Yezdani Mona, Yu Sue-Jean, Lee David I
University of Pennsylvania, 51 N. 39th St, MOB 300, Philadelphia, PA, 19104, USA.
Curr Urol Rep. 2016 May;17(5):40. doi: 10.1007/s11934-016-0596-0.
Partial nephrectomy has become an accepted treatment of cT1 renal masses as it provides improved long-term renal function compared to radical nephrectomy (Campbell et al. J Urol. 182:1271-9, 2009). Hilar clamping is utilized to help reduce bleeding and improve visibility during tumor resection. However, concern over risk of kidney injury with hilar clamping has led to new techniques to reduce length of warm ischemia time (WIT) during partial nephrectomy. These techniques have progressed over the years starting with early hilar unclamping, controlled hypotension during tumor resection, selective arterial clamping, minimal margin techniques, and off-clamp procedures. Selective arterial clamping has progressed significantly over the years. The main question is what are the exact short- and long-term renal effects from increasing clamp time. Moreover, does it make sense to perform these more time-consuming or more complex procedures if there is no long-term preservation of kidney function? More recent studies have shown no difference in renal function 6 months from surgery when selective arterial clamping or even hilar clamping is employed, although there is short-term improved decline in estimated glomerular filtration rate (eGFR) with selective clamping and off-clamp techniques (Komninos et al. BJU Int. 115:921-8, 2015; Shah et al. 117:293-9, 2015; Kallingal et al. BJU Int. doi: 10.1111/bju.13192, 2015). This paper reviews the progression of total hilar clamping to selective arterial clamping (SAC) and the possible difference its use makes on long-term renal function. SAC may be attempted based on surgeon's decision-making, but may be best used for more complex, larger, more central or hilar tumors and in patients who have renal insufficiency at baseline or a solitary kidney.
部分肾切除术已成为cT1期肾肿块的一种公认治疗方法，因为与根治性肾切除术相比，它能改善长期肾功能（坎贝尔等人，《泌尿外科杂志》，第182卷：1271 - 1279页，2009年）。肾门阻断用于在肿瘤切除期间帮助减少出血并提高视野清晰度。然而，对肾门阻断导致肾损伤风险的担忧促使人们开发新技术以缩短部分肾切除术期间的热缺血时间（WIT）。这些技术多年来不断发展，从早期的肾门提前松开、肿瘤切除期间的控制性低血压、选择性动脉阻断、最小切缘技术和无阻断手术开始。多年来，选择性动脉阻断有了显著进展。主要问题是增加阻断时间对肾脏的确切短期和长期影响是什么。此外，如果没有长期的肾功能保留，进行这些更耗时或更复杂的手术是否有意义？最近的研究表明，在采用选择性动脉阻断甚至肾门阻断的情况下，术后6个月肾功能没有差异，尽管采用选择性阻断和无阻断技术时，估计肾小球滤过率（eGFR）在短期内下降有所改善（科米诺斯等人，《英国泌尿学杂志》，第115卷：921 - 928页，2015年；沙阿等人，第117卷：293 - 299页，2015年；卡林加尔等人，《英国泌尿学杂志》，doi: 10.1111/bju.13192，2015年）。本文回顾了从完全肾门阻断到选择性动脉阻断（SAC）的进展及其使用对长期肾功能可能产生的差异。SAC可根据外科医生的决策尝试使用，但可能最适合用于更复杂、更大、更靠近中心或肾门的肿瘤，以及基线时存在肾功能不全或单肾的患者。
