腹腔镜肾部分切除术中肾低温保护现状

腹腔镜肾部分切除术目前已得到广泛的开展，其技术难题是肾脏创面止血及对肾实质和集合系统的修补，阻断肾蒂有助于术中止血及修补。肾实质和集合系统，但可能引起肾缺血损伤，而术中低温技术可将肾缺血损伤降到最低。本综述简要总结了目前报道的三种腹腔镜肾切除术中肾低温技术的特点，并期待有更简单易行且效果确切的腹腔镜肾低温保护技术，以促进腹腔镜肾部分切除术的进一步发展和普及。     

腹腔镜肾部分切除术

目的:探讨腹腔镜肾部分切除术临床应用的可行性。方法:为1例重复肾畸形患者行腹腔镜肾部分切除术。结果:手术顺利,无并发症,术后7d出院,恢复良好。结论:腹腔镜肾部分切除术具有患者创伤小,出血少,解剖清晰,康复快,并发症少等优点。     

腹腔镜下肾部分切除术

腹腔镜下肾部分切除术由于具有创伤小、恢复快的优点，其在临床应用的研究进展越来越受关注，如该项术式的适应症、术前淮备、术中难点、手术途径及并发症等。     

腹腔镜下肾部分切除术

腹腔镜下肾部分切除术由于具有创伤小、恢复快的优点 ,其在临床应用的研究进展越来越受关注 ,如该项术式的适应症、术前准备、术中难点、手术途径及并发症等。     

腹腔镜肾部分切除术的研究进展

腹腔镜肾部分切除术是一种微创、有效且能适当保留患肾功能单位的手术,随着腹腔镜技术、肾脏缺血阻断及止血技术的发展,这项手术日益安全可靠,本文就腹腔镜肾部分切除手术的研究进展作一综述。     

后腹腔镜下肾部分切除术的临床分析

目的 评价腹膜后腹腔镜肾部分切除术的可行性及临床价值.方法 39例肾占位患者行后腹腔镜肾部分切除术,肿瘤直径2.5 ～4.6cm,平均3.8cm.手术时,所有的患者都行肾蒂血管阻断.评价手术时间、肾蒂阻断时间、出血量、并发症及肿瘤复发情况.结果 38例手术顺利完成,1例中转开放,阻断肾蒂时间为21～ 36min,平均26min,手术时间70～145min,平均102min,术中出血60 ～ 900ml,平均105 ml.术后病理为32例肾癌,7例错构瘤.术后并发尿漏1例,放置双J管治愈.术后住院7 ～15d,平均l0d,随访3 ～36个月无肿瘤复发.结论 腹膜后腹腔镜肾部分切除术患者创伤小,术后康复快,值得临床推广.有可能代替开放手术,可能成为治疗肾脏局限性占位病变的首选治疗方法.     

后腹腔镜肾动脉高选择性阻断与全阻断肾部分切除术疗效比较

目的:比较分析后腹腔镜下高选择性肾动脉阻断与肾动脉全阻断治疗T1a期肾透明细胞癌(4cm)的临床疗效。方法:回顾性分析我院2011年1月~2013年10月55例T1a期肾透明细胞癌(4cm)患者行后腹腔镜肾部分切除术(RLPN)的临床资料。根据术式分为高选择性肾动脉阻断组27例和肾动脉全阻断组患者28例,通过比较两组患者肾动脉阻断时间、手术时间、术中出血量、术后肾功能(术后24小时肌酐)、术后并发症、住院时间及生存随访情况等,研究分析两组手术方式的临床疗效。结果:两组肾动脉阻断时间、术中出血量、住院时间差异有统计学意义(P0.05);两组手术时间、术后肾功能(术后24小时肌酐)、术后并发症及生存随访情况的差异均无统计学意义(P0.05)。结论:后腹腔镜肾动脉高选择性阻断肾部分切除术患者较肾动脉全阻断肾部分切除术患者具有肾动脉阻断时限宽、术中出血量少、术后肾功能影响小及术后恢复快等优点,后腹腔镜肾动脉高选择性阻断肾部分切除术治疗肾透明细胞癌是一种可行有效的治疗方案。     

