Sequential bilateral minimum incision endoscopic radical nephrectomy in dialysis patients with bilateral renal cell carcinomas

Since 1998, we have performed minimum incision endoscopic surgery (MIES) for renal cell carcinoma (RCC). For seven dialysis patients with bilateral RCC, we have performed sequential bilateral MIES radical nephrectomy. It was carried out by retroperitoneal approach through a single minimum incision that narrowly permitted extraction of the specimen using endoscopy and direct stereovision, without trocar ports, without gas insufflation and without the insertion of the hands of operators into the operative field. Although six of the seven patients had multiple complications in addition to chronic renal failure (CRF), bilateral kidneys were successfully removed by sequential MIES radical nephrectomy without major operative complication. Postoperative recovery was prompt with all patients resuming oral feeding and walking by the second postoperative day. Sequential bilateral MIES radical nephrectomy, leaving the peritoneal cavity intact and without imposing circulatory stress caused by gas insufflation, is a feasible treatment for bilateral RCCs in dialysis patients.     

Portless endoscopic radical nephrectomy via a single minimum incision in 80 patients

AIM: To assess the feasibility of our portless endoscopic radical nephrectomy via a single minimum incision, which narrowly permitted extraction of the specimen in the initial 80 patients. METHODS: Radical nephrectomy was carried out extraperitoneally in patients with T1-3aN0M0 renal tumors using an endoscope through a single minimum incision without trocar ports and gas. All the instruments used were reusable. RESULTS: The average length of incision, operative time and estimated blood loss were 6.6 cm (range, 4-9 cm), 3. 1 h (range, 1.7-5.6 h) and 324 mL (range, 10-2288 mL), respectively. The complication rate was 2.5% (2/80); complications included injury of the pleura and hemorrhage from the vena cava, both of which were repaired by suture during operation. Transfusion was performed in three patients (3.8%). Average times to oral feeding and walking were both 1.4 days. Wound pain was minimal and analgesics were generally not required by the second postoperative day. In patients with larger incisions (7 cm or more), estimated blood loss increased (approximately 100 mL on average) and oral feeding resumed later (0.3 days on average), relative to patients with smaller incisions (6 cm or less). However, overall results were similar between the two patient groups. In patients with a large tumor (7 cm or greater), operative time did not increase and complications and transfusions were both avoided. CONCLUSION: Portless endoscopic radical nephrectomy via a single minimum incision is a safe, reproducible, cost-effective and minimally invasive treatment option for patients with T1-3aN0M0 renal tumors.     

Oncological outcome of minimum incision endoscopic radical nephrectomy for pathologically organ confined renal cell carcinoma

Objective:   To date, follow-up after minimum incision endoscopic radical nephrectomy (MIES radical nephrectomy) for renal cell carcinoma (RCC) has not been reported. Minimum incision indicates an incision that narrowly permits the extraction of the specimen. To evaluate the oncological outcome of the patients with pathologically organ confined (pT1-2N0M0) RCC treated with this operation, the results in those patients were analyzed.
Methods:   From 1998 to 2006, 154 consecutive patients underwent MIES radical nephrectomy under diagnosis of clinical T1-2N0M0 RCC in our hospital. Of the patients, 127 patients with pathologically confirmed organ confined (pT1-2N0M0) RCC constituted the current study population. Overall, the recurrence-free and cancer-specific survival rates of the patients treated with MIES radical nephrectomy were calculated using the Kaplan-Meier method and compared with those of the patients treated with open radical nephrectomy using the log rank test.
Results:   The median follow-up period was 34 months (range: 3–98 months). Of the 127 pT1-2N0M0 patients treated with MIES radical nephrectomy, the disease recurred in nine patients and four patients died of the cancer during follow-up. The five-year overall, recurrence-free and cancer-specific survival rates were 95.0%, 90.8% and 95.8%, respectively. Overall, the recurrence-free and cancer-specific survival rates were not different from those of patients treated with open radical nephrectomy.
Conclusion:   MIES radical nephrectomy has the validity in adequate cancer control and is one of the recommendable options as a minimally invasive surgery for patients with organ confined RCC.     

