肾段动脉阻断技术在腹腔镜肾部分切除手术中的应用与技术要点分析（附光盘）

随着小肾癌检出率的增加以及泌尿外科医生对肾脏热缺血损伤认识的提升,肾肿瘤保留。肾单位手术越来越受到业界的关注。腹腔镜下肾段动脉阻断肾部分切除术可以有效地避免正常肾单位的热缺血再灌注损伤。作者重点阐述该技术的各项注意事项和技术要点。     

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.     

机器人辅助和普通腹腔镜肾部分切除术治疗肾血管平滑肌脂肪瘤的比较

目的对比肾血管平滑肌脂肪瘤（RAML）患者中应用机器人辅助肾部分切除术（RAPN）与普通腹腔镜下肾部分切除术（LPN）的安全性及有效性。 方法收集2016年1月至2021年8月我院收治的肾血管平滑肌脂肪瘤患者198例,其中80例为机器人辅助肾部分切除术组,118例为腹腔镜下肾部分切除术组。采用倾向性评分匹配后分析比较两术式的临床指标。 结果198例患者中有3例术中中转开放（包括2例LPN,1例RAPN）,1例LPN术中损伤输尿管,其余均顺利完成手术。RAPN组术中热缺血时间显著低于LPN组;RAPN组术后血红蛋白（Hb）差值百分比及eGFR差值百分比均显著低于LPN组（P<0.05）;手术时间、术中估计出血量、术中及术后输血率、术后并发症、术后引流量、引流管留置时间、胃肠道功能恢复时间、术后住院时间方面两组差异无统计学意义。 结论在肾血管平滑肌脂肪瘤患者中,应用机器人辅助肾部分切除术相较于普通腹腔镜下肾部分切除术具有显著优势,手术出血更少,热缺血时间更短,能更大程度保留肾功能。     

Robot-assisted laparoscopic partial nephrectomy: the NYU technique

The introduction of the daVinci surgical system has changed the way both surgeon and patient view radical prostatectomy. We hypothesized that the same theoretical and tangible benefits may be realized when employing the system for partial nephrectomy. This paper reviews our technique of robot-assisted laparoscopic partial nephrectomy (RALPN) utilizing the daVinci surgical system. Intraoperative hilar clamping is utilized in all cases. With the daVinci system, the tumor is excised with cold scissors, biopsies are taken from the base for frozen-section study, sutures are placed at the base, Gelfoam/fibrin glue is activated in the defect, a Surgicel bolster is laid in the defect, and mattress sutures are placed prior to releasing the clamp. After performing 12 RALPNs, it appears this technique is safe, feasible, and reproducible both for small exophytic masses and for deeper lesions involving the collecting system. A RALPN requires two surgeons, both well versed in laparoscopic and robotic techniques.     

Hydro-jet dissection for laparoscopic nephrectomy: a new technique

Objectives. The Hydro-Jet technique has been used to cut various industrial materials. In the medical field, this technique has been successfully used for selective dissection of the parenchyma of organs such as the liver. Recently, this technique was successfully used for laparoscopic cholecystectomy in humans. We developed a new Hydro-Jet probe and a technique of Hydro-Jet dissection during laparoscopic nephrectomy (LN) in a porcine model and compared the results with those of conventional laparoscopy.Methods. Fourteen pigs underwent unilateral LN using the Hydro-Jet and a conventional LN on the contralateral side. A Muritz 1000 Hydro-Jet generator was used. An adjustable water pressure gauge allowed manual control up to a maximum of 30 atm, and coagulation was applied by way of a bipolar thermoapplicator. The bent end of the probe allowed both blunt dissection and concomitant high-pressure water application. Results were compared with regard to ease of anatomic dissection, complications, and operative time between the two techniques.Results. LN was successful in all animals with no conversion to open surgery. The dissector allowed anatomic planes to be created in a relatively bloodless field, and continuous water flow allowed a clear view for the operator. The high-pressure stream resulted in excellent dissection of adventitial and soft tissue adjacent to vascular structures, with complete preservation of vessels and ureter for selective ligation. The dissection time was shortened (mean 27 minutes for the Hydro-Jet versus 40 minutes for the conventional technique).Conclusions. To our knowledge, we describe the first report of Hydro-Jet dissection for LN as an alternative to the conventional technique. The improved anatomic dissection may decrease complications. Moreover, shorter operating times were achieved, which may result in cost savings. Further studies in humans are necessary to investigate this technique.     

