Johnston William K, Kelel Kristy M, Hollenbeck Brent K, Daignault Stephanie, Wolf J Stuart
Department of Urology, University of Michigan and Veterans Administration Medical Center, Ann Arbor, Michigan 48109-0330, USA.
J Urol. 2006 Jun;175(6):2307-11. doi: 10.1016/S0022-5347(06)00282-5.
We assessed the acute effectiveness of closure after partial nephrectomy of 7 techniques in a large hypertensive porcine model using shallow and deep resections to approximate clinical situations.
Open surgical partial nephrectomy with hilar clamping was performed in pigs weighing 150 to 200 lbs, including small-a quarter length and a quarter width of kidney, medium-a third length and a third width of kidney, and into the renal sinus and up to the collecting system, and large-lower pole heminephrectomy at the renal sinus. Seven agents were compared after a single application, namely thrombin/collagen granules, polyethylene glycol hydrogel, fibrin glue, thrombin/gelatin granules, cyanoacrylate glue, fibrin glue/gelatin sponge and sutured bolster. Failure and success were determined by the presence or absence of bleeding, respectively, after unclamping and by an increase in SBP to 100 and then to 200 mm Hg with dopamine infusion.
Of 70 partial nephrectomies the success rates were 33% and 14% for thrombin/collagen granules, and 67% and 0% for polyethylene glycol hydrogel in small and medium resections; 100%, 71% and 0% for fibrin glue, and 100%, 86% and 0% for thrombin/gelatin granules in small, medium and large resections; and 67% and 80% for cyanoacrylate glue, 100% and 20% for fibrin glue/gelatin sponge, and 100% for sutured bolster in medium and large resections, respectively. Of the kidneys that did not bleed at an SBP of 100 mm Hg 31% bled at 200 mm Hg.
There is considerable variability among agents. Most were effective for small resections and some worked for medium resections but for large resections only sutured bolster was consistently effective. SBP also appears to be an important factor. These results bear on the selection of techniques during laparoscopic partial nephrectomy.
在一个大型高血压猪模型中，我们评估了7种技术在部分肾切除术后闭合的急性有效性，采用浅切除和深切除以模拟临床情况。
对体重150至200磅的猪进行开放性手术部分肾切除术并阻断肾门，包括小范围切除——肾长的四分之一和宽的四分之一，中范围切除——肾长的三分之一和宽的三分之一，深入肾窦直至集合系统，以及大范围切除——肾窦处的下极半肾切除术。单次应用后比较7种制剂，即凝血酶/胶原颗粒、聚乙二醇水凝胶、纤维蛋白胶、凝血酶/明胶颗粒、氰基丙烯酸酯胶、纤维蛋白胶/明胶海绵和缝合支撑。阻断后有无出血分别确定失败和成功，通过静脉输注多巴胺使收缩压升至100 mmHg然后升至200 mmHg。
在70例部分肾切除术中，凝血酶/胶原颗粒在小范围和中范围切除中的成功率分别为33%和14%，聚乙二醇水凝胶在小范围和中范围切除中的成功率分别为67%和0%；纤维蛋白胶在小范围、中范围和大范围切除中的成功率分别为100%、71%和0%，凝血酶/明胶颗粒在小范围、中范围和大范围切除中的成功率分别为100%、86%和0%；氰基丙烯酸酯胶在中范围和大范围切除中的成功率分别为67%和80%，纤维蛋白胶/明胶海绵在中范围和大范围切除中的成功率分别为100%和20%，缝合支撑在中范围和大范围切除中的成功率均为100%。在收缩压为100 mmHg时未出血的肾脏中，31%在收缩压为200 mmHg时出血。
各制剂之间存在相当大的差异。大多数制剂对小范围切除有效，一些对中范围切除有效，但对于大范围切除，只有缝合支撑始终有效。收缩压似乎也是一个重要因素。这些结果关系到腹腔镜部分肾切除术中技术的选择。
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