CO_2气腹预处理对模拟腹腔镜肾部分切除术环境下大鼠肾缺血再灌注损伤的影响

目的:探讨在模拟腹腔镜肾部分切除术(laparoscopic partial nephrectomy,LPN)环境下不同CO2气腹压力对大鼠肾缺血再灌注损伤的影响。方法:模拟LPN建立操作模型,将40只雄性Wistar大鼠平均分为4组:无气腹预处理组(NPre组),低压气腹预处理组(LPre组),中压气腹预处理组(MPre组)和高压气腹预处理组(HPre组),气腹预处理压力分别为0、5、10和15mmHg。气腹预处理方式为供气10min、放气10min,在10min放气阶段行开腹、暴露肾蒂血管等操作;随后夹闭左肾蒂血管并关腹,给予10mmHg的持续供气。术中各组大鼠完全阻断左肾血供45min,于再灌注24h时间节点切取左肾,比较各组大鼠肾小管损伤评分及氧化损伤指标超氧化物歧化酶(SOD)、谷胱甘肽过氧化物酶(GSH-PX)、总抗氧化能力(T-AOC)和丙二醛(MDA)的变化。结果:NPre组大鼠肾脏出现严重的缺血再灌注损伤,与LPre组的损伤程度差异无统计学意义(P0.05),而MPre组和HPre组的损伤程度明显减轻(P0.05);MPre组和HPre组大鼠肾脏损伤程度差异无统计学意义(P0.05)。结论:经过45min的血流阻断,大鼠肾组织出现了严重的缺血再灌注损伤;低压气腹预处理不能减轻损伤,中压和高压气腹预处理则可显著提高肾组织对缺血的耐受性。气腹预处理可作为LPN术中减轻肾缺血再灌注损伤的有效方法。     

腹膜后腹腔镜与开放性分支肾动脉阻断肾部分切除术治疗肾肿瘤的疗效比较

<正>肾肿瘤是泌尿系常见疾病,其发病率及死亡率在全身肿瘤中约占2%。随着腹腔镜技术的迅速发展,腹膜后腹腔镜肾部分切除术得到广泛应用,与根治性肾切除术远期疗效相近,并可保留部分肾单位,因此腹膜后腹腔镜肾部分切除术成为T1a期肾癌的常用术式[1-2]。以往肾部分切除术需阻断肾动脉主干,热缺血时间控制在30 min内,手术操作具有一     

Laparoscopic partial nephrectomy in cold ischemia: renal artery perfusion

PURPOSE: Laparoscopic partial nephrectomy represents a feasible option for patients with small renal masses. We describe our initial experience with laparoscopic partial nephrectomy in cold ischemia achieved by renal artery perfusion. MATERIALS AND METHODS: From November 2001 to March 2003 laparoscopic partial nephrectomy in cold ischemia was performed in 15 patients with renal cell carcinoma. Cold ischemia was achieved by continuous perfusion of Ringers lactate at 4C through the renal artery, which was clamped. Tumor excision was performed in a bloodless field with biopsy taken from the tumor bed. The collecting system was repaired if needed. Renal reconstruction was performed by suturing over hemostatic bolsters. RESULTS: All procedures were successfully completed laparoscopically by our new technique. Mean operative time was 185 minutes (range 135 to 220). Mean ischemia time was 40 minutes (range 27 to 101). Estimated mean intraoperative blood loss was 160 ml (range 30 to 650). Entry to the collecting system in 6 patients was repaired intraoperatively. Additional vascular repair was done in 2 patients. There were no significant postoperative complications. Postoperative followup in 8 patients showed that the renal parenchyma was not damaged by the ischemic period. CONCLUSIONS: Our initial experience of incorporating cold ischemia via arterial perfusion into laparoscopic partial nephrectomy shows the feasibility and safety of the technique. We believe that this approach has the potential to make laparoscopic partial nephrectomy for renal cell carcinoma safe and reliable.     

Conservative management of renal artery pseudoaneurysm following partial nephrectomy

A bleeding renal artery pseudoaneurysm is a recognised complication occurring after partial nephrectomy. The bleeding is usually suspected when a patient presents with haematuria following the procedure and the reported management is with radiologically guided embolisation. We report a case of renal artery pseudoaneurysm successfully managed conservatively, giving another potential management option in non-torrential haemorrhage.     

Laparoscopic partial nephrectomy versus laparoscopic cryoablation for multiple ipsilateral renal tumors