后腹腔镜术切除无功能积水肾的疗效观察

目的：探讨后腹腔镜下切除无功能积水肾的可行性和安全性及规避手术风险的方法。方法：对62例积水无功能肾患者行后腹腔镜积水无功能肾切除术。术前常规行肾脏CT平扫及增强检奄。利用PACS系统仔细阅片,了解肾动脉分支及走向。然后建立腹膜后腔隙,参照解剖标志充分显露。肾蒂血管,用Hem-o—lok夹闭肾蒂血管后切断,分离切除患肾,留置腹膜后引流管,并统计手术时间、术中m血量和术中术后并发症,观察手术效果。结果：62例患者手术均获得成功,手术时间为50～180min,平均为130min。术中出血10～100m1．平均37ml。术中损伤腹膜3例,胸膜1例,未发现血管损伤、腹腔脏器损伤等并发症。引流管于术后2～3天拔除,术后住院5～10天,平均6．5天。结论：后腹腔镜下积水无功能肾切除术安全可行,术中通过辨认解剖标志结扎肾蒂血管和沿正确的平面游离患肾是手术成功的关键。     

Gasless single-port access endoscopic surgery in urology: Minimum incision endoscopic surgery, MIES

Minimum incision endoscopic surgery (MIES) is a gasless, single-port access, cost-effective, and minimally invasive surgery that has been in development since the late 1990s. Use of MIES has steadily increased in Japan and Asia and has been introduced into Europe and the USA. In 2006, MIES was certified by the Japanese government as an advanced surgery and since 2008 it has been covered by the Japanese universal health insurance system as a new surgical technique. Briefly, MIES involves an initial minimum incision (a single port) that permits extraction of the target specimen. A wide working space through the port is then made by separating the anatomical plane extraperitoneally. This is maintained with special retractors instead of gas insufflation. All instruments including an endoscope are inserted through the port and the operation is completed. The size of the port can be tailored to the situation if necessary, which contributes to preclusion of patient selection. The procedure uses only two disposable devices that are inexpensive, resulting in low equipment costs. Surgeons have the benefits of magnified vision through endoscopy as well as stereovision and panoramic vision of naked eyes through the port, which reduces the technical demands of the procedure. Techniques for two basic MIES procedures allow MIES to be performed for most urological organs and in extraordinary cases by their modifications. Thus, the MIES system permits minimally invasive surgery without use of CO₂ gas, which is ideal from medical, environmental and economic perspectives, is cost-effective and minimizes patient selection.     

腹腔镜在巨大肾积水保肾手术中的应用

目的 探讨腹腔镜在巨大肾积水保肾手术中的应用价值和初步临床经验.方法 本组6例.男2例,女4例.年龄15～57岁,平均28岁.5例因腰部胀痛不适及腹部肿块就诊,1例妊娠4个月者于体检B超发现.其中先天性肾盂输尿管连接部（UPJ）梗阻3例,UPJ梗阻继发肾下盏多发结石2例,肾盂结石伴息肉形成1例.6例均合并巨大肾积水,左侧4例,右侧2例;肾积水量2250～8300 ml,IVU均不显影.采用经腹腔途径腹腔镜施行解除肾盂出口梗阻、肾盂成形、肾裁剪及肾折叠固定术.结果 6例手术均获成功,手术时间2.5～5.0 h,出血量50～150 ml,术后平均住院时间7.2 d.术后3个月复查腹部B超：肾积水明显减轻者5例,肾窦分离为1.8、2.0、2.5、2.5、2.8cm,肾脏外形较正常略小者1例.术后3个月行IVU检查均出现不同程度显影.随访3个月～2年,逆行肾盂造影未发现肾盂输尿管吻合口明显狭窄.结论 巨大肾积水保肾治疗采用腹腔镜技术有效、可行.     

Laparoscopic nephrectomy for a girl with giant hydronephrosis of a horseshoe kidney

We report our experience of laparoscopic nephrectomy on a girl with giant hydronephrosis of a horseshoe kidney. An 8-year-old girl presented with a 4-month history of right abdominal pain. We performed laparoscopic nephrectomy for the non-functioning moiety of a horseshoe kidney secondary to uretero-pelvic junction obstruction. Laparoscopic nephrectomy is a feasible and safe method with good indications especially for children with a horseshoe kidney disease.     

