹腔径路肾部分切除术,创伤小、术后恢复快,明显优于开放手术,值得大力推广。但应严格掌握适应证。