高选择性肾动脉分支阻断与全阻断下腹腔镜保留肾单位手术疗效及肾功能对比

doi:10.3969/j.issn.1674-490X.2020.01.006

摘要/Abstract

摘要： 目的探讨肾动脉主干阻断(main renal artery clamping,MRAC)与高选择性肾段动脉分支阻断(selective segmental renal artery clamping, SSRAC)下行腹腔镜保留肾单位手术(laparoscopic nephron sparing surgery, LNSS)的临床效果及安全性评价。方法回顾性分析2017年10月至2018年10月收治的T1期局限性肾肿瘤患者84例,其中行SSRAC下LNSS 42例(S组),行MRAC下LNSS 42例(M组)。比较2种手术方法的手术时间、术中失血量、术中热缺血时间、术后住院时间、切缘阳性率;术前术后SCr、BUN;术中、术后并发症发生率等。结果所有手术顺利完成,无手术切缘阳性者,无术中中转为MRAC者。S组手术时间、术中失血量较M组增加,差异有统计学意义(P<0.05),2组术中热缺血时间、术后引流量、术后住院时间等差异无统计学意义(P>0.05);2组术前SCr、BUN水平差异无统计学意义(P>0.05),术后1 d血SCr、BUN水平较术前显著升高,S组术后1 d SCr、BUN显著低于M组(P<0.05);2组患者术中术后并发症发生率差异无统计学意义(P>0.05)。结论 SSRAC是新的肾动脉阻断技术,应用于LNSS患者治疗效果显著、安全性高,且对肾脏功能影响小,本研究尚需要大样本数据支持。

关键词: 高选择性肾动脉分支阻断, 肾动脉全阻断, 腹腔镜保留肾单位手术, T1局限肾肿瘤, 热缺血

Abstract: Objective To investigate the clinical efficacy and safety of laparoscopic nephron sparing surgery(LNSS)with the two different methods, main renal artery clamping(MRAC)and selective segmental renal artery clamping(SSRAC). Methods 84 patients, who had the localized renal tumor in stage T1, admitted from October 2017 to October 2018 were conducted a retrospective analysis,42 of the patients were operated with the method of SSRAC(Group S), and the other 42 patients were operated with the method of MRAC(Group M). The operative time, intraoperative blood loss, intraoperative warm ischemia time, postoperative hospital stay, positive margins, the values of serum creatinine rate(SCr)and blood urea nitrogen(BUN)before and after surgery, intraoperative and postoperative complications rate and so on were compared between the two surgical methods. Results All the operations were successfully completed, and there was no positive margins. There was no intraoperative transfer to MRAC in group S. There was no significant difference in the operation time and intraoperative blood loss between the Group S and the Group M(P<0.05). There was no significant difference in the duration of warm ischemia, postoperative drainage, and postoperative hospital stay(P>0.05). There was no significant difference in preoperative SCr and BUN levels between the two groups(P>0.05). The levels of SCr and BUN in the 1st day of postoperative period were significantly higher than those before surgery. There was significant difference in SCr and BUN between the 1st day after operations in the Group S(P<0.05). There was no significant difference in the incidence of postoperative complications between the two groups(P>0.05). Conclusion SSRAC is a new renal artery occlusion technique. It is effective and safe in patients with LNSS, and its effect on renal function is small. This study still needs to be supported with large amounts of sample cases.

Key words: selective segmental renal artery clamping, main renal artery clamping, laparoscopic nephron sparing surgery, the localized renal tumor in stage T1, warm ischemia

中图分类号:

潘秀敏,张金立,闫红丽,李梦琳,郭敬如. 高选择性肾动脉分支阻断与全阻断下腹腔镜保留肾单位手术疗效及肾功能对比[J]. 医学研究与教育, 2020, 37(1): 30-35.

