Azhar Raed A, Metcalfe Charles, Gill Inderbir S
aUSC Institute of Urology, Catherine & Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA bUrology Department, King Abdulaziz University, Jeddah, Saudi Arabia.
Curr Opin Urol. 2015 Mar;25(2):95-9. doi: 10.1097/MOU.0000000000000140.
Partial nephrectomy provides equivalent long-term oncologic and superior functional outcomes as radical nephrectomy for T1a renal masses. Herein, we review the various vascular clamping techniques employed during minimally invasive partial nephrectomy, describe the evolution of our partial nephrectomy technique and provide an update on contemporary thinking about the impact of ischemia on renal function.
Recently, partial nephrectomy surgical technique has shifted away from main artery clamping and towards minimizing/eliminating global renal ischemia during partial nephrectomy. Supported by high-fidelity three-dimensional imaging, novel anatomic-based partial nephrectomy techniques have recently been developed, wherein partial nephrectomy can now be performed with segmental, minimal or zero global ischemia to the renal remnant. Sequential innovations have included early unclamping, segmental clamping, super-selective clamping and now culminating in anatomic zero-ischemia surgery. By eliminating 'under-the-gun' time pressure of ischemia for the surgeon, these techniques allow an unhurried, tightly contoured tumour excision with point-specific sutured haemostasis. Recent data indicate that zero-ischemia partial nephrectomy may provide better functional outcomes by minimizing/eliminating global ischemia and preserving greater vascularized kidney volume.
Contemporary partial nephrectomy includes a spectrum of surgical techniques ranging from conventional-clamped to novel zero-ischemia approaches. Technique selection should be tailored to each individual case on the basis of tumour characteristics, surgical feasibility, surgeon experience, patient demographics and baseline renal function.
对于T1a期肾肿瘤，部分肾切除术与根治性肾切除术相比，具有同等的长期肿瘤学效果和更好的功能预后。在此，我们回顾了微创部分肾切除术中采用的各种血管阻断技术，描述了我们部分肾切除术技术的演变，并提供了关于缺血对肾功能影响的当代观点的最新信息。
最近，部分肾切除术的手术技术已从主要动脉阻断转向在部分肾切除术中尽量减少/消除整体肾缺血。在高保真三维成像的支持下，最近开发了基于新解剖学的部分肾切除术技术，现在可以在对肾残余组织进行节段性、最小或零整体缺血的情况下进行部分肾切除术。一系列创新包括早期松开阻断、节段性阻断、超选择性阻断，现在最终发展为解剖学零缺血手术。通过消除外科医生面临的缺血“限时”压力，这些技术能够从容不迫地进行轮廓精确的肿瘤切除，并进行针对性的缝合止血。最近的数据表明，零缺血部分肾切除术通过尽量减少/消除整体缺血并保留更大的血管化肾体积，可能提供更好的功能预后。
当代部分肾切除术包括一系列手术技术，从传统的阻断式到新的零缺血方法。技术选择应根据肿瘤特征、手术可行性、外科医生经验、患者人口统计学特征和基线肾功能，针对每个病例进行量身定制。
