Krane L Spencer, Mufarrij Patrick W, Manny Theodore B, Hemal Ashok K
Department of Urology, Wake Forest University, Winston-Salem, North Carolina 27157-1094, USA.
Can J Urol. 2013 Feb;20(1):6662-7.
Partial nephrectomy without renal vascular occlusion has been introduced to improve outcomes in patients undergoing robotic partial nephrectomy (RPN). We prospectively evaluated unclamped RPN at our institution and compared this to other clamping techniques in a non-randomized fashion.
Ninety-five consecutive patients who successfully completed RPN between June 2010 and October 2011 are included in this analysis. All RPNs were performed by a single surgeon. Clamping technique was artery and vein (AV), artery alone (AO) or unclamped (U) without hypotensive anesthesia. Clamping decision was based on surgeon preference and feasibility of minimizing ischemia. All patients had bilateral functional renal units.
Eighteen (19%), 58 (61%) and 19 (20%) patients had AV, AO and U technique respectively. Preoperative characteristics including age (p = 0.43), body mass index (p = 0.40) and RENAL nephromety distribution (p = 0.10) were similar. In AV and AO, mean warm ischemia time were 19 and 17 minutes and similar between the two cohorts (p = 0.39). Mean glomerular filtration rate (GFR) and overall percentage decrease in GFR at time of at last follow up were (64, 69, 81, p = 0.12) and (6%, 6%,and 2%,p = 0.79) for AV, AO and U respectively. Median follow up for last serum creatinine was 113 days and was similar between all cohorts (p = 0.37). Complication rate (p = 0.37), positive margin rate (p = 0.84), and change in hemoglobin concentration postoperatively (p = 0.94) were similar between cohorts.
Unclamped partial nephrectomy is possible in patients undergoing RPN. In this study, it does not significantly alter perioperative or postoperative renal function or change rate of complications. Minimal ischemia, irrespective of clamping technique, in patients with bilateral renal units does not appear to adversely effect intermediate term renal function in these patients.
为改善接受机器人辅助部分肾切除术（RPN）患者的治疗效果，引入了不阻断肾血管的部分肾切除术。我们对本机构开展的无阻断RPN进行了前瞻性评估，并以非随机方式将其与其他阻断技术进行比较。
本分析纳入了2010年6月至2011年10月期间连续成功完成RPN的95例患者。所有RPN均由同一位外科医生实施。阻断技术分为动脉和静脉（AV）、仅动脉（AO）或不阻断（U），且不采用降压麻醉。阻断决策基于外科医生的偏好以及将缺血降至最低的可行性。所有患者均有双侧功能性肾单位。
分别有18例（19%）、58例（61%）和19例（20%）患者采用了AV、AO和U技术。术前特征，包括年龄（p = 0.43）、体重指数（p = 0.40）和RENAL肾计量评分分布（p = 0.10）相似。在AV和AO组中，平均热缺血时间分别为19分钟和17分钟，两组间相似（p = 0.39）。在最后一次随访时，AV、AO和U组的平均肾小球滤过率（GFR）及GFR总体下降百分比分别为（64、69、81，p = 0.12）和（6%、6%、2%，p = 0.79）。最后一次血清肌酐的中位随访时间为113天，所有组间相似（p = 0.37）。各组间并发症发生率（p = 0.37）、切缘阳性率（p = 0.84）及术后血红蛋白浓度变化（p = 0.94）相似。
接受RPN的患者可行无阻断部分肾切除术。在本研究中，它不会显著改变围手术期或术后肾功能，也不会改变并发症发生率。对于有双侧肾单位的患者，无论采用何种阻断技术，最小化缺血似乎不会对这些患者的中期肾功能产生不利影响。
