Gill Inderbir S, Desai Mihir M, Kaouk Jihad H, Meraney Anoop M, Murphy David P, Sung Gyung Tak, Novick Andrew C
Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
J Urol. 2002 Feb;167(2 Pt 1):469-7; discussion 475-6. doi: 10.1016/S0022-5347(01)69066-9.
We describe our technique of and single institutional experience with purely laparoscopic partial nephrectomy for renal tumor, wherein the focus is to duplicate established open techniques of oncologic nephron sparing surgery.
Since August 1999 laparoscopic partial nephrectomy for renal tumor has been performed in 50 patients. Of the patients 24 (48%) had either a compromised contralateral kidney (20) or a solitary kidney (4). Mean tumor size was 3.0 cm. (range 1.4 to 7). In 9 patients (18%) the inner margin of the tumor was in close proximity to the pelvicaliceal system. Our current laparoscopic technique involves preoperative ureteral catheterization, laparoscopic renal ultrasonography, transient atraumatic clamping of the renal artery and vein, tumor excision with an approximate 0.5 cm. margin using cold endoshears and/or J-hook electrocautery, pelvicaliceal suture repair (if necessary) and suture repair of the renal parenchymal defect over surgicel bolsters. In 1 case renal surface hypothermia was achieved laparoscopically with ice slush. All suturing and knot tying were performed with free hand intracorporeal laparoscopic techniques exclusively.
All procedures were successfully completed without open conversion. Mean surgical time was 3.0 hours (range, 0.75 to 5.8) and mean blood loss was 270.4 cc (range 40 to 1,500). Mean warm ischemia time was 23 minutes (range, 9.8 to 40). Caliceal entry in 18 cases (36%) was suture repaired in a watertight manner. Following caliceal repair, none of these 18 patients had a postoperative urine leak. Hospital stay averaged 2.2 days (range 1 to 9). Major complications occurred in 3 patients (6%) including intraoperative hemorrhage in 1, delayed hemorrhage necessitating nephrectomy in 1 and urine leak in 1. Renal cell carcinoma was confirmed on pathological examination in 34 patients (68%), and all had negative inked surgical margins for cancer. During a mean followup of 7.2 months (range 1 to 17) no patient has had local or port site recurrence or metastatic disease.
Laparoscopic partial nephrectomy is a viable alternative for select patients with a renal tumor. The largest single institutional experience to date is presented wherein the open techniques of nephron sparing surgery have been duplicated laparoscopically.
我们描述了我们采用纯腹腔镜下肾部分切除术治疗肾肿瘤的技术及单中心经验，重点是复制成熟的开放性保留肾单位肿瘤手术技术。
自1999年8月以来，对50例患者实施了腹腔镜下肾部分切除术治疗肾肿瘤。其中24例（48%）患者对侧肾存在功能受损（20例）或为孤立肾（4例）。肿瘤平均大小为3.0 cm（范围1.4至7 cm）。9例（18%）患者肿瘤的内侧边缘紧邻肾盂肾盏系统。我们目前的腹腔镜技术包括术前输尿管插管、腹腔镜肾超声检查、肾动脉和静脉的短暂无创伤性阻断、使用冷剪和/或J形钩电灼以约0.5 cm的切缘切除肿瘤、肾盂肾盏缝合修复（如有必要）以及在外科止血海绵垫上对肾实质缺损进行缝合修复。1例患者通过腹腔镜用冰泥实现了肾表面低温。所有缝合和打结均仅采用徒手体内腹腔镜技术完成。
所有手术均成功完成，未中转开放手术。平均手术时间为3.0小时（范围0.75至5.8小时），平均失血量为270.4 cc（范围40至1500 cc）。平均热缺血时间为23分钟（范围9.8至40分钟）。18例（36%）肾盂穿破病例进行了严密的缝合修复。在肾盂修复后，这18例患者均未出现术后尿漏。平均住院时间为2.2天（范围1至9天）。3例患者（6%）发生了严重并发症，包括1例术中出血、1例因延迟出血而行肾切除术以及1例尿漏。病理检查确诊34例患者（68%）为肾细胞癌，所有患者手术切缘癌染色均为阴性。在平均7.2个月（范围1至17个月）的随访期间，无患者出现局部或切口部位复发或转移疾病。
腹腔镜下肾部分切除术是部分肾肿瘤患者的一种可行替代方案。本文展示了迄今为止最大的单中心经验，其中开放性保留肾单位手术技术已在腹腔镜下得以复制。