Mini incision live donor nephrectomy: an optimal approach for the developing countries

OBJECTIVE: Laparoscopic donor nephrectomy (LD) is rapidly gaining popularity, however, this may not be affordable by donors in many developing countries because of its high cost. We describe our mini flank incision (MD) donor nephrectomy technique and its outcome. METHODS: A 7-10-cm subcostal rib sparing transverse incision was given 2 cm lateral to the tip of the 12th rib, towards the lateral border of rectus muscle. All dissections were performed with help of long retractors and instruments, vessels were transfixed and cut. In last 45 cases, vessels were clipped with Liga or Weck clips. Donors and recipients outcome was analysed. RESULT: From January 2000 to December 2002 a total of 148 patients underwent donor nephrectomy by mini incision technique. Mean patient age was 44.8 +/- 7.3 yr (range 20-70 yr). Nephrectomies were performed in 115 patients on the left side and in 33 cases on the right side. The mean incision length was 9.1 +/- 1.8 cm (range 7-10 cm). Mean operative time was 105 +/- 10.5 min (70-130 min). Mean analgesic (Tramadol) requirement was 205 +/- 52 mg; postoperative hospital stay was 2.2 +/- 0.5 d. Twelve per cent patients developed fever and 4% had superficial wound infection in postoperative period. Three patients required blood transfusion. Mean convalescence period was 22 +/- 2.8 d. CONCLUSION: Extrapleural, extraperitoneal, subcostal mini incisions live donor nephrectomy is a relatively safe procedure with low morbidity. This technique has a shorter hospital stay, early convalescence and better cosmesis. It is cost-effective and is an ideal substitute for the developing country.     

后腹腔镜肾切除的临床研究

目的通过与开放性肾切除比较,评估后腹腔镜肾切除的临床应用价值。方法从2003年2月至2006年10月,我科行后腹腔镜肾切除26例,其中巨大肾积水12例,肾性高血压8例（5例先天性肾发育不良、3例外伤性肾萎缩）,肾盂肿瘤6例。同期开放手术36例,其中巨大肾积水22例,肾性高血压7例,肾盂肿瘤7例。记录腹腔镜组及开放组的手术时间、术中失血量、术后恢复时间、住院时间及术后应用止痛剂次数。结果腹腔镜手术组除1例因出血改为开放外,其余均顺利完成肾切除,开放手术亦均顺利完成。与开放手术相比,后腹腔镜肾切除除手术时间长外,术中出血量、术后应用止痛剂次数、术后恢复时间和住院时间均显著优于开放手术组。结论巨大肾积水致肾功丧失及肾性高血压需肾切除者应首选腹腔镜肾切除,特别是后腹腔镜手术,其可避免腹腔内并发症。对于小的肾盂肿瘤,应首先考虑腹腔镜肾切除,其可避免腰部切口,减少相应并发症。与开放手术相比,后腹腔镜肾切除具有创伤小、恢复快、出血少等优点,具有一定的临床应用价值。     

腹腔镜肾切除术治疗巨大肾积水5例报告

目的：介绍腹腔镜肾切除术治疗巨大肾积水的临床经验.方法：2005年1月～2009年2月采用腹腔镜经后腹腔途径行肾切除术治疗巨大肾积水患者5例,男2例,女3例,平均年龄39（18～57）岁.5例均为肾盂输尿管连接部狭窄,其中左侧3例,右侧2例.观察手术时间、术中出血量,住院天数、并发症及手术效果.结果：5例均成功施行腹腔镜肾切除术,平均肾积水量4 500（3 000～11 000）ml,平均手术时间85（60～115）min,术中平均出血量45（10～80）ml.其中1例术前放置输尿管支架管引流尿液并控制感染,4例术中需切开肾皮质吸出部分或全部积水,以降低肾张力.结论：巨大肾积水行腹腔镜肾切除术安全、可行,通过放置输尿管支架管或切开肾皮质放出部分或全部积水对患肾减压有助于手术操作.     

