R.E.N.A.L评分在机器人辅助肾部分切除术中的应用

目的:探讨肾脏肿瘤测量评分系统(R.E.N.A.L评分)在机器人辅助腹腔镜肾部分切除术(RALPN)中评估手术成功率和手术结果的价值。方法:2010年3月~2014年5月,回顾性分析我科施行的45例RALPN的手术数据,并进行R.E.N.A.L评分。其中低危组(R.E.N.A.L评分7分)20例,中危组(R.E.N.A.L评分7~9分)15例,高危组(R.E.N.A.L评分≥10分)10例。将三组患者手术成功率、手术数据进行比较。结果:低危组均顺利完成RALPN;中危组13例完成RALPN,2例因行RALPN困难而行机器人辅助腹腔镜根治性肾切除术(RALRN);高危组7例完成RALPN,3例行RALRN。所有手术均在机器人辅助腹腔镜下完成,无中转开放手术。低危组平均手术时间(OT)、热缺血时间(WIT)、失血量(EBL)分别为(65.0±1.4)min、(14.0±0.9)min和(35.0±4.7)ml。中危组平均OT、WIT和EBL分别为(95.0±2.7)min、(22.0±1.6)min和(110.0±7.1)ml。高危组平均OT、WIT和EBL分别为(150.0±4.9)min、(30.0±2.1)min和(320.0±15.6)ml。三组间OT、WIT和EBL的差异有统计学意义(P0.05)。三组患者术后均无并发症出现。结论:对于RALPN,术前R.E.N.A.L评分同样与手术成功率、手术时间、失血量和热缺血时间有关。R.E.N.A.L评分≥10分不应该成为RALPN的禁忌证。     

R.E.N.A.L.,PADUA和C-index三种评分系统在肾部分切除术中的应用价值研究

目的 探讨R.E.N.A.L.,PADUA和C-index三种评分系统在肾部分切除术中的应用价值.方法 对本院2013年1月至2020年6月收治的134例行PN的单侧肾肿瘤患者临床资料进行回顾性分析,阅读134例单侧肾肿瘤患者术前影像学资料,应用R.E.N.AL.,PADUA和C-index三种评分系统对肾肿瘤解剖特征...     

'Zero ischaemia', sutureless laparoscopic partial nephrectomy for renal tumours with a low nephrometry score

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Ischaemic injury produced by hilar clamping during partial nephrectomy is the main determinant of renal function loss. The exact measurement of ipsilateral renal function loss can be underestimated by serum creatinine levels and estimated GFR. Few reports of unclamped laparoscopic partial nephrectomy (LPN) are available in the literature, although this technique shows promising results. The present study includes a series of patients with the longest follow‐up of LPN without hilar clamping and without parenchymal reconstruction. Excellent cancer control and optimum renal functional preservation suggest that this technique could be performed in selected patients, i.e. those with small and peripheral tumours (also classified as low nephrometry score tumours).

OBJECTIVE

• ? To describe the technique and report the results of ‘zero ischaemia’, sutureless laparoscopic partial nephrectomy (LPN) for renal tumours with a low nephrometry score.

PATIENTS AND METHODS

• ? Between August 2003 and January 2010, data from 101 consecutive patients who underwent ‘zero ischaemia’, sutureless LPN were collected in a prospectively maintained database.
• ? Inclusion criteria were tumour size ≤4 cm, predominant exophytic growth and intraparenchymal depth ≤1.5 cm, with a minimum distance of 5 mm from the urinary collecting system.
• ? Hilar vessels were not isolated, tumour dissection was performed with 10‐mm LigaSure^TM (Covidien, Boulder, CO, USA) and haemostasis was performed with coagulation and biological haemostatic agents without reconstructing the renal parenchyma.
• ? Clinical, perioperative and follow‐up data were collected prospectively, and modifications of functional outcome variables were analysed using the paired Wilcoxon test.

