Schiff Jonathan D, Palese Michael, Vaughan E Darracott, Sosa R Ernest, Coll Diedre, Del Pizzo Joseph J
James Buchanan Brady Foundation Department of Urology, New York-Weill Cornell Medical Center, New York, NY, USA.
BJU Int. 2005 Oct;96(6):811-4. doi: 10.1111/j.1464-410X.2005.05718.x.
To compare a contemporary series of laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) at one institution, to evaluate the size and types of tumour in each group and the early outcome after each procedure, as LPN is replacing open radical nephrectomy as the standard of care for uncomplicated renal tumours but partial nephrectomy remains significantly more difficult laparoscopically, especially if the goal is to duplicate the open surgical technique.
We retrospectively analysed the records of all patients who underwent partial nephrectomy at our institution from January 2000 to April 2004, identifying 66 who had LPN and compared them with 59 who had OPN (mean age at LPN and OPN, 62.1 and 64.2 years, respectively; 70% men in each group). Variables analysed included operative time, blood loss, creatinine levels before and after partial nephrectomy, time to resuming clear liquids and regular diet, length of stay, tumour size, tumour pathological type and complications. Groups were compared using Student's t-test, with P < 0.05 taken to indicate significance.
Of those having LPN, 59% had right-sided tumours, vs 53% in the OPN group; the respective mean tumour size was 2.2 and 3.4 cm, the mean operative duration 144 and 239 min (both P < 0.001), and the mean estimated blood loss 236 and 363 mL (P = 0.09). Seven patients in the OPN group had obligatory partial nephrectomy for either a solitary kidney (two) or azotaemia (five). No patient in the LPN group required an obligatory partial nephrectomy. Serum creatinine levels were measured before and 1 and 2 days after surgery, and were 88, 88 and 97 micromol/L for the LPN group, and 97, 106 and 106 micromol/L for the OPN group. Clear fluids were started a mean of 41 h after surgery, a regular diet resumed 76 h after and discharge was 129 h after surgery in the OPN group; the respective values for the LPN group were 24 h (P = 0.01), 49 h (P = 0.2) and 82 h (P < 0.001). Complications were similar in both groups but the pathological subtypes differed.
LPN offers early functional advantages over OPN in terms of earlier resumption of diet and slightly earlier discharge. However, the two groups of patients were clearly not evenly matched for size nor pathological subtypes, with larger, malignant subtypes more predominant in the OPN group. These results suggest that while LPN is a safe, effective treatment for small renal tumours, obligatory partial nephrectomy or large tumours continue to be performed using open techniques with good results.
在同一机构比较当代一系列腹腔镜下肾部分切除术（LPN）和开放性肾部分切除术（OPN），评估每组肿瘤的大小和类型以及每种手术术后的早期结局。因为LPN正在取代开放性根治性肾切除术成为治疗单纯性肾肿瘤的标准术式，但肾部分切除术在腹腔镜下仍显著更具难度，尤其是如果目标是复制开放手术技术的话。
我们回顾性分析了2000年1月至2004年4月在本机构接受肾部分切除术的所有患者的记录，确定66例行LPN的患者，并将他们与59例行OPN的患者进行比较（LPN组和OPN组的平均年龄分别为62.1岁和64.2岁；每组70%为男性）。分析的变量包括手术时间、失血量、肾部分切除术前和术后的肌酐水平、恢复清流食和正常饮食的时间、住院时间、肿瘤大小、肿瘤病理类型及并发症。采用Student t检验对两组进行比较，P<0.05表示有显著性差异。
LPN组中，59%为右侧肿瘤，而OPN组为53%；各自的平均肿瘤大小分别为2.2 cm和3.4 cm，平均手术时长分别为144分钟和239分钟（均P<0.001），平均估计失血量分别为236 mL和363 mL（P=0.09）。OPN组中有7例患者因单肾（2例）或氮质血症（5例）而必须行肾部分切除术。LPN组中无患者需要行必须的肾部分切除术。在手术前、术后1天和2天测量血清肌酐水平，LPN组分别为88、88和97 μmol/L，OPN组分别为97、106和106 μmol/L。OPN组术后平均41小时开始进清流食，术后76小时恢复正常饮食，术后129小时出院；LPN组的相应值分别为24小时（P=0.01）、49小时（P=0.2）和82小时（P<0.001）。两组并发症相似，但病理亚型不同。
就更早恢复饮食和稍早出院而言，LPN较OPN具有早期功能优势。然而，两组患者在肿瘤大小和病理亚型方面显然并不均衡，OPN组中更大、恶性亚型更为多见。这些结果表明，虽然LPN是治疗小肾肿瘤的一种安全、有效的方法，但对于必须行肾部分切除术或大肿瘤，继续采用开放技术进行手术也能取得良好效果。