腹股沟斜切口在后腹腔镜活体供肾切取术中的临床应用分析

研究腹股沟斜切口在后腹腔镜活体供肾切取术中应用的安全性和有效性。方法回顾性分析2008年5月至2012年3月在烟台毓璜顶医院泌尿外科行后腹腔镜活体供肾切取术的76例供者临床资料,根据供肾取出切口的不同将其分为两组,腹股沟切口组40例供者和腰部切口组36例供者分别采用腹股沟斜切口和腰部切口取出供肾。比较两组供者手术时间、术中出血量、供肾血管长度、住院时间、术后切口并发症发生情况和切口美容满意度。结果腹股沟切口组40例供者手术均成功;腰部切口组33例供者手术成功,3例因肾粘连和肾周脂肪组织较多改开放手术;两组均未发生死亡和严重并发症。两组手术时间和术中出血量差异均无统计学意义（P均＞0.01）。腹股沟切口组供肾热缺血时间为（1．6±1．2）min,短于腰部切口组,差异有统计学意义（t＝5．18,P＜0．01）。腹股沟切口组左、右侧供肾动脉血管长度分别为（2．6±0.4）cm和（3．7±0．3） cm,均长于腰部切口组;腹股沟切口组左、右侧供肾静脉血管长度分别为（3．50±0．40）cm和（1．70±0．23）cm,均长于腰部切口组,差异均有统计学意义（t＝4．75,7．32,76．3,6．45,P均＜0.01）。腹股沟切口组术后需接受镇痛治疗和腰腹部外观不对称的供者比例均低于腰部切口组,切口美容满意度高于腰部切口组,差异有统计学意义（χ2＝12．52,7．41,32.53,P均＜0．01）;腹股沟切口组无供者发生切口膨出,腰部切口组有6例供者发生切口膨出,两组比较差异有统计学意义（P＝0．009）。腹股沟切口组住院时间明显短于腰部切口组（t＝3.42,P＜0．01）。结论采用腹股沟斜切口的后腹腔镜活体供肾切取术能够提高手术安全性,保证最佳供肾血管长度,明显缩短供肾热缺血时间,减少切口并发症,提高供者切口美容满意度,值得临床推广。     

Mini-flank supra-11th rib incision for open partial or radical nephrectomy

OBJECTIVE: To report our approach to partial (PN) or radical nephrectomy (RN) using a supra-11th mini-flank incision, as the widespread availability of advanced imaging has increased the detection of incidental, lower-stage renal tumours that are generally amenable to resection using smaller incisions. PATIENTS AND METHODS: The study included 167 consecutive patients undergoing PN/RN for renal tumours treated between February 2000 and March 2003 using the supra-11th rib mini-flank approach. Variables analysed were age, gender, nephrectomy type (PN vs RN), operative duration, estimated blood loss (EBL), hospital stay, tumour size and location, pathological stage and histology, perioperative transfusions, and complications. Patients undergoing PN were examined for ischaemia type (cold, warm, none) and duration of renal artery clamping. The interval after surgery to initiate solid diet and discontinue patient-controlled analgesia, and overall pain control, were analysed and compared between PN and RN. RESULTS: In all, 133 patients (80%) underwent PN and 34 (20%) RN, at a median age of 61.7 years. The median operative duration was 2.9 h, the EBL 400 mL, tumour size 3.2 cm and median hospital stay 5 days. At a median follow-up of 18.2 months, there were seven (4%) late complications: six patients had a flank bulge and one had a reducible hernia. Surgical margins were negative in 164 (98%) patients. CONCLUSIONS: The supra-11th rib mini-flank incision offers a practical alternative to traditional open or laparoscopic PN or RN. Using a small (8 cm) incision with no rib resection, this approach affords optimum exposure without compromising cancer control, with excellent cosmetic results and a lower risk of late complications at the wound site.     