RESULTS

• ? The median (range) tumour size was 2.4 (1.5–4) cm, and the median (range) intraparenchymal depth was 0.7 (0.4–1.4) cm.
• ? Hilar clamping was not necessary in any patient, and suture was performed in four patients to ensure complete haemostasis. The median (range) operation duration was 60 (45–160) min, and median (range) intraoperative blood loss was 100 (20–240) mL.
• ? Postoperative complications included fever (n= 4), low urinary output (n= 3) and haematoma, which was treated conservatively (n= 2). The median (range) hospital stay was 3 (2–5) days. The pathologist reported 30 benign tumours and renal cell carcinoma in 71 cases (pT1a in 69 patients, and pT1b in two patients).
• ? At a median follow‐up of 57 months, one patient underwent radical nephrectomy for ipsilateral recurrence. The 1‐year median (range) decrease of split renal function at renal scintigraphy was 1 (0–5) %.

CONCLUSIONS

• ? Zero ischaemia LPN is a reasonable approach to treating small and peripheral tumours, and a sutureless procedure is feasible in most cases.
• ? This technique has a low complication rate and provides excellent functional outcome without impairing oncological results.

     

RENAL nephrometry score predicts surgical outcomes of laparoscopic partial nephrectomy

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? For small renal tumours, partial nephrectomy provides excellent cancer control and preserves renal function. The RENAL Nephrometry Score is useful for quantifying anatomic features relevant to surgical decision‐making. In patients undergoing laparoscopic partial nephrectomy, this study shows a correlation between RENAL Nephrometry Score and estimated blood loss, warm ischemia time, and length of hospital stay, suggesting that the RENAL Nephrometry Score may be useful for predicting the technical challenge posed by a renal tumour.

OBJECTIVE

? To assess the use of the RENAL Nephrometry Score (RNS), which has been proposed as an anatomical classification system for renal masses, aiming to predict surgical outcomes for patients undergoing laparoscopic partial nephrectomy (LPN).

MATERIALS AND METHODS

? In the present study, 159 consecutive patients who underwent LPN were reviewed and RNS was calculated for 141 patients with solitary renal masses who had complete radiographic data. ? Renal tumours were categorized by RNS as low (nephrometry sum 4–6), intermediate (sum 7–9) and high (sum 10–12).

RESULTS

? Of the 141 patients, there were 43 (30%) low, 91 (65%) intermediate and seven (5%) high score lesions. There was no statistically significant difference in the demographics of the three groups. ? There was a significant difference in warm ischaemia time (16 vs 23 vs 31 min; P < 0.001), estimated blood loss (163 vs 312 vs 317 mL; P= 0.034) and length of hospital stay (1.2 vs 1.9 vs 2.3 days; P < 0.001) between the low, intermediate and high score groups, respectively. There was no difference in overall operative time (P= 0.862), transfusion rate (P= 0.665), complication rate (P= 0.419), preoperative creatinine clearance (P= 0.888) or postoperative creatinine clearance (P= 0.473) between the groups. ? Sixty‐one lesions (43%) were anterior and 80 (57%) were posterior. No difference was found among any intra‐operative, pathological or postoperative outcomes when comparing anterior vs posterior lesions.

CONCLUSIONS

? In patients undergoing LPN, a higher RNS was significantly associated with an increased estimated blood loss, warm ischaemia time and length of hospital stay. ? The RNS may stratify tumours based on the technical difficulty of performing LPN.     

Renal nephrometry score is associated with urine leak after partial nephrectomy

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? There have been no studies to date that look at the relationship between kidney tumour location and the risk of developing a urine leak. This study is the first to add to the literature showing that tumour complexity does increase the risk of developing a urine leak.

OBJECTIVE

? To determine if the RENAL nephrometry score is associated with urine leak after partial nephrectomy for tumours ≤7 cm.

PATIENTS AND METHODS

? Thirty‐one patients who developed urine leak after partial nephrectomy between 1998 and 2006 were identified. Each patient was individually matched (1 : 4 by age, gender and surgery date) to 124 patients who had undergone partial nephrectomy but without urine leak. ? Associations of RENAL nephrometry scores and each component of the score (Radius; Endophytic; Nearness to collecting system; and Location) with urine leak were evaluated using conditional logistic regression.

RESULTS

? Mean tumour size for the 31 patients who developed urine leak was 3.4 cm (median 3.5; range 1.5–5.9). Mean RENAL score was 8 (median 8; range 5–11). ? Each unit increase in RENAL score was associated with a 35% increased odds of urine leak (OR 1.35; 95% CI 1.08–1.69; P= 0.009). ? On multivariable analysis, tumours that were <50% exophytic (OR 16.65; 95% CI 2.75–100.71; P= 0.002), completely endophytic (OR 17.02; 95% CI 2.88–100.55; P= 0.002), or located at the renal pole (OR 4.34; 95% CI 1.30–14.53; P= 0.017) were associated with urine leak. ? If the score attributed to tumour location was reversed (polar location given a higher score), each unit increase in RENAL score was associated with an 89% increased odds of urine leak (OR 1.89; 95% CI 1.40–2.55; P < 0.001).