后腹腔镜肾部分切除术在治疗肾肿瘤的临床应用

目的探讨后腹腔镜保留肾单位的肾部分切除术治疗肾肿瘤的临床应用价值。方法 11例患者施行后腹腔镜保留肾单位的肾部分切除术的临床资料,其中男8例,女3例,年龄平均51.2岁,肿瘤直径3～4cm回顾性分析。结果所有手术均获成功,手术时间70～120min,血管阻断时间20～40min,术中失血100～300ml,术后无出血、尿漏等并发症。术后病理9例肾脏透明细胞癌(T1N0M0),2例肾血管平滑肌脂肪瘤,随访3～15个月无局部复发。结论后腹腔镜下保留肾单位的肾部分切除术治疗早期肾脏肿瘤,安全、有效,兼有创伤小,康复快等优点,近期疗效满意,远期疗效有待进一步观察。     

后腹腔镜下肾部分切除术治疗肾脏肿瘤

【摘要】 目的 探讨后腹腔镜下肾部分切除术的方法和临床应用价值。方法 选取2013年7月至2017年11月在本院收治37例肾脏肿瘤患者施行后腹腔镜下肾部分切除术,其中肾透明细胞癌T1a期23例,T1b期4例,肾错构瘤9例,T1a期肾嫌色细胞癌1例。术中充分游离肾脏和肿块表面脂肪,血管夹阻断肾动脉主干动脉,距肿块边缘正常组织0.5 cm处切除肿块,缝合创面并用Hem-o-lock固定减张。结果 36例成功施行腹腔镜下切除术,其中1例因行肾段动脉阻断未完全,出血较多中转开放手术,2例未行肾动脉阻断。手术时间65～225 min,平均95 min,术中出血量20～1000 mL,平均125 mL,肾动脉阻断时间10～35 min,平均24 min。1例术后2周继发出血,行介入栓塞治疗后出血停止。住院时间11～27 d,平均14.6 d,随访3～27个月,无远期并发症,肿瘤未见复发。结论 后腹腔镜下肾部分切除术治疗肾脏肿瘤创伤小,恢复快,效果显著,值得推广。     

Renal artery pseudoaneurysm after laparoscopic partial nephrectomy for renal cell carcinoma in a solitary kidney

Abstract Renal artery pseudoaneurysms are a well‐documented complication following trauma or percutaneous urological procedures, but are rare after partial nephrectomy. We present the case of a 34‐year‐old woman who, after undergoing a left nephrectomy in childhood due to Wilms’ tumor, had a pseudoaneurysm in a solitary kidney after laparoscopic right partial nephrectomy with extraperitoneal approach for a renal cell carcinoma. The segmental renal artery feeding the pseudoaneurysm was embolized with coils without significant loss of residual renal function.     

超选择性肾动脉分支阻断在腹腔镜机器人辅助肾部分切除术中的应用

肾癌在成年人恶性肿瘤发病率中约占3%,峰值发病率在60~70岁。肾部分切除术(partial nephrectomy,PN)近年已成为治疗局限性肾肿瘤的金标准[1]。自1991年,Clayman完成了首例腹腔镜肾切除术以来[2],腹腔镜广泛应用于肾疾病的治疗。近年,随着科技的进步和新设备的应用,尤其是高清及3D腹腔镜、机器人的使用,使肾部分切除术向更加精准化、微创化的方向发展。     

后腹腔镜下肾部分切除术治疗肾肿瘤的疗效评价

目的 探讨后腹腔镜下肾部分切除术治疗肾肿瘤的手术方式和临床效果. 方法 2002年6月至2009年12月对113例肾癌患者行后腹腔镜下肾部分切除术.患者平均年龄52(26～73)岁.肿瘤位于左肾51例,右肾62例.肿瘤直径平均3.7(1.2～6.3)cm.临床分期T1a 98例,T1b15例.腔镜下阻断肾动脉,以冷刀切开肾实质完整切除肿瘤.行肾楔形切除84例,肾极切除22例,半肾切除7例.腔镜下重建肾盂肾盏,2-0可吸收线间断或连续缝合关闭肾实质.开放肾动脉后取出标本.术后卧床10～14 d. 结果 113例手术均顺利完成,无中转开放及腹腔脏器损伤病例.平均手术时间85(60～125)min,平均热缺血时间24(19～43)min,术中平均出血150(50～350)ml,无术中输血患者.术后病理确诊肾透明细胞癌87例、乳头状肾细胞癌9例、嫌色细胞癌7例、肾血管周细胞瘤6例、嗜酸细胞瘤4例,肿瘤切缘均阴性.术后未出现尿漏,发生肉眼血尿2例,其中行肾切除术1例、血尿自行消失1例.随访3～41个月,未见肿瘤局部复发.结论 后腹腔镜下肾部分切除术治疗肾肿瘤安全有效,手术创伤小,有可能替代开放手术.     