Portless endoscopic adrenalectomy via a single minimal incision using a retroperitoneal approach: Experience with initial 30 cases

AIM: To assess the feasibility of portless endoscopic adrenalectomy via a single minimum incision that narrowly permits extraction of the specimen. METHODS: For 30 cases of adrenal tumor, portless endoscopic surgery through a single flank incision (3-9 cm; mean, 5.6 cm) was performed without gas inflation or trocar port placement. All of the instruments used during surgery were reusable. The cases included primary aldosteronism (12), Cushing's syndrome (6), preclinical Cushing's syndrome (3), pheochromocytoma (1), non-functioning cortical adenoma (6), adrenocortical carcinoma (1) and adrenocortical hemorrhage (1). RESULTS: Resection of the tumor was successfully completed, without complications, in all of the cases. Operative time was between 83 and 240 min (mean, 147 min). Estimated blood loss was 5-470 mL (mean, 139 mL). None of the patients required blood transfusion. Postoperative course was uneventful. Wound pain was mild and walking and full oral feeding were resumed on the first and second postoperative day, respectively, in the majority of cases. CONCLUSIONS: Adrenal tumors are good candidates for portless endoscopic surgery, which is safe, cost-effective, minimally invasive and matches favorably with laparoscopic surgery.     

术前护理干预对腹壁巨大切口疝术后恢复

［摘要］目的 探讨对腹壁巨大切口疝手术患者系统的护理干预,总结经验。方法 回顾分析和了解2015年10月~2016年10月我院行腹壁巨大切口疝修补术的16例患者进行全面系统性的护理干预,内容包括术前健康宣教、呼吸功能干预、腹壁顺应性干预,皮肤和肠道的准备等;记录术前、手术、术后时间,观察术后心率、血氧饱和度、腹内压的变化。结果 接受手术15例患者术前准备时间19.09±4.06天,手术时间161±39min,术后住院时间11.2±3.7天,随访2~12月,无复发。结论 全面、系统的术前干预可以取得患者的充分信任与配合,较好的完成各项术前准备工作,降低术后并发症的发生。     

Kidney folding: the Y-plasty--a means of creating a dependent ureteropelvic junction in the child with giant hydronephrosis

PURPOSE: Occasionally, in the presence of severe dilatation and parenchymal thinning, postoperative obstruction or stasis may secondarily occur even after creation of a funneled ureteropelvic junction. Preferential filling of a severely dilated lower pole may kink or distort the ureteropelvic junction, causing this problem. MATERIALS AND METHODS: A requirement for renal folding is a large hydronephrotic kidney with severe mid renal parenchymal thinning. After pyeloplasty if it is apparent that secondary obstruction is a possibility, and simple lateral or posterior fixation of the lower pole to retroperitoneal fascia will not resolve the problem, the lower pole can be brought superiorly adjacent to the upper pole and fixed in position with 2 or 3, 2-zero or 3-zero polyglactin sutures, creating a "Y" configuration with the ureteropelvic junction dependent from all calices. We reviewed the records of 5 children who underwent this procedure. RESULTS: Five patients with severe upper tract dilatation were treated successfully. Four underwent primary pyeloplasty with concomitant renal folding, and 1 had persistent hydronephrosis with recurrent pyonephrosis before undergoing this procedure secondarily. All patients achieved excellent results with normal drainage postoperatively. CONCLUSIONS: Renal folding is a simple surgical maneuver that can be applied easily and successfully when the situation warrants. It allows creation of a dependent, funneled ureteropelvic junction in the presence of giant hydronephrosis.     

后腹腔镜切除积水无功能肾17例

目的探讨后腹腔镜积水无功能肾切除术的手术方法和效果。方法对17例积水无功能肾患者行后腹腔镜积水无功能肾切除术。腰部3个Trocar穿刺入路,手指法建立后腹膜气腹,游离出部分病变肾脏后先将肾脏切开一小口,吸净积水肾内的积水,然后再游离肾脏,用钛夹或Hem-o-lok夹闭肾蒂血管后切断,切除患肾,留置腹膜后引流管。统计手术时间、术中出血量和术中、术后并发症及观察手术效果。结果17例手术均获得成功,手术时间为150．300min,平均为170min。术中出血10-80ml,平均30ml。引流管于术后2-3d拔除,无大出血、感染、腹膜破裂、腹腔脏器损伤等并发症。结论后腹腔镜积水无功能肾切除术是一种微创、安全、有效、恢复快的术式。