CONCLUSION

? The RENAL nephrometry score is associated with risk of urine leak after partial nephrectomy. When assessing risk of urine leak, reversal of the score attributed to tumour location may improve risk prediction.     

C index is associated with both short-term and long-term renal functional outcome after partial nephrectomy

ObjectivesPartial nephrectomy is the standard treatment for the small renal mass. C index, one of the nephrometric systems, was found to be associated with short-term renal functional outcome after laparoscopic partial nephrectomy. We conducted this study to externally validate the application of C index as a prognostic factor of long-term renal functional outcome after open partial nephrectomy (OPN) for small renal mass.Materials and MethodsThe medical records of 65 consecutive patients undergoing OPN from June 2004 to November 2011 were reviewed. C index was calculated on preoperative computed tomography or magnetic resonance images. The estimated glomerular filtration rate was calculated using the modification of diet in renal disease 2 equation. Short-term and long-term renal functional outcomes were assessed by the nadir estimated glomerular filtration rate within postoperative 1 week and 1 to 2 years. The correlation between C index, perioperative parameters, and renal functional outcomes were examined.ResultsThe median C index in our cohort was 2.2. C index was associated with operative time, cold ischemia time, estimated blood loss, and length of hospital stay (p = 0.03, 0.001, 0.001, and 0.02, respectively). On logistic linear regression analysis, C index (p = 0.01) and operative time (p < 0.001) were associated with the short-term percent decrease of the estimated glomerular filtration rate, whereas C index (p = 0.03) was associated with the long-term percent decrease of the estimated glomerular filtration rate. Under the criteria of C index ≤ 2.5, the sensitivity/specificity were 83.3%/53.8% and 80%/52% in predicting chronic kidney disease stage 3 or greater in the short-term and long-term follow-up, respectively. Moreover, the mean long-term percent decrease of the estimated glomerular filtration rate in patients with C index ≤ 2.5 was much higher compared with that of patients with C index > 2.5 (18.1% vs. 0%, p = 0.001).ConclusionC index could serve as an indicator for both short-term and long-term renal functional decrease after OPN. For patients with C index ≤ 2.5, a comprehensive analysis of vascular anatomy and planning for dissection are crucial in preoperative assessment, and every effort should be exerted to minimize renal parenchymal damage during surgery.     

R.E.N.A.L.评分系统在经腹腹腔镜肾部分切除术治疗T1a期肾肿瘤中的应用

目的探讨肾脏肿瘤测量评分系统（R.E.N.A.L.评分系统）在T1a期肾肿瘤行经腹入路腹腔镜肾部分切除术（TLPN）中的应用价值。 方法回顾性分析2010年7月至2016年10月首都医科大学附属北京天坛医院泌尿外科67例行TLPN的T1a期肾肿瘤患者的临床资料,其中男52例（78％）,女15例（22％）,年龄26~75岁,平均（56±13）岁。肿瘤平均直径（2.5±0.8）cm,其中左侧32例（48％）,右侧35例（52％）;应用R.E.N.A.L.评分系统对肾脏肿瘤进行量化评分。比较低、中与高评分组在肿瘤最大径、热缺血时间、术中出血量、手术时间、术前术后肌酐及住院天数等临床指标的差异。 结果67例患者均顺利完成TLPN,无中转开放及死亡病例。平均R.E.N.A.L.评分为（6.3±1.7）分,其中低评分组有37例（55％）,中评分组有24例（36％）,高评分组有6例（9％）,低、中与高评分组肿瘤最大直径差异有统计学意义（F=5.230,P=0.008）,热缺血时间、术中出血量、手术时间、术前术后肌酐及住院天数差异均无统计学意义（P>0.05）。 结论使用R.E.N.A.L.评分系统评估TLPN治疗T1a期肾肿瘤手术风险及手术难易程度的价值有限,临床应用需慎重。     

