Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, Ohio; Department of Urology, University of Miami, Miami, Florida.
Glickman Urological Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
J Urol. 2015 Jun;193(6):1889-98. doi: 10.1016/j.juro.2015.01.093. Epub 2015 Jan 29.
Partial nephrectomy is the reference standard for the management of small renal tumors and is commonly used for localized kidney cancer. A primary goal of partial nephrectomy is to preserve as much renal function as possible. New baseline glomerular filtration rate after partial nephrectomy can have prognostic significance with respect to long-term outcomes. Recent studies provide an increased understanding of the factors that determine functional outcomes after partial nephrectomy as well as preventive measures to minimize functional decline. We review these advances, highlight ongoing controversies and stimulate further research.
A comprehensive literature review consistent with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria was performed from January 2006 to April 2014 using PubMed®, Cochrane and Ovid Medline. Key words included partial nephrectomy, renal function, warm ischemia, hypothermia, nephron mass, parenchymal volume, surgical approaches to partial nephrectomy, preoperative and intraoperative imaging, enucleation, hemostatic agents and energy based resection. Relevant reviews were also examined as well as their cited references. An additional Google Scholar search was conducted to broaden the scope of the review. Only English language articles were included in the analysis. The primary outcomes of interest were the new baseline level of function after early postoperative recovery, percent decline in function, potential etiologies and preventive measures.
Decline in function after partial nephrectomy averages approximately 20% in the operated kidney, and can be due to incomplete recovery from the ischemic insult or loss of nephron mass related to parenchymal excision or collateral damage during reconstruction. Compensatory hypertrophy in the contralateral kidney after partial nephrectomy in adults is marginal and decline in global renal function for patients with 2 kidneys averages about 10%, although there is some variance based on tumor size and location. Irreversible ischemic injury can be minimized by pharmacological intervention or surgical approaches such as hypothermia, limited warm ischemia, or zero or segmental ischemia. Excessive loss of nephron mass can be minimized by improved preoperative or intraoperative imaging, use of a bloodless field, enucleation and vascular microdissection. Hemostatic agents or energy based resection that minimizes the need for parenchymal and capsular suturing can also optimize preservation of the vascularized nephron mass.
Our understanding of the decline in renal function after partial nephrectomy has advanced considerably, including better appreciation of its magnitude and impact in various settings, possible etiologies and potential preventive measures. Many controversies persist and this remains an important area of investigation.
部分肾切除术是小肾癌治疗的标准方法，常用于局限性肾癌。部分肾切除术的主要目标是尽可能保留更多的肾功能。部分肾切除术后新的肾小球滤过率基线可对长期结果具有预后意义。最近的研究提供了对决定部分肾切除术后功能结果的因素以及预防措施的深入了解，以尽量减少功能下降。我们综述了这些进展，强调了当前的争议并激发了进一步的研究。
根据 PRISMA（系统评价和荟萃分析的首选报告项目）标准，从 2006 年 1 月至 2014 年 4 月，我们在 PubMed®、Cochrane 和 Ovid Medline 上进行了全面的文献综述。关键词包括部分肾切除术、肾功能、热缺血、低温、肾单位质量、实质体积、部分肾切除术的手术方法、术前和术中影像学、剜除术、止血剂和能量基切除术。还检查了相关的综述及其引用的参考文献。还进行了额外的 Google Scholar 搜索以扩大综述范围。仅纳入了分析中的英文文章。主要观察结果是术后早期恢复后新的功能基线水平、功能下降百分比、潜在病因和预防措施。
部分肾切除术后功能下降平均约为 20%，这可能是由于缺血损伤不完全恢复或由于实质切除或重建过程中的侧支损伤导致肾单位质量损失。成年人部分肾切除术后对侧肾脏的代偿性肥大微不足道，2 个肾脏的患者整体肾功能下降约为 10%，尽管基于肿瘤大小和位置存在一定差异。通过药理学干预或手术方法（如低温、有限的热缺血、零或节段性缺血）可将不可逆的缺血性损伤最小化。通过改进术前或术中影像学、使用无血术野、剜除术和血管微解剖术可最大程度减少肾单位质量的过度损失。止血剂或能量基切除术可最大程度减少实质和包膜缝合的需要，从而优化血管化肾单位质量的保留。
我们对部分肾切除术后肾功能下降的认识已经取得了很大进展，包括更好地了解其在各种情况下的程度和影响、可能的病因和潜在的预防措施。许多争议仍然存在，这仍然是一个重要的研究领域。