BACKGROUND: Management of multiple ipsilateral renal tumors is a dilemma in clinical practice. The effects of minimally invasive nephron-sparing procedures in this group of patients have not been assessed. OBJECTIVE: To evaluate the technical feasibility and outcomes of laparoscopic partial nephrectomy (LPN) and laparoscopic cryoablation (LCA) for multiple ipsilateral renal tumors. DESIGN, SETTING, AND PARTICIPANTS: Between September 1999 and December 2006, 27 patients were treated with minimally invasive nephron sparing surgery (LPN or LCA) for synchronous multiple ipsilateral renal tumors in a single operating session at our institution. Fourteen patients with 28 tumors underwent LPN, and 13 patients with 31 tumors underwent LCA as the sole treatment modality. INTERVENTION: Medical records were retrospectively reviewed and data were collected. MEASUREMENTS: Demographic, intraoperative, postoperative, and intermediate-term follow-up data were compared between the two groups. RESULTS AND LIMITATIONS: Patients in the LPN group had fewer tumors (2 vs. 2.4, p=0.04) and larger dominant tumor size (3.6 vs. 2.5 cm, p=0.005) in the affected kidney and lower preoperative serum creatinine levels (1 vs. 1.4 mg/dl, p=0.02). Compared to the LCA group, patients in the LPN group had greater estimated blood loss (200 vs. 125 ml, p=0.02) and longer hospital stays (90 vs. 52.3h, p=0.02). There were no open conversions, and no kidneys were lost. Complication rate, renal functional outcomes, and intermediate-term cancer-specific survival rates were similar between the two groups. CONCLUSIONS: Both LPN and LCA are viable options for patients with multiple ipsilateral renal tumors in select patients. Renal functional outcomes, complication rates, and intermediate-term survival rates are comparable between the two groups in this small series.     

常温下结扎肾血管分支肾部分切除术

为了对双肾肾肿瘤或孤立肾肾肿瘤患者在切除肿瘤时最大限度地保存其肾功能，自行设计了常温无断血法肾部分切除术。即在肾窦内分离出肾动脉的所有分枝，找出阻断血运后能使肿瘤处于缺血区域的分枝并结扎之。手术出血少，正常肾组织大部分血运不受影响。应用４例，术后都达到了预期效果，手术前后肾功能无明显改变，随访最长者已两年余，肿瘤无复发。此方法尤其适用于肿瘤位于肾脏上下极，且直径不超过３ｃｍ者。     

腹腔镜肾癌根治性切除术(附1例报告)

目的 :探讨腹腔镜肾癌根治性切除术的临床应用。方法 :为 1例 74岁的肾癌患者行手辅式腹腔镜根治性肾切除术。结果 :手术顺利完成 ,无并发症 ,术后 5d出院 ,恢复良好。结论 :腹腔镜肾癌根治性切除术具有患者创伤小 ,出血少 ,康复快 ,并发症少等优点 ,并有美观的效果     

腹腔镜肾部分切除术与根治性切除术治疗T2a期肾癌比较研究及三年随访总结

目的 比较在我院治疗的T2a期肾癌行腹腔镜肾部分切除术及腹腔镜肾癌根治性切除术的临床疗效。方法 回顾性分析2014年6月至2017年6月在伊犁州友谊医院泌尿外科经腹腔镜手术治疗的108例T_2a期肾癌的临床资料,其中行腹腔镜肾部分切除术患者56例,行腹腔镜肾癌根治术者52例。比较两种手术方式临床指标。结果 两组手术时间、术中出血量、术中输血率、术后住院期并发症发生率、术后住院时间对比差异均无统计学意义(P均>0.05);两组术后第3、6个月血肌酐相比较,差异均无统计学意义(P均>0.05),腹腔镜肾部分切除术组术后第12个月及36个月血肌酐显著低于腹腔镜肾癌根治术组,相比较差异均有统计学意义(P均<0.05)。术后随访3年,其中腹腔镜肾部分切除术组复发率为7.14%,根治术组复发率为9.62%,两组相比较差异无统计学意义(P>0.05)。结论 与腹腔镜肾癌根治术相比较,肾部分切除术在治疗T_2a期肾癌时不增加手术时间、术中出血量、住院时间及手术并发症,同时能够充分地保护肾功能,在情况允许时可作为优先选择的手术方式。     

后腹腔镜下肾切除时肾动静脉的处理

目的介绍后腹腔镜下肾切除过程中处理肾脏血管的经验. 方法 52例后腹腔镜下肾切除,全麻,健侧卧位.腰部3个trocar穿刺入路(2个10 mm,1个5 mm).自制水囊扩张器扩张后腹腔,首先分离肾动脉,尽量远离肾门,分离1～2 cm即可用直线切割器切断,肾静脉同法处理.注意肾动脉、静脉分离时沿纵轴即主干方向游离,否则易撕裂血管. 结果 52例肾动静脉分离切断过程顺利.6例肾动脉为双支动脉,1例为三支动脉.5例肾静脉为双支静脉.1例精索静脉损伤出血改为开放手术.术后无血管并发症. 结论后腹腔镜下直线切割器切断肾动静脉安全、可靠.     

