Anderson Barrett G, Potretzke Aaron M, Du Kefu, Vetter Joel, Figenshau R Sherburne
Division of Urologic Surgery, Washington University School of Medicine, 4960 Children's Place, Campus Box 8242, St. Louis, MO, 63110, USA.
Department of Urology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
J Robot Surg. 2018 Sep;12(3):401-407. doi: 10.1007/s11701-017-0745-6. Epub 2017 Aug 31.
In the interest of renal functional preservation, partial nephrectomy has supplanted radical nephrectomy as the preferred treatment for T1 renal masses. This procedure usually involves the induction of renal warm ischemia by clamping the hilar vessels prior to tumor excision. Performing robot-assisted partial nephrectomy (RAPN) "off-clamp" can theoretically prevent renal functional loss associated with warm ischemia. We describe our institutional experience and compare perioperative and renal functional outcomes using a propensity score matched cohort. We conducted a retrospective comparison from a prospectively maintained database of all patients who underwent RAPN from 2009 to 2015. Of those patients, 143 underwent off-clamp RAPN. Fifty off-clamp RAPN patients were propensity score matched with fifty clamped RAPN patients based on renal function, tumor size, and R.E.N.A.L. nephrometry score. The cohorts were compared across demographics, operative information, perioperative outcomes, and renal functional outcomes. For all off-clamp RAPN patients, mean nephrometry score was 7.1, mean estimated blood loss (EBL) was 236.9 mL, perioperative complication rate was 7.7%, and mean decrease in estimated glomerular filtration rate (eGFR) was 7.1% at a median follow-up of 9.2 months. In the propensity score matched cohorts, off-clamp RAPN resulted in a shorter mean operative time (172.0 versus 196.0 min, p = 0.025) and a lower mean EBL (179.7 versus 283.2 mL, p = 0.046). A lower complication rate of 6.0% in the off-clamp group compared with 20.0% in the clamped group approached significance (p = 0.071). Mean preoperative eGFR was similar in both cohorts. Importantly, there was no significant difference in decrease in eGFR between the clamped cohort (9.8%) and off-clamp cohort (11.9%) at a median follow-up of 9.0 months (p = 0.620). Off-clamp RAPN did not result in improved renal functional preservation in our experience. Surprisingly, the off-clamp cohort experienced lower intraoperative blood loss, shorter operative times, and fewer complications.
为了保留肾功能，部分肾切除术已取代根治性肾切除术，成为T1期肾肿块的首选治疗方法。该手术通常包括在肿瘤切除前通过夹闭肾门血管来诱导肾脏热缺血。理论上，实施机器人辅助部分肾切除术（RAPN）“不夹闭”可以防止与热缺血相关的肾功能丧失。我们描述了我们机构的经验，并使用倾向评分匹配队列比较围手术期和肾功能结果。我们对2009年至2015年期间所有接受RAPN的患者的前瞻性维护数据库进行了回顾性比较。在这些患者中，143例接受了不夹闭RAPN。根据肾功能、肿瘤大小和R.E.N.A.L.肾计量评分，将50例不夹闭RAPN患者与50例夹闭RAPN患者进行倾向评分匹配。对两组患者的人口统计学、手术信息、围手术期结果和肾功能结果进行比较。所有不夹闭RAPN患者的平均肾计量评分为7.1，平均估计失血量（EBL）为236.9 mL，围手术期并发症发生率为7.7%，在中位随访9.2个月时，估计肾小球滤过率（eGFR）的平均下降率为7.1%。在倾向评分匹配队列中，不夹闭RAPN的平均手术时间较短（172.0对196.0分钟，p = 0.025），平均EBL较低（179.7对283.2 mL，p = 0.046）。不夹闭组的并发症发生率为6.0%，夹闭组为20.0%，差异接近显著（p = 0.071）。两组患者术前平均eGFR相似。重要的是，在中位随访9.0个月时，夹闭队列（9.8%）和不夹闭队列（11.9%）的eGFR下降没有显著差异（p = 0.620）。根据我们的经验，不夹闭RAPN并没有改善肾功能的保留。令人惊讶的是，不夹闭队列的术中失血量更低，手术时间更短，并发症更少。
