Shah Paras H, George Arvin K, Moreira Daniel M, Alom Manaf, Okhunov Zhamshid, Salami Simpa, Waingankar Nikhil, Schwartz Michael J, Vira Manish A, Richstone Lee, Kavoussi Louis R
Department of Urology, Smith Institute for Urology, New Hyde Park, NY, USA.
National Cancer Institute - Urologic Oncology Branch, Bethesda, MD, USA.
BJU Int. 2016 Feb;117(2):293-9. doi: 10.1111/bju.13309. Epub 2015 Oct 1.
To evaluate whether elective off-clamp laparoscopic partial nephrectomy (LPN) affords long-term renal functional benefit compared with the on-clamp approach.
This is a retrospective review of patients who underwent elective LPN between 2006 and 2011. Patients were followed longitudinally for up to 5 years. In all, 315 patients with radiographic evidence of a solitary renal mass and normal-appearing contralateral kidney underwent elective LPN; 209 were performed on-clamp vs 106 off-clamp. One patient who required conversion from LPN to open PN was excluded from the study. Additionally, four patients in the on-clamp cohort who underwent subsequent radical nephrectomy for local-regional recurrence were excluded from longitudinal functional evaluation after their procedure. The primary objective was to evaluate differences in postoperative estimated glomerular filtration rate (eGFR) between hilar clamping groups. Subgroup analyses were performed for patients with clamp times >30 min and those with baseline renal insufficiency (eGFR <60 mL/min/1.73m(2) ). Risk of developing worsened or new-onset renal insufficiency was also compared.
The mean preoperative eGFR was similar between the on-clamp and off-clamp cohorts (80.7 vs 84.1 mL/min/1.73m(2) , P > 0.05). Univariable and multivariable analyses did not show significant differences in postoperative eGFR between both groups among all-comers, those with clamp times >30 min, and patients with baseline renal insufficiency. Risk of chronic kidney disease was not diminished by the off-clamp approach with up to 5 years of follow-up.
Progressive recovery of renal function after hilar clamping in the elective setting eclipses short-term functional benefit achieved with off-clamp LPN by 6 months; there was no significant difference in eGFR or the percentage incidence of chronic kidney disease between the on-clamp and off-clamp cohorts with up to 5 years follow-up. As such, eliminating transient ischaemia during elective LPN does not confer clinical benefit.
评估选择性非阻断性腹腔镜肾部分切除术（LPN）与阻断性手术相比是否能带来长期肾功能益处。
这是一项对2006年至2011年间接受选择性LPN患者的回顾性研究。对患者进行长达5年的纵向随访。共有315例有影像学证据显示为孤立性肾肿块且对侧肾脏外观正常的患者接受了选择性LPN；其中209例采用阻断性手术，106例采用非阻断性手术。1例需要从LPN转为开放性肾部分切除术的患者被排除在研究之外。此外，阻断性手术组中4例因局部区域复发而随后接受根治性肾切除术的患者在手术后被排除在纵向功能评估之外。主要目的是评估肾门阻断组之间术后估计肾小球滤过率（eGFR）的差异。对钳夹时间>30分钟的患者和基线肾功能不全（eGFR<60 mL/min/1.73m²）的患者进行亚组分析。还比较了发生肾功能恶化或新发肾功能不全的风险。
阻断性手术组和非阻断性手术组术前平均eGFR相似（80.7 vs 84.1 mL/min/1.73m²，P>0.05）。单因素和多因素分析显示，在所有患者、钳夹时间>30分钟的患者以及基线肾功能不全的患者中，两组术后eGFR均无显著差异。在长达5年的随访中，非阻断性手术方法并未降低慢性肾病的风险。
在选择性手术中，肾门阻断后肾功能的逐步恢复在6个月时超过了非阻断性LPN所带来的短期功能益处；在长达5年的随访中，阻断性手术组和非阻断性手术组的eGFR或慢性肾病的发生率百分比无显著差异。因此，在选择性LPN期间消除短暂性缺血并不能带来临床益处。
