Lattouf Jean-Baptiste, Beri Avi, D'Ambros Oswald F J, Grüll Martin, Leeb Karl, Janetschek Günter
Department of Urology, Krankenhaus der Elisabethinen, Linz, Austria.
Eur Urol. 2008 Aug;54(2):409-16. doi: 10.1016/j.eururo.2008.04.007. Epub 2008 Apr 11.
Laparoscopic partial nephrectomy for hilar tumors is a cutting edge procedure for which little data is available in the current literature.
To describe our technique and results of laparoscopic partial nephrectomy for renal hilar tumors.
DESIGN, SETTING, AND PARTICIPANTS: Between April 2000 and September 2006, 94 partial laparoscopic nephrectomies were performed at our institution. A total of 18 (19.1%) patients had hilar tumors. A hilar tumor was defined as a lesion suspicious for renal cell carcinoma in contact with a major renal vessel on preoperative cross-sectional imaging. In 3 (16.7%) of the patients, the indication for nephron-sparing surgery was imperative. Mean tumor size was 3 cm (range, 2-4.5). Eight (44.4%) surgeries were performed with renal artery perfusion for cold ischemia; the remaining surgeries were performed under warm ischemia.
INTERVENTION(S): After occluding the renal artery and controlling the renal vein by using separate rubber band tourniquets, we excised the tumor mass including delicate mobilization away from the blood vessels. Although we used to insert a ureteral stent at the beginning of our experience with laparoscopic partial nephrectomies, we no longer do so. All surgeries were performed by a single urologist (G.J.).
Operative time, ischemia time, blood loss, renal function using the Cockroft formula as well as renal scans, operative and post-operative complications, pathology parameters.
All surgeries were completed laparoscopically. Mean surgical time was 238 min (range, 150-420). Mean ischemia times were 42.5 min (range, 27-63) and 34.1 min (range, 24-56) for the cold and warm ischemia groups, respectively. Estimated intraoperative blood loss was 165 ml (range, 50-500). There were two (11%) entries into major vessels during tumor excision, namely a segmental renal artery in one patient and a segmental renal vein in another. Both of these occurrences were managed laparoscopically. One patient necessitated laparoscopic reexploration for urine extravasation in the immediate postoperative period. All postoperative nuclear scans (available in 12 of 18 patients) showed functional kidney moiety. Mean split renal function was 38.6% (range, 24-50) on the operated side. Histopathological examination confirmed renal cell carcinoma in 14 (77.8%) of the patients. One (7.1%) patient had a positive surgical margin on the surface that was adjacent to the renal artery. In a median follow-up of 26 mo (range, 1-59), no local recurrence or systemic progression occurred.
Laparoscopic partial nephrectomy for hilar tumors is a feasible and safe procedure in the hands of experienced laparoscopic surgeons. Oncological results seem excellent, but further follow-up is needed for accurate long-term assessment of this surgical approach.
腹腔镜下肾门肿瘤部分切除术是一种前沿手术，目前文献中关于该手术的资料较少。
描述我们开展腹腔镜下肾门肿瘤部分切除术的技术及结果。
设计、场所和参与者：2000年4月至2006年9月期间，我们机构共进行了94例腹腔镜下部分肾切除术。其中共有18例（19.1%）患者患有肾门肿瘤。肾门肿瘤定义为术前横断面成像显示与主要肾血管接触、怀疑为肾细胞癌的病变。3例（16.7%）患者必须进行保留肾单位手术。肿瘤平均大小为3厘米（范围2 - 4.5厘米）。8例（44.4%）手术采用肾动脉灌注进行冷缺血；其余手术在热缺血下进行。
使用单独的橡皮筋止血带阻断肾动脉并控制肾静脉后，我们切除肿瘤块，包括小心地将其与血管分离。在我们开展腹腔镜下部分肾切除术初期，我们通常会插入输尿管支架，但现在不再这样做。所有手术均由一名泌尿外科医生（G.J.）完成。
手术时间、缺血时间、失血量、使用Cockcroft公式评估的肾功能以及肾脏扫描结果、手术中和术后并发症、病理参数。
所有手术均通过腹腔镜完成。平均手术时间为238分钟（范围150 - 420分钟）。冷缺血组和热缺血组的平均缺血时间分别为42.5分钟（范围27 - 63分钟）和34.1分钟（范围24 - 56分钟）。估计术中失血量为165毫升（范围50 - 500毫升）。肿瘤切除过程中有2例（11%）出现主要血管损伤，1例患者损伤节段性肾动脉，另1例患者损伤节段性肾静脉。这两例均通过腹腔镜处理。1例患者术后早期因尿外渗需要进行腹腔镜再次探查。所有术后核素扫描（18例患者中的12例有结果）显示保留的肾部分有功能。患侧平均分肾功能为38.6%（范围24 - 50%）。组织病理学检查证实14例（77.8%）患者为肾细胞癌。1例（7.1%）患者在与肾动脉相邻表面的手术切缘阳性。中位随访26个月（范围1 - 59个月），未发生局部复发或全身进展。
对于有经验的腹腔镜外科医生来说，腹腔镜下肾门肿瘤部分切除术是一种可行且安全的手术。肿瘤学结果似乎良好，但需要进一步随访以准确评估该手术方法的长期效果。
