机器人辅助部分肾切除术超选择性夹闭与主动脉夹闭的回顾性比较。
Robotic partial nephrectomy with superselective versus main artery clamping: a retrospective comparison.
机构信息
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA.
USC Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck Medical Center of USC, University of Southern California, Los Angeles, CA, USA.
出版信息
Eur Urol. 2014 Oct;66(4):713-9. doi: 10.1016/j.eururo.2014.01.017. Epub 2014 Jan 25.
BACKGROUND
Concerns have been raised regarding partial nephrectomy (PN) techniques that do not occlude the main renal artery.
OBJECTIVE
Compare the perioperative outcomes of superselective versus main renal artery control during robotic PN.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis of 121 consecutive patients undergoing robotic PN using superselective control (group 1, n=58) or main artery clamping (group 2, n=63).
INTERVENTION
Group 1 underwent tumor-specific devascularization, maintaining ongoing arterial perfusion to the renal remnant at all times. Group 2 underwent main renal artery clamping, creating global renal ischemia.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
Perioperative and functional data were evaluated. The Pearson chi-square or Fisher exact and Wilcoxon rank sum tests were used.
RESULTS AND LIMITATIONS
All robotic procedures were successful, all surgical margins were negative, and no kidneys were lost. Compared with group 2 tumors, group 1 tumors were larger (3.4 vs 2.6cm, p=0.004), more commonly hilar (24% vs 6%, p=0.009), and more complex (PADUA 10 vs 8, p=0.009). Group 1 patients had longer median operative time (p<0.001) and transfusion rates (24% vs 6%, p<0.01) but similar estimated blood loss (200 vs 150ml), perioperative complications (15% vs 13%), and hospital stay. Group 1 patients had less decrease in estimated glomerular filtration rate at discharge (0% vs 11%, p=0.01) and at last follow-up (11% vs 17%, p=0.03). On computed tomography volumetrics, group 1 patients trended toward greater parenchymal preservation (95% vs 90%, p=0.07) despite larger tumor size and volume (19 vs 8ml, p=0.002). Main limitations are the retrospective study design, small cohort, and short follow-up.
CONCLUSIONS
Robotic PN with superselective vascular control enables tumor excision without any global renal ischemia. Blood loss, complications, and positive margin rates were low and similar to main artery clamping. In this initial developmental phase, limitations included more perioperative transfusions and longer operative time. The advantage of superselective clamping for better renal function preservation requires validation by prospective randomized studies.
PATIENT SUMMARY
Preserving global blood flow to the kidney during robotic partial nephrectomy (PN) does not lead to a higher complication rate and may lead to better postoperative renal function compared with clamped PN techniques.
背景
人们对不阻断主肾动脉的部分肾切除术（PN）技术提出了担忧。
目的
比较机器人辅助 PN 中选择性与主肾动脉控制的围手术期结果。
设计、设置和参与者：对 121 例连续接受机器人辅助 PN 的患者进行回顾性分析，其中 58 例采用超选择性控制（组 1），63 例采用主肾动脉夹闭（组 2）。
干预措施
组 1 进行肿瘤特异性去血管化，始终保持肾残部持续动脉灌注。组 2 行主肾动脉夹闭，造成全肾缺血。
观察指标和统计学分析
评估围手术期和功能数据。采用 Pearson 卡方或 Fisher 确切检验和 Wilcoxon 秩和检验。
结果和局限性
所有机器人手术均成功，所有手术切缘均为阴性，无肾脏丢失。与组 2 肿瘤相比，组 1 肿瘤更大（3.4 对 2.6cm，p=0.004），更常见于肾门（24%对 6%，p=0.009），更复杂（PADUA 10 对 8，p=0.009）。组 1 患者的中位手术时间更长（p<0.001）和输血率（24%对 6%，p<0.01）更高，但估计失血量（200 对 150ml）、围手术期并发症（15%对 13%）和住院时间相似。组 1 患者出院时（0%对 11%，p=0.01）和最后一次随访时（11%对 17%，p=0.03）估计肾小球滤过率下降较少。在 CT 体积测量中，尽管肿瘤较大（19 对 8ml，p=0.002），但组 1 患者的实质保存率呈增加趋势（95%对 90%，p=0.07）。
主要局限性在于回顾性研究设计、小样本量和短期随访。
结论
机器人辅助 PN 采用超选择性血管控制，可在不造成任何全肾缺血的情况下切除肿瘤。出血量、并发症和切缘阳性率低，与主肾动脉夹闭相似。在这一初始发展阶段，局限性包括更多的围手术期输血和更长的手术时间。与夹闭 PN 技术相比，超选择性夹闭在保留肾功能方面的优势需要前瞻性随机研究来验证。
患者总结
与夹闭 PN 技术相比，在机器人辅助部分肾切除术（PN）中保留肾脏的整体血流不会导致更高的并发症发生率，并且可能导致术后肾功能更好。
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