Department of Urologic Surgery, The E. Wolfson Medical Center, Holon and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
BJU Int. 2012 Sep;110(5):738-42. doi: 10.1111/j.1464-410X.2012.10955.x. Epub 2012 Feb 14.
What's known on the subject? and What does the study add? Complex tumour features (e.g. size, hilar location, multifocality) are generally considered contraindicative for LPN and only a handful of studies reporting encouraging outcomes with more complex tumours. Herein we suggest that in experience hands the benefits of minimally-invasive surgery may be safely extended to patients with more complex renal masses.
To report on our experience in extending the indications for LPN beyond the single, T1a renal mass assessing the perioperative outcomes in a comparative fashion.
Retrospective review of consecutive patients undergoing LPN for a renal mass in an academic centre between 2005-2010. 150 patients were divided into two groups based on tumours characteristics: straightforward T1a (group 1: single, <4 cm, n = 84) and complex (group 2: multiple and/or hilar and/or ≥4 cm, n = 66). Comparison of demographic, clinical, radiographic and perioperative outcomes (operative times, blood loss, warm ischemia times, intra- and postoperative complications).
In group 2, 19 tumours were hilar, 15 were multifocal and 44 measured ≥4 cm; 2 of these criteria were present in 7, and all three in 3 cases. Warm ischemia times and blood loss were comparable (medians of 21 vs 20 min, and 100 vs 100 mL). Operative times were longer in group 2 (190 vs 140min, P < 0.001). Complications occurred in 11.9% and 12.1% of patients in group 1 and 2, with Clavien grade 3 events in 8.3 and 10.9%, respectively (P = 1.00 and P = 0.547). There were 4 conversions to laparoscopic radical nephrectomy (1 in group 1, 3 in group 2).
With adequate laparoscopic expertise, the indications for LPN can be safely extended beyond the single, small, peripheral T1a renal mass. In this series, more complex masses were effectively treated with LPN combining the advantages of minimally-invasive surgery to those of nephron-sparing approach.
肿瘤特征复杂（例如大小、位置、多灶性）通常被认为是不适合保留肾单位手术（LPN）的指征，但少数研究报告了对更复杂肿瘤采用 LPN 获得令人鼓舞结果的经验。在此，我们建议在有经验的医生手中，微创手术的益处可以安全地扩展到具有更复杂肾肿瘤的患者。
报告我们在学术中心对超出单个 T1a 肾肿瘤适应证的 LPN 经验，并以比较的方式评估围手术期结果。
回顾性分析 2005 年至 2010 年在学术中心接受 LPN 治疗的连续肾肿瘤患者。根据肿瘤特征，将 150 例患者分为两组：简单 T1a 组（组 1：单发，<4cm，n=84）和复杂组（组 2：多发和/或位于肾门和/或≥4cm，n=66）。比较两组患者的人口统计学、临床、影像学和围手术期结果（手术时间、失血量、热缺血时间、术中及术后并发症）。
组 2 中有 19 个肿瘤位于肾门，15 个为多灶性，44 个肿瘤直径≥4cm；其中 2 个标准同时存在于 7 例患者中，所有 3 个标准同时存在于 3 例患者中。热缺血时间和失血量相似（中位数分别为 21 分钟和 100 毫升）。组 2 的手术时间更长（190 分钟比 140 分钟，P<0.001）。组 1 和 2 患者的并发症发生率分别为 11.9%和 12.1%，Clavien 3 级事件分别为 8.3%和 10.9%（P=1.00 和 P=0.547）。有 4 例转为腹腔镜根治性肾切除术（组 1 中 1 例，组 2 中 3 例）。
在有足够腹腔镜经验的情况下，LPN 的适应证可以安全地扩展到单个、小的、外周 T1a 肾肿瘤以外。在本系列中，更复杂的肿瘤通过 LPN 有效治疗，将微创手术的优势与保肾手术的优势相结合。
