USC Institute of Urology, Center for Advanced Robotic and Laparoscopic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
Eur Urol. 2012 Jan;61(1):67-74. doi: 10.1016/j.eururo.2011.08.040. Epub 2011 Aug 31.
Robot-assisted and laparoscopic partial nephrectomies (PNs) for medial tumors are technically challenging even with the hilum clamped and, until now, were impossible to perform with the hilum unclamped.
Evaluate whether targeted vascular microdissection (VMD) of renal artery branches allows zero-ischemia PN to be performed even for challenging medial tumors.
DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort evaluation of 44 patients with renal masses who underwent robot-assisted or laparoscopic zero-ischemia PN either with anatomic VMD (group 1; n=22) or without anatomic VMD (group 2; n=22) performed by a single surgeon from April 2010 to January 2011.
Zero-ischemia PN with VMD incorporates four maneuvers: (1) preoperative computed tomographic reconstruction of renal arterial branch anatomy, (2) anatomic dissection of targeted, tumor-specific tertiary or higher-order renal arterial branches, (3) neurosurgical aneurysm microsurgical bulldog clamp(s) for superselective tumor devascularization, and (4) transient, controlled reduction of blood pressure, if necessary.
Baseline, perioperative, and postoperative data were collected prospectively.
Group 1 tumors were larger (4.3 vs 2.6 cm; p=0.011), were more often hilar (41% vs 9%; p=0.09), were medial (59% and 23%; p=0.017), were closer to the hilum (1.46 vs 3.26 cm; p=0.0002), and had a lower C index score (2.1 vs 3.9; p=0.004) and higher RENAL nephrometry scores (7.7 vs 6.2; p=0.013). Despite greater complexity, no group 1 tumor required hilar clamping, and perioperative outcomes were similar to those of group 2: operating room time (4.7 and 4.1h), median blood loss (200 and 100ml), surgical margins for cancer (all negative), major complications (0% and 9%), and minor complications (18% and 14%). The median serum creatinine level was similar 2 mo postoperatively (1.2 and 1.3mg/dl). The study was limited by the relatively small sample size.
Anatomic targeted dissection and superselective control of tumor-specific renal arterial branches facilitate zero-ischemia PN. Even challenging medial and hilar tumors can be excised without hilar clamping. Global surgical renal ischemia has been eliminated for most patients undergoing PN at our institution.
即使夹闭肾门，机器人辅助和腹腔镜部分肾切除术（PN）对内侧肿瘤也是具有挑战性的，并且直到现在，在不夹闭肾门的情况下，对内侧肿瘤进行 PN 都是不可能的。
评估针对肾动脉分支的靶向血管显微解剖（VMD）是否允许即使是具有挑战性的内侧肿瘤也能进行零缺血 PN。
设计、设置和参与者：对 2010 年 4 月至 2011 年 1 月间由同一位外科医生进行的 44 例接受机器人辅助或腹腔镜零缺血 PN 的肾肿块患者进行前瞻性队列评估，这些患者要么进行解剖 VMD（组 1；n=22），要么不进行解剖 VMD（组 2；n=22）。
VMD 的零缺血 PN 包括四项操作：（1）术前对肾动脉分支解剖结构进行 CT 重建，（2）对特定肿瘤的三级或更高分支进行解剖，（3）神经外科动脉瘤显微手术夹（多个）用于超选择性肿瘤去血管化，以及（4）必要时短暂、控制血压下降。
前瞻性收集基线、围手术期和术后数据。
组 1 肿瘤较大（4.3 对 2.6cm；p=0.011），更靠近肾门（41%对 9%；p=0.09），位于内侧（59%对 23%；p=0.017），靠近肾门（1.46 对 3.26cm；p=0.0002），C 指数评分较低（2.1 对 3.9；p=0.004），RENAL 肾单位评分较高（7.7 对 6.2；p=0.013）。尽管复杂性更大，但组 1 中的肿瘤均无需肾门夹闭，且围手术期结果与组 2 相似：手术室时间（4.7 和 4.1h）、中位失血量（200 和 100ml）、癌症手术切缘（均为阴性）、主要并发症（0%和 9%）和小并发症（18%和 14%）。术后 2 个月时血清肌酐水平相似（1.2 和 1.3mg/dl）。该研究受到相对较小样本量的限制。
针对肾动脉分支的解剖靶向解剖和超选择性控制有助于实现零缺血 PN。即使是具有挑战性的内侧和肾门肿瘤也可以在不夹闭肾门的情况下切除。在我们的机构中，大多数接受 PN 的患者已经消除了全球手术肾缺血。
