Alyami Fahad A, Rendon Ricardo A
Department of Urology, Dalhousie University, Halifax, NS.
Can Urol Assoc J. 2013 May-Jun;7(5-6):E281-6. doi: 10.5489/cuaj.1003.
Laparoscopic partial nephrectomy (LPN) is frequently used to manage cT1a renal masses. While data on safety and long-term oncological outcomes of LPN for T1a tumours are widely available, it is limited for >T1a lesions. We report our experience with LPN for >4 cm renal masses from a Canadian tertiary centre.
Between January 2003 and July 2011, 52 consecutive LPN for >4 cm renal masses were performed. Demographic, pathological and clinical data were obtained from a prospectively maintained database.
The mean patient age was 60 years (62% male). Median tumour size was 4.8 (range: 4.2-11) cm. The median surgical time was 145 minutes, and the median estimated blood loss was 100 mL. The median warm ischemia time was 24 minutes. Four (7.7%) cases required conversion to open surgery. One case was converted to total nephrectomy for clinical and pathological evidence of T3 disease. The surgical margin was positive in 1 case (1.9%). Four (7.7%) patients developed a urine leak postoperatively; 3 of them managed with a ureteric stent. Four (7.7%) patients developed postoperative bleeding requiring selective angioembolization. The median hospital stay was 4 days. There was no statistically significant difference between preoperative and postoperative estimated glomerular filtration rate and mean arterial blood pressure (p = 0.5, p = 0.1, respectively).
This series demonstrates that LPN although technically challenging has acceptable short-term surgical outcomes. Long-term assessment of oncological outcomes is required. Laparoscopic partial nephrectomy >4 cm renal tumours should not be considered a standard of care, but excellent results can be achieved in well-selected patients and in experienced hands with no impact in renal function or blood pressure.
腹腔镜下肾部分切除术（LPN）常用于治疗cT1a期肾肿瘤。虽然关于LPN治疗T1a期肿瘤的安全性和长期肿瘤学结局的数据广泛可得，但对于>T1a期病变的数据有限。我们报告了加拿大一家三级中心对直径>4 cm肾肿瘤行LPN的经验。
2003年1月至2011年7月，连续对52例直径>4 cm的肾肿瘤行LPN。人口统计学、病理和临床数据来自前瞻性维护的数据库。
患者平均年龄为60岁（62%为男性）。肿瘤中位数大小为4.8（范围：4.2 - 11）cm。手术中位数时间为145分钟，估计失血中位数为100 mL。热缺血中位数时间为24分钟。4例（7.7%）病例需要转为开放手术。1例因T3疾病的临床和病理证据转为根治性肾切除术。1例（1.9%）手术切缘阳性。4例（7.7%）患者术后发生尿漏；其中3例通过输尿管支架处理。4例（7.7%）患者术后发生出血，需要选择性血管栓塞。住院中位数时间为4天。术前和术后估计肾小球滤过率及平均动脉血压之间无统计学显著差异（分别为p = 0.5，p = 0.1）。
本系列研究表明，LPN尽管在技术上具有挑战性，但短期手术结局可接受。需要对肿瘤学结局进行长期评估。直径>4 cm肾肿瘤的腹腔镜下肾部分切除术不应被视为标准治疗方法，但在精心挑选的患者和经验丰富的术者手中可取得优异结果，且对肾功能或血压无影响。
