Lam John S, Bergman Jonathan, Breda Alberto, Schulam Peter G
Department of Urology, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, CA 90095, USA.
Nat Clin Pract Urol. 2008 Jun;5(6):308-17. doi: 10.1038/ncpuro1121. Epub 2008 May 13.
Surgical resection remains the standard treatment for clinically localized renal cell carcinoma. Pathological features of the surgical specimen, including the margin status, play an important part in determining the patient's prognosis. Negative surgical margins have traditionally been sought to maximize the efficacy of treatment. Initial concerns that partial nephrectomy might have high local recurrence rates compared with radical nephrectomy have now been minimized as a result of technological advances and refinements in surgical technique. Current concerns in relation to partial nephrectomy include the width of parenchymal tissue that should be removed to avoid positive surgical margins, effects of positive margins on recurrence-free survival, and the use of frozen-section analysis to determine margin status. Size of the surgical margin in partial nephrectomy does not seem to affect the risk of local tumor recurrence, and not all positive surgical margins lead to recurrent disease. Intraoperative frozen-section analysis is not definitive and its value in guiding the surgical management of renal tumors remains to be defined. Laparoscopic partial nephrectomy is emerging as an attractive approach for selected renal masses. Intraoperative use of ultrasound, cold-scissor parenchymal transection, embolization, and hilar clamping to achieve a bloodless operative field with clear visibility, may minimize the risk of positive margins during partial nephrectomy.
手术切除仍然是临床局限性肾细胞癌的标准治疗方法。手术标本的病理特征，包括切缘情况，在确定患者预后方面起着重要作用。传统上一直追求阴性手术切缘以最大化治疗效果。最初担心部分肾切除术与根治性肾切除术相比可能有较高的局部复发率，如今由于技术进步和手术技术的改进，这种担忧已降至最低。目前与部分肾切除术相关的问题包括为避免手术切缘阳性应切除的实质组织宽度、阳性切缘对无复发生存的影响以及使用冰冻切片分析来确定切缘情况。部分肾切除术中手术切缘的大小似乎不影响局部肿瘤复发风险，而且并非所有手术切缘阳性都会导致疾病复发。术中冰冻切片分析并不确定，其在指导肾肿瘤手术管理中的价值仍有待确定。腹腔镜部分肾切除术正成为一种针对特定肾肿块的有吸引力的方法。术中使用超声、冷剪刀实质切开、栓塞和肾门阻断以获得视野清晰的无血手术区域，可能会降低部分肾切除术中切缘阳性的风险。
