非阻断机器人辅助部分肾切除术：我们能走多远？

Off-Clamp Robot-Assisted Partial Nephrectomy: How Far Shall We Proceed?

作者信息

Abdel Raheem Ali, Santok Glen Denmer, Kim Lawrence H C, Chang Ki Don, Lum Trenton G H, Yoon Young Eun, Han Woong Kyu, Choi Young Deuk, Rha Koon Ho

机构信息

1 Department of Urology, Urological Science Institute, Yonsei University College of Medicine , Seoul, South Korea .

2 Department of Urology, Tanta University Medical School , Tanta, Egypt .

出版信息

J Laparoendosc Adv Surg Tech A. 2018 May;28(5):579-585. doi: 10.1089/lap.2017.0464. Epub 2017 Oct 19.

DOI:10.1089/lap.2017.0464

PMID:29048977

Abstract

BACKGROUND

Off-clamp robot-assisted partial nephrectomy (RAPN) is associated with increased intraoperative blood loss compared with on-clamp technique. Our aim was to demonstrate our surgical technique and to determine which tumors are ideally suited for this technique.

METHODS

Sixty-two patients who underwent off-clamp RAPN for renal tumor between 2006 and 2016 were retrospectively analyzed. Increased estimated blood loss (EBL) volume was defined as more than 75 percentile. receiver operating characteristic (ROC) analysis was used to determine exact cut-off tumor size and the preoperative aspects and dimensions used for an anatomical (PADUA) score that are associated with increased EBL. Risk factors for increased EBL >400 mL and chronic kidney disease (CKD) upstaging were evaluated using logistic regression analysis.

RESULTS

The median follow-up period was 20 months (interquartile range [IQR]: 12-84). Patient's mean age, mean tumor size, and mean body mass index were 53.5 ± 12.2 years, 2.6 ± 1.5 cm, and 25 ± 4.1 kg/m, respectively. Median EBL volume was 200 mL (IQR: 100-400). ROC analysis showed that tumor size of 3.2 cm (area under the curve [AUC] = 0.82, P < .001) and PADUA score of 9 (AUC = 0.79, P = .001) were cut-off values for increased EBL >400 mL. Patients with tumor size >3.2 cm had longer operative time (116 versus 163 minutes, P = .002), more EBL (150 versus 575 mL, P < .001), and higher blood transfusion rate (0% versus 18.8%, P = .015), with increased tendency of conversion to radical nephrectomy (0% versus 12.5%, P = .063) compared with tumor size ≤3.2 cm. Overall CKD upstaging was present in 22 patients (35.4%). Multivariable logistic regression analysis showed that EBL >400 mL was the only predictor of CKD upstaging (odds ratio: 6.704, P = .009).

CONCLUSIONS

Our study showed that the risk of intraoperative bleeding and transfusion rate during off-clamp RAPN is increased if tumor size >3.2 cm and/or PADUA complexity score ≥9. Moreover, EBL >400 mL was a risk factor of CKD upstaging, despite zero ischemia. Further larger prospective studies are warranted to validate our results.

摘要

背景

与夹闭技术相比，非夹闭机器人辅助部分肾切除术（RAPN）术中失血量增加。我们的目的是展示我们的手术技术，并确定哪些肿瘤最适合这种技术。

方法

回顾性分析了2006年至2016年间接受非夹闭RAPN治疗肾肿瘤的62例患者。估计失血量（EBL）增加定义为超过第75百分位数。采用受试者操作特征（ROC）分析来确定与EBL增加相关的精确肿瘤大小临界值以及用于解剖学（PADUA）评分的术前特征和维度。使用逻辑回归分析评估EBL>400 mL增加和慢性肾脏病（CKD）分期升级的危险因素。

结果

中位随访期为20个月（四分位间距[IQR]：12 - 84）。患者的平均年龄、平均肿瘤大小和平均体重指数分别为53.5±12.2岁、2.6±1.5 cm和25±4.1 kg/m²。中位EBL量为200 mL（IQR：100 - 400）。ROC分析显示，肿瘤大小3.2 cm（曲线下面积[AUC]=0.82，P<.001）和PADUA评分为9（AUC = 0.79，P =.001）是EBL>400 mL增加的临界值。肿瘤大小>3.2 cm的患者手术时间更长（116对163分钟，P =.002），EBL更多（150对575 mL，P<.001），输血率更高（0%对18.8%，P =.015），与肿瘤大小≤3.2 cm的患者相比，转为根治性肾切除术的趋势增加（0%对12.5%，P =.063）。总体22例患者（3�.4%）存在CKD分期升级。多变量逻辑回归分析显示，EBL>400 mL是CKD分期升级的唯一预测因素（比值比：6.704，P =.009）。