Habib4X双极射频辅助无肾动脉阻断腹腔镜下肾部分切除术的临床分析

目的 探讨Habib 4X双极射频辅助无肾动脉阻断腹腔镜肾部分切除术的临床效果.方法 2010年10月至2011年6月采用Habib 4X双极射频辅助腹腔镜肾部分切除术(laparoscopic partial nephrectomy with radiofrequency ablation,LRA)和腹腔镜肾部分切除术(laparoscopic partial nephrectomy,LPN)治疗肾肿瘤(T1N0M0)患者14例,肿瘤均为外向型生长.LRA组6例,男4例,女2例;年龄38 ～75岁,平均60岁;肿瘤位于左肾3例,右肾3例;肾上极2例、中极2例、下极2例;肿瘤最大径2.1 ～3.5 cm,平均3.1 cm.LPN组8例,男4例,女4例;年龄36 ～ 77岁,平均61岁;肿瘤位于左肾3例,右肾5例;肾上极3例、中极2例、下极3例;肿瘤最大径2.0～3.7 cm,平均3.0 cm.记录手术时间、术中出血量、术后住院时间、术后并发症等指标,比较手术前后Hb、SCr、患侧肾小球滤过率(glomeruar filtration rate,GFR)的变化. 结果 14例手术均获成功,无中转开放手术者.LRA组无需阻断肾蒂,手术前后Hb、SCr、患侧GFR比较分别为(127±19)和(124±19) g/L、(96 ±39)和(92±29) μmol/L、(42±12)和(40±13) ml/min,差异均无统计学意义(P＞0.05).LPN组术中阻断肾动脉20 ～ 52 min,平均31.5 min.手术前后Hb、SCr、患侧GFR分别为(130 ±17)和(112±15) g/L,(92 ±31)和(110±28)μmol/L,(43 ±14)和(30 ±11)ml/min,差异均有统计学意义(P＜0.05).LRA组和LPN组手术时间分别为(86±20)min、(112 ±43)min,术中出血量分别为(94±18) ml、(256 ±58)ml,术后住院时间分别为(5.0±0.8)d、(7.8±1.2)d,组间比较差异均有统计学意义(P＜0.05).LRA组术后无出血、肉眼血尿和漏尿等并发症. 结论 Habib 4X双极射频辅助腹腔镜无肾动脉阻断肾部分切除术治疗肾肿瘤安全有效,在手术时间、术中出血量和术后恢复等方面均优于LPN.     

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.     

Hand-assisted laparoscopic partial nephrectomy after 60 cases: comparison with open partial nephrectomy

Background  Partial nephrectomy is the surgical standard of care for favorably located, small renal tumors. As the incidence of renal cell carcinoma (RCC) and detection of small kidney masses have increased over the past 20 years, minimally invasive management of these lesions has become more common. We report our single-institution experience with hand-assisted laparoscopic partial nephrectomy (HALPN) compared with open partial nephrectomy (OPN). Methods  Relevant outcome and demographic information was collected prospectively for HALPNs (N = 60) and retrospectively for OPNs (N = 40). A p-value of < 0.05 denotes statistical significance. Results  Average tumor size (2.6 cm HALPN versus 2.6 cm OPN, p = 0.97) was similar. Mean operative times were shorter for HALPN compared with OPN (161 versus 191 min, p = 0.027). HALPN was also associated with less blood loss (mean 120 cc versus 353 cc, p = 0.0003). Warm ischemia time was shorter for HALPN (mean 27.0 min versus 33.0 min, p = 0.035), as was hospital stay (mean 4.9 days versus 6.9 days, p = 0.007). Although four HALPN renal tumors required intraoperative margin re-excision (based on immediate gross evaluation by a pathologist), the final positive margin rate was 0%. A 5% final positive margin rate was observed in the OPN group. There were two conversions from HALPN to HAL radical nephrectomy and no conversions to an open technique. The HALPN minor complication rate was 18.3% versus 32.5% for OPN (p = 0.10). Complications included delayed bleeding (1, 2.5% OPN), urine leak (2, 5% OPN; 2, 3.3% HALPN), hypoxia, and nausea or fever lasting >3 days. Tumor pathology was as follows: 80.7% and 80% RCC, 12.3% and 8% oncocytoma, and 7% and 12% angiomyolipoma, for HALPN and OPN, respectively in each case. Conclusions  HALPN is associated with diminished blood loss, operating time, warm ischemia time, positive margin rates, and length of stay compared with OPN. In our institution, HALPN is the standard approach for patients with small, surgically accessible renal tumors.