参考文献

[1] BIER S, AUFDERKLAMM S, TODENHOFER T, et al. Prediction of postoperative risks in laparoscopic partial nephrectomy using RENAL, mayo adhesive probability and renal pelvic score[J]. Anticancer Res, 2017, 37(3): 1369-1374. DOI: 10.21873/anticanres.11457.
[2] PATEL P, NAYAK J G, LIU Z H, et al. A multicentered, propensity matched analysis comparing laparoscopic and open surgery for pT3a renal cell carcinoma[J]. J Endourol, 2017, 31(7): 645-650.
[3] BANEGAS M P, HARLAN L C, MANN B, et al. Toward greater adoption of minimally invasive and nephron-sparing surgical techniques for renal cell cancer in the United States[J]. Urol Oncol: Semin Orig Investig, 2016, 34(10): 433.e9-433.e17.
[4] THOMPSON R H, LANE B R, LOHSE C M, et al. Renal function after partial nephrectomy: effect of warm ischemia relative to quantity and quality of preserved kidney[J]. Urology, 2012, 79(2): 356-360.
[5] RIZKALA E R, KHALIFEH A, AUTORINO R, et al. Zero ischemia robotic partial nephrectomy: sequential preplaced suture renorrhaphy technique[J]. Urology, 2013, 82(1): 100-104.
[6] BOROFSKY M S, GILL I S, HEMAL A K, et al. Near-infrared fluorescence imaging to facilitate super-selective arterial clamping during zero-ischaemia robotic partial nephrectomy[J]. BJU Int, 2013, 111(4): 604-610.
[7] VOLPE A, BLUTE M L, FICARRA V, et al. Renal ischemia and function after partial nephrectomy: a collaborative review of the literature[J]. Eur Urol, 2015, 68(1): 61-74. DOI: 10.1016/j.eururo.2015.01.025.
[8] LI X, HUANG Y, LIU W Y, et al. A model for assuring clamping success during laparoscopic partial nephrectomy with segmental renal artery clamping[J]. World J Urol, 2016, 34(10): 1421-1427. DOI: 10.1007/s00345-016-1785-7.
[9] LESLIE S, GOH A C, GILL I S. Partial nephrectomy: contemporary indications, techniques and outcomes[J]. Nat Rev Urol, 2013, 10(5): 275-283. DOI: 10.1038/nrurol.2013.69.
[10] ITO H, MAKIYAMA K, KAWAHARA T, et al. Modified C index: Novel predictor of postoperative renal functional loss of laparoscopic partial nephrectomy[J]. Can Urol Assoc J, 2017, 11(5): 215. DOI: 10.5489/cuaj.4192.
[11] CAMPBELL S C, NOVICK A C, BELLDEGRUN A, et al. Guideline for management of the clinical T1 renal mass[J]. J Urol, 2009, 182(4): 1271-1279.
[12] LJUNGBERG B, BENSALAH K, CANFIELD S, et al. EAU guidelines on renal cell carcinoma: 2014 update[J]. Eur Urol, 2015, 67(5): 913-924.
[13] BONVENTRE J V, YANG L. Cellular pathophysiology of ischemic acute kidney injury[J]. J Clin Invest, 2011, 121(11): 4210-4221. DOI: 10.1172/jci45161.
[14] FUNAHASHI Y, YOSHINO Y, SASSA N, et al. Comparison of warm and cold ischemia on renal function after partial nephrectomy[J]. Urology, 2014, 84(6): 1408-1413.
[15] SONG C, BANG J K, PARK H K, et al. Factors influencing renal function reduction after partial nephrectomy[J]. J Urol, 2009, 181(1): 48-54.
[16] BAGHERI F, PUSZTAI C, FARKAS L, et al. Impact of parenchymal loss on renal function after laparoscopic partial nephrectomy under warm ischemia[J]. World J Urol, 2016, 34(12): 1629-1634. DOI: 10.1007/s00345-016-1798-2.
[17] GILL I S, EISENBERG M S, ARON M, et al. “Zero ischemia” partial nephrectomy: novel laparoscopic and robotic technique[J]. Eur Urol, 2011, 59(1): 128-134.
[18] SHAO P F, QIN C, YIN C J, et al. Laparoscopic partial nephrectomy with segmental renal artery clamping: technique and clinical outcomes[J]. Eur Urol, 2011, 59(5): 849-855.
[19] SHAO P F, TANG L J, LI P, et al. Precise segmental renal artery clamping under the guidance of dual-source computed tomography angiography during laparoscopic partial nephrectomy[J]. Eur Urol, 2012, 62(6): 1001-1008.
[20] DESAI M M, DE CASTRO ABREU A L, LESLIE S, et al. Robotic partial nephrectomy with superselective versus main artery clamping: A retrospective comparison[J]. Eur Urol, 2014, 66(4): 713-719.