腹腔镜下不阻断与全部阻断肾动脉肾部分切除术比较的Meta分析

目的比较腹腔镜下不阻断肾动脉肾部分切除术与全部阻断肾动脉肾部分切除术的安全性和疗效,并为肾部分切除术的手术方式选择提供理论依据。 方法通过检索PubMed,Embase,Chochranelibrary,Web of Scince,CNKI和万方等数据库,搜索腹腔镜下不阻断肾动脉肾部分切除术与全部阻断肾动脉肾部分切除术疗效比较的临床对照研究文献,检索时限均从建库至2017年10月31日。按照纳入和排除标准,筛查文献并质量评价和数据提取,并进行Meta分析。 结果共13篇临床对照研究,共涉及肾部分切除术患者1 423例,其中不阻断肾动脉行肾部分切除术557例（不阻断组）,肾动脉全部阻断行肾部分切除术866例（完全阻断组）。Meta分析结果显示：完全不阻断组与全部阻断组在肿瘤大小（P=0.03）、总并发症发生率（P=0.02）、术中失血量（P=0.001）方面差异有统计学意义,不阻断组肿瘤大小,总并发症发生率小于全部阻断组,不阻断组术中失血量多于全部阻断组;在手术时间（P=0.43）、术后住院时间（P=0.28）、切缘阳性率（P=0.56）、尿漏（P=0.27）、输血（P=0.92）等方面差异无统计学意义,而术后远期肾功能变化上差异有统计学意义（P=0.04）,不阻断组肾功能丢失小。 结论腹腔镜不阻断肾动脉肾部分切除术具有与肾动脉完全阻断术一样的安全性,而且在保护远期肾功能上具有优势。     

选择性肾动脉阻断与全阻断行后腹腔镜肾部分切除术的对照研究

目的:对比分析选择性肾动脉阻断及肾动脉全阻断后腹腔镜肾部分切除术(retroperitoneal laparoscopic partial ne-phrectomy,RLPN)治疗肾癌的有效性及安全性。方法:回顾分析2008年1月至2011年5月79例患者行RLPN的临床资料(肿瘤直径≤4 cm)。79例患者分为选择性肾动脉阻断组(42例)和肾动脉全阻断组(37例),对比两组患者肾动脉阻断时间、手术时间、术中出血量、术中输血率、术后并发症、住院时间及生存随访情况等。结果:两组肾动脉阻断时间、手术时间差异有统计学意义(P<0.05);术后住院时间、术中出血量和术中输血率差异无统计学意义(P>0.05);术后并发症发生率分别为2.4%(1/42)及2.7%(1/37),两组差异无统计学意义(P>0.05)。术后随访6～48个月,无一例复发或转移。结论:对于较小的肾癌,选择性肾动脉阻断术的动脉阻断时间可适当延长,虽然手术时间延长,但出血量未明显增加,利于保护正常区域肾单位,术后肾功能恢复更好。     

Transperitoneal laparoscopic partial nephrectomy in the renal tumor treatment

Laparoscopic surgery is a surgical technique the urologist should add to his surgical armamentarium. Its performance tries to mimic the surgical phases of open surgery, and also its indications. Laparoscopic partial nephrectomy is a sophisticated technique that requires wide experience in the performance of endoscopic strategies. We are submitting our experience with 35 laparoscopic partial transperitoneal nephrectomies with a mean follow-up of 25 months. The mean surgical time was 200 minutes, the mean bleeding 190 cc, and the mean hospitalisation five days. Two postoperative bleedings were identified, there were no conversions, and positive margins were notified in two cases, where upon a conservative attitude was adopted.     

