Sections of Urologic Oncology and Minimally Invasive and Robotic Urologic Surgery, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.
J Urol. 2012 May;187(5):1667-73. doi: 10.1016/j.juro.2011.12.068. Epub 2012 Mar 15.
We used what is to our knowledge a new method to estimate volume loss after partial nephrectomy to assess the relative contributions of ischemic injury and volume loss on functional outcomes.
We analyzed the records of 301 consecutive patients who underwent conventional partial nephrectomy between 2007 and 2010 with available data to meet inclusion criteria. Percent functional volume preservation was measured at a median of 1.4 years after surgery. Modification of diet in renal disease-2 estimated glomerular filtration rate was measured preoperatively and perioperatively, and a median of 1.2 years postoperatively. Statistical analysis was done to study associations.
Hypothermia or warm ischemia 25 minutes or less was applied in 75% of cases. Median percent functional volume preservation was 91% (range 38%-107%). Percent glomerular filtration rate preservation at nadir and late time points was 77% and 90% of preoperative glomerular filtration rate, respectively. On multivariate analysis percent functional volume preservation and warm ischemia time were associated with nadir glomerular filtration rate while only percent functional volume preservation was associated with late glomerular filtration rate (each p <0.001). Late percent glomerular filtration rate preservation and percent functional volume preservation were directly associated (p <0.001). Recovery of function to 90% or greater of percent functional volume preservation predicted levels was observed in 86% of patients. In patients with de novo postoperative stage 3 or greater chronic kidney disease, percent functional volume preservation and Charlson score were associated with late percent glomerular filtration rate preservation. Warm ischemia time was not associated with late functional glomerular filtration rate decreases in patients considered high risk for ischemic injury.
In this cohort volume loss and not ischemia time was the primary determinant of ultimate renal function after partial nephrectomy. Technical modifications aimed at minimizing volume loss during partial nephrectomy while still achieving negative margins may result in improved functional outcomes.
我们使用了一种新方法来评估部分肾切除术后的体积损失，以评估缺血性损伤和体积损失对功能结果的相对贡献。
我们分析了 2007 年至 2010 年间接受常规部分肾切除术且符合纳入标准的 301 例连续患者的记录。术后中位数 1.4 年时测量功能性体积保留的百分比。术前和围手术期测量改良肾脏病饮食试验-2 估计肾小球滤过率，术后中位数 1.2 年。进行统计学分析以研究相关性。
75%的病例采用了 25 分钟或更短时间的低温或温热缺血。功能性体积保留的中位数为 91%（范围为 38%-107%）。肾小球滤过率的最低点和晚期保留率分别为术前肾小球滤过率的 77%和 90%。多变量分析显示，功能性体积保留和温热缺血时间与肾小球滤过率最低点相关，而仅功能性体积保留与晚期肾小球滤过率相关（均为 p<0.001）。晚期肾小球滤过率保留率与功能性体积保留率直接相关（p<0.001）。86%的患者达到了功能性体积保留率 90%或更高的功能恢复水平。在新发术后 3 期或更高级别的慢性肾脏病患者中，功能性体积保留率和 Charlson 评分与晚期肾小球滤过率保留率相关。在缺血性损伤高风险患者中，温热缺血时间与晚期功能性肾小球滤过率下降无关。
在本队列中，体积损失而不是缺血时间是部分肾切除术后最终肾功能的主要决定因素。旨在最大限度地减少部分肾切除术中体积损失的技术改进，同时仍能达到负切缘，可能会导致功能结果的改善。