改良R.E.N.A.L.评分在RLPN治疗T1期肾癌中的临床应用及评价

目的 评价改良R.E.N.A.L.评分系统在后腹腔镜下T1期肾癌肾部分切除术中的临床应用效果.方法 回顾性分析2007年1月-2012年6月39例T1期肾癌患者临床资料,对相关资料使用改良设计的R.E.N.A.L评分系统进行评分.分析评分结果与手术时间、热缺血时间、术中出血量、围手术期并发症等因素的相互关系。结果 改良的R.E.N.A.L.评分系统与术中热缺血时间、手术时间、术中失血量存在明显关联（P＜0.05）,而因为研究对象较少,只有1例中等手术难度患者术后出现并发症,暂时无法评估改良R.E.N.A.L.评分系统与手术并发症之间的关系,有待进一步增加样本量。结论 改良R.E.N.A.L.评分系统较为准确地评价了后腹腔镜下T1肾癌肾部分切除术的手术难度,可作为术前T1肾癌患者后腹腔镜下肾癌肾部分切除术手术难度分级标准。     

Robotic partial nephrectomy outcomes at a single institution and experience with R.E.N.A.L. nephrometry score

Partial nephrectomy is the current gold-standard treatment of small renal masses. The articulated instruments of the surgical robot have made the laparoscopic approach more feasible. We present our experience with 50 robot-assisted laparoscopic partial nephrectomy (RALPN) surgeries and attempt to validate a recently reported nephrometry score. From July 2008 to July 2010, 50 (53 planned) elective RALPNs were performed utilizing the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). All patients had an enhancing renal mass on CT scan pre-operatively. Clinicopathologic, surgical, and renal functional (Cockcroft–Gault formula) outcomes were recorded prospectively and analyzed. Mean tumor size, length of surgery (LS), warm ischemia time (WIT), and nephrometry scores were 3.6 cm (1–8), 303 min (133–610), 29.1 min (11–42), and 6.8 (4–11) respectively. Renal cell carcinoma was found in 39 (78%) patients. When evaluating the nephrometry score, comparison of low, medium, and high complexity tumors for length of surgery, WIT, and estimated blood loss (EBL) showed no difference (p > 0.05). Nearness to the collecting system (N score 1 vs. N score 3) showed increased EBL (195 ml vs. 510 mL, p = 0.005), and location relative to polar lines (L score 1 and L score 2) increased mean LS (265 vs. 359 min, p = 0.02). RALPN is safe and effective. Nephrometry scores are a method of standardizing tumor complexity and can be utilized in comparing tumor cohorts but may not be predictive of intra-operative outcomes.     

Impact of temporary hilar clamping during laparoscopic partial nephrectomy on postoperative renal function: a prospective study

PURPOSE: Laparoscopic partial nephrectomy for small renal tumors has been increasingly performed in the last few years. We prospectively evaluated preoperative and postoperative differential renal function by renal scan in patients with contralaterally functioning kidneys who underwent laparoscopic partial nephrectomy with hilar clamping. MATERIALS AND METHODS: From July 2002 to June 2003, 17 consecutive patients were included in this prospective protocol and underwent laparoscopic partial nephrectomy for exophytic tumors using en bloc hilar clamping. Preoperative renal scan with differential function was performed 1 month before and 3 months after surgery in all patients. technetium labeled diethylenetetraminepentaacetic acid scan was performed in all patients. RESULTS: Mean warm ischemia time was 22.50 +/- 9.78 minutes (range 10 to 44). Preoperative differential renal function and glomerular filtration rate (GFR) in the affected kidneys were 50.20% +/- 4.90% (range 43 to 58) and 75.56 +/- 16.45 ml per minutes (range 39.4 to 105). At postoperative month 3 differential renal function and GFR in the affected kidney were 48.07% +/- 7.16% (range 39% to 63%) and 72.03 +/- 18.17 ml per minutes (range 31 to 101). There was a nonsignificant negative association between hilar clamp time and change in renal function (postoperative - preoperative) of the affected kidney (r = -0.26, p = 0.31), and a positive correlation between clamp time and change in GFR (r = 0.39, p = 0.12) that did not reach statistical significance. CONCLUSIONS: In patients with contralaterally functioning kidney, temporary hilar clamping with a mean warm ischemia time of 22.5 minutes results in preservation of renal function in the affected kidney. Larger studies with longer followup are necessary to study the impact of warm ischemia further.