Hand assisted laparoscopic radical nephrectomy for renal carcinoma using a new abdominal wall sealing device

PURPOSE: We report our initial experience with a hand assisted laparoscopic radical nephrectomy for patients with renal carcinoma, and compare our results to those of conventional open radical nephrectomy. MATERIALS AND METHODS: The clinical data on 6 consecutive patients who underwent hand assisted laparoscopic radical nephrectomy for stage T1N0M0 renal cell carcinoma were reviewed. We performed hand assisted laparoscopic surgery using the new LAP DISC* abdominal wall sealing device. We compared the results of this procedure with those of conventional open radical nephrectomy in 12 patients with stage T1N0M0 renal cell carcinoma. RESULTS: The hand assisted laparoscopic radical nephrectomy for renal carcinoma was successfully performed without any major or minor complications in all 6 patients. Mean operation time for the laparoscopic group was significantly longer than that for the open surgery group (303 minutes versus 224 minutes, p = 0.0042). However, no significant difference was observed in mean estimated blood loss for the 2 groups (264 ml. in the laparoscopic group versus 341 ml. in the open surgery group). The frequency of parenteral analgesia postoperatively in the laparoscopic group was significantly lower than that in the open surgery group (16.7% versus 75.0%, p = 0.043). In addition, the laparoscopic group seemed to recover more rapidly than the open surgery group. The abdominal wall sealing device was easy to attach to the abdominal wall, and allowed rapid hand removal and reinsertion. CONCLUSIONS: Our preliminary results indicate that a hand assisted laparoscopic radical nephrectomy with the abdominal wall sealing device is an effective and safe surgical procedure, and is less invasive than open radical nephrectomy.     

Laparoscopic partial nephrectomy with segmental renal artery clamping: technique and clinical outcomes

Background

Warm ischemic injury is one of the most important factors affecting renal function in partial nephrectomy (PN). The technique of segmental renal artery clamping emerges as an alternative to conventional renal artery clamping for renal hilar control.

Objective

To evaluate the feasibility and efficiency of laparoscopic PN (LPN) with segmental renal artery clamping in comparison with the conventional technique.

Design, setting, and participants

A total of 75 patients underwent LPN from June 2007 to November 2009. All patients had T1a or T1b tumor in one kidney and a normal contralateral kidney. Thirty-seven patients underwent surgeries with main renal artery clamping, and 38 underwent surgeries with segmental artery clamping.

Intervention

All procedures were performed by the same laparoscopic surgeon.

Measurements

Blood loss, operation time, warm ischemia (WI) time, and complications affected renal function before and after operation were recorded.

Results and limitations

All LPNs were completed without conversion to open surgery or nephrectomy. The novel technique slightly increased WI time (p < 0.001) and intraoperative blood loss (p = 0.006), while it provided better postoperative affected renal function (p < 0.001) compared with the conventional technique. The total complication rate was 12%. Among the 38 cases where segmental renal artery clamping was performed, 7 had to convert to the conventional method. Tumor size and location influenced the number of clamped segmental arteries. Long-term postoperative renal function is still awaited.

Conclusions

LPN with segmental artery clamping is safe and feasible in clinical practice. It minimizes the intraoperative WI injury and improves early postoperative affected renal function compared with main renal artery clamping.     

Prospective study of robotic partial nephrectomy for renal cancer in Japan: Comparison with a historical control undergoing laparoscopic partial nephrectomy

Objectives

To evaluate the outcomes of robotic partial nephrectomy compared with those of laparoscopic partial nephrectomy for T1 renal tumors in Japanese centers.

Methods

Patients with a T1 renal tumor who underwent robotic partial nephrectomy were eligible for inclusion in the present study. The primary end‐point consisted of three components: a negative surgical margin, no conversion to open or laparoscopic surgery and a warm ischemia time ≤25 min. We compared data from these patients with the data from a retrospective study of laparoscopic partial nephrectomy carried out in Japan.

Results

A total of 108 patients were registered in the present study; 105 underwent robotic partial nephrectomy. The proportion of patients who met the primary end‐point was 91.3% (95% confidence interval 84.1–95.9%), which was significantly higher than 23.3% in the historical data. Major complications were seen in 19 patients (18.1%). The mean change in the estimated glomerular filtration rate in the operated kidney, 180 days postoperatively, was ?10.8 mL/min/1.73 m² (95% confidence interval ?12.3–9.4%).

Conclusions

Robotic partial nephrectomy for patients with a T1 renal tumor is a safe, feasible and more effective operative method compared with laparoscopic partial nephrectomy. It can be anticipated that robotic partial nephrectomy will become more widely used in Japan in the future.