使用近红外荧光导航的超选择性机器人辅助部分肾切除术与肾动脉早期松解夹闭术的前瞻性配对分析结果。
Super-selective robot-assisted partial nephrectomy using near-infrared flurorescence versus early-unclamping of the renal artery: results of a prospective matched-pair analysis.
机构信息
Department of Urology, Grenoble University Hospital, Grenoble, France.
UJF-Grenoble 1, CNRS, INSERM, TIMC-IMAG UMR 5525, 38041 Grenoble, France.
出版信息
Int Braz J Urol. 2018 Jan-Feb;44(1):53-62. doi: 10.1590/S1677-5538.IBJU.2017.0311.
INTRODUCTION
Super-selective clamping of tumor-specific segmental arteries was developed to eliminate ischemia of the remnant kidney while limiting hemorrhage during partial nephrectomy. The objective is to evaluate the benefice of super-selective clamping on renal functional outcome, compared to early-unclamping of the renal artery.
MATERIALS AND METHODS
From March 2015 to July 2016, data from 30 patients undergoing super-selective robot-assisted PN (RAPN) for a solitary tumor by a single surgeon were prospectively collected. Tumor devascularization was assessed using indocyanine green near-infrared fluorescence. A matched-pair analysis with a retrospective cohort undergoing early-unclamping was conducted, adjusting on tumor complexity and preoperative eGFR. Perioperative, oncologic and functional outcomes using DMSA-renal scintigraphy were assessed. Multivariate analysis was performed to identify predictors of postoperative renal function and de novo chronic kidney disease (CKD).
RESULTS
Super-selective RAPN was successful in 23/30 patients (76.7%), 5 requiring secondary main artery clamping due to persistent tumor fluorescence. Matched-pair analysis showed similar operating time, blood loss, positives margins and complication rates. Super-selective clamping was associated with an improved eGFR variation at discharge (p=0.002), 1-month (p=0.01) and 6-month post-op (-2%vs-16% p=0.001). It also led to a better relative function on scintigraphy (46%vs40% p=0.04) and homolateral eGFR (p=0.04), and fewer upstaging to CKD stage ≥3 (p=0.03). On multivariate analysis, super-selective clamping was a predictor of postoperative renal function.
CONCLUSION
Super-selective RAPN leads to an improved preservation of renal function and a reduced risk of de novo CKD stage≥3, while keeping the benefit of main artery clamping on perioperative outcomes.
简介
超选择性夹闭肿瘤特异性节段性动脉被开发出来，以消除部分肾切除术中残余肾脏的缺血，同时限制出血。目的是评估与早期肾动脉松解相比，超选择性夹闭对肾功能结果的益处。
材料和方法
从 2015 年 3 月到 2016 年 7 月，前瞻性收集了由一名外科医生对 30 例孤立肿瘤进行超选择性机器人辅助部分肾切除术（RAPN）的患者数据。使用吲哚菁绿近红外荧光评估肿瘤去血管化。对行早期松解的回顾性队列进行了配对分析，并调整了肿瘤复杂性和术前 eGFR。使用 DMSA-肾闪烁扫描评估围手术期、肿瘤学和功能结果。进行多变量分析以确定术后肾功能和新发慢性肾脏病（CKD）的预测因素。
结果
23/30 例（76.7%）患者成功进行了超选择性 RAPN，5 例由于持续的肿瘤荧光而需要二次主动脉夹闭。配对分析显示手术时间、出血量、阳性切缘和并发症发生率相似。超选择性夹闭与出院时 eGFR 变化（p=0.002）、1 个月（p=0.01）和 6 个月（-2%对-16%，p=0.001）时 eGFR 改善相关。它还导致闪烁扫描的相对功能更好（46%对 40%，p=0.04）和同侧 eGFR 更好（p=0.04），新发 CKD 分期≥3 的风险降低（p=0.03）。多变量分析显示，超选择性夹闭是术后肾功能的预测因素。
结论
超选择性 RAPN 可改善肾功能的保护，并降低新发 CKD 分期≥3 的风险，同时保持主动脉夹闭对围手术期结果的益处。
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