Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
Imaging Institute, Cleveland Clinic, Cleveland, Ohio.
J Urol. 2014 Jul;192(1):30-5. doi: 10.1016/j.juro.2013.12.035. Epub 2013 Dec 25.
The precision of excision and reconstruction to optimize vascularized parenchymal preservation is a major determinant of renal function after partial nephrectomy. We assessed partial nephrectomy surgical precision using volumetric computerized tomography and analyzed predictive factors.
We analyzed the records of 122 patients treated with partial nephrectomy in whom detailed analysis of the precision of excision and reconstruction specific to the operated kidney could be performed. We used volumetric computerized tomography to measure functional parenchymal volume before and after partial nephrectomy in the operated kidney. The glomerular filtration rate in the operated kidney was determined by the MDRD2 (Modification of Diet in Renal Disease 2) equation along with renal scan in patients with a contralateral kidney. Surgical precision was defined as actual postoperative parenchymal volume/predicted postoperative parenchymal volume, presuming loss of a 5 mm rim of normal parenchyma related to excision and reconstruction.
Median patient age was 61 years and 64 patients (52%) underwent an open procedure. Cold ischemia was used in 50 patients (median 26 minutes) and limited warm ischemia (median 20 minutes) was used in 72. The R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior and location relative to polar line) nephrometry score indicated low, intermediate and high complexity in 43 (35%), 55 (45%) and 24 patients (20%), respectively. A total of 45 patients (37%) with a solitary kidney were included in analysis. The median precision of excision and reconstruction was 93%. The median preserved glomerular filtration rate was 80% in the operated kidney. A solitary kidney was the only significant predictor of excision and reconstruction precision on univariable and multivariable analysis.
A solitary kidney significantly impacted partial nephrectomy surgical precision. This was likely related to the recognized need to preserve as much renal parenchyma as possible to optimize renal function in the absence of a contralateral kidney.
优化血管化实质保存的切除和重建精度是部分肾切除术术后肾功能的主要决定因素。我们使用体积计算机断层扫描评估部分肾切除术的手术精度，并分析预测因素。
我们分析了 122 例接受部分肾切除术治疗的患者的记录，这些患者可以对手术肾脏的切除和重建进行详细的精度分析。我们使用体积计算机断层扫描测量手术肾脏切除前后的功能性实质体积。对于对侧肾脏正常的患者，通过 MDRD2（肾脏病饮食改良）方程和肾脏扫描确定手术肾脏的肾小球滤过率。手术精度定义为实际术后实质体积/预测术后实质体积，假设与切除和重建相关的正常实质损失 5 毫米边缘。
中位患者年龄为 61 岁，64 例（52%）接受开放手术。50 例（中位 26 分钟）使用冷缺血，72 例（中位 20 分钟）使用有限的热缺血。R.E.N.A.L.（半径、外生/内生、肿瘤与收集系统或窦腔的接近程度、前后和相对于极线的位置）肾切除术评分表明低、中、高复杂性分别为 43 例（35%）、55 例（45%）和 24 例（20%）。共有 45 例（37%）孤立肾患者纳入分析。切除和重建的中位精度为 93%。手术肾脏的中位保留肾小球滤过率为 80%。孤立肾是单变量和多变量分析中切除和重建精度的唯一显著预测因素。
孤立肾显著影响部分肾切除术的手术精度。这可能与在没有对侧肾脏的情况下尽可能保留更多的肾实质以优化肾功能的认识有关。
