Phillips Jason M, Narula Navneet, Deane Leslie A, Box Geoffrey N, Lee Hak J, Ornstein David K, McDougall Elspeth M, Clayman Ralph V
Department of Urology, University of California-Irvine, Irvine, California, USA.
J Urol. 2008 Dec;180(6):2348-52. doi: 10.1016/j.juro.2008.08.029. Epub 2008 Oct 18.
While most laparoscopic nephron sparing surgery is performed using cold scissors, energy based devices may also be used. A criticism of this approach has been the potential thermal destruction of the cellular architecture at the tumor margin, precluding the ability to accurately determine whether tumor cells are present. We clinically characterized the histological appearance of tumor margins excised with cold scissors, and bipolar and ultrasonic shears.
We evaluated 40 renal mass excisions performed by a total of 3 urologists at our institution between February 2003 and March 2007. There were 10 bipolar (5 mm LigaSure), 20 ultrasonic (Harmonic Scalpel) and 10 cold excisions. All slides were randomly evaluated twice by a single pathologist blinded to surgeon and excision method. Histological interpretation of the margin was scored as clear vs indeterminate. Variables, including margin fragmentation, artifact, extravascular blood clot, parenchymal hemorrhage, capillary congestion and vessel sealing, were assessed and scored on a scale of 0 to 3, that is 0--none, 1-1% to 25%, 2-26% to 50% and 3--greater than 50%.
The pathologist was able to confidently identify cells at the margin as being malignant or benign in all cases. Histologically the ultrasonic scalpel demonstrated increased fragmentation and extravascular blood clotting compared with those of the other cutting methods (p <0.025 and <0.026, respectively). The ultrasonic scalpel also showed increased artifact depth compared to that of cold cutting (p <0.001). There were no statistical differences between the groups regarding margin artifact, parenchymal hemorrhage or capillary congestion. No statistical significance was observed in any variables between bipolar and cold cutting.
Despite some degree of cellular damage the ability to determine whether cells at the margin were benign or malignant was not affected by using an energy based bipolar or ultrasonic device.
虽然大多数腹腔镜肾部分切除术是使用冷剪刀进行的，但也可使用基于能量的设备。对这种方法的一种批评是，肿瘤边缘的细胞结构可能受到热破坏，从而无法准确确定是否存在肿瘤细胞。我们从临床角度对用冷剪刀、双极电剪和超声刀切除的肿瘤边缘的组织学外观进行了表征。
我们评估了2003年2月至2007年3月期间在我们机构由3位泌尿外科医生共进行的40例肾肿物切除术。其中有10例使用双极电剪（5毫米LigaSure），20例使用超声刀（超声刀），10例使用冷剪刀切除。所有切片均由一位对手术医生和切除方法不知情的病理学家随机评估两次。边缘的组织学解释分为清晰和不确定。对包括边缘破碎、假象、血管外血凝块、实质出血、毛细血管充血和血管封闭等变量进行评估，并按0至3分进行评分，即0表示无，1表示1%至25%，2表示26%至50%，3表示大于50%。
病理学家在所有病例中都能够自信地将边缘的细胞鉴定为恶性或良性。组织学上，与其他切割方法相比，超声刀显示出更多的破碎和血管外凝血（分别为p <0.025和<0.026）。与冷切割相比，超声刀还显示出假象深度增加（p <0.001）。在边缘假象、实质出血或毛细血管充血方面，各组之间没有统计学差异。双极电剪和冷切割之间在任何变量上均未观察到统计学意义。
尽管存在一定程度的细胞损伤，但使用基于能量的双极或超声设备并不影响确定边缘细胞是良性还是恶性的能力。
