Shpot E V, Mamedkasimov N A, Alyaev Yu G, Rapoport L M, Proskura A V, Mashin G A
FGAOU VO of I.M. Sechenov First Moscow State Medical University of Minzdrav of Russia, Moscow, Russia.
Clinic of Urology and Male Reproductive Health named after R.M. Fronstein of FGAOU VO of I.M. Sechenov First Moscow State Medical University of Minzdrav of Russia, Moscow, Russia.
Urologiia. 2018 Dec(6):95-100.
to carry out a comparative analysis of treatment results of patients with renal tumors who were undergone to nephron-sparing surgery, depending on the type of temporary and definite hemostasis.
a total of 163 laparoscopic partial nephrectomies were performed by single surgeon from January 2015 to July 2018. The comparative analysis of treatment results of patients with renal tumors based on following parameters: tumor stage, features of the tumor site, the duration of surgery, the amount of blood loss, complications rate and grade as well as functional and oncological outcomes, depending on the type of temporary and definite hemostasis, was conducted. For preoperative planning the generally accepted nephrometric scale R.E.N.A.L. was used as well as 3D-reconstruction of the tumor.
Of the 163 patients, 64 were women (39.3%). The mean age of patients was 56.7+/-11.1 (25-80 years). A clinical stage T1a, T1b, T2 and T3a was diagnosed in 77, 20, 2 and 64 cases, respectively. The average tumor size was 34.8+/-1.1 (11-78 mm). The mean operative time was 84.5+/-32.2 min (30-180). Laparoscopic transperitoneal access was used in 90 patients (55.21%), retroperitoneoscopic approach was chosen in 73 cases (44.79%). The tumor had exophytic growth in 110 cases (67.5%) and in 53 cases it was endophytic (32.5%), while in 59 cases it localized in renal sinus (36.2%). The operative time was significantly shorter in the Group of zero ischemia (72.2+/-29.02 [p<0.001]) and bipolar coagulation of the tumor bed (60.8+/-31.7 [p<0.001]). The mean volume of blood loss was 160.8+/-142.7 ml (30-900). A GFR calculated by the MDRD equation (mean level was 75.7 ml/min/1.73 m2) on the next day and 6 months after surgery showed a slight decrease in group of zero ischemia, compared to other groups: next day and 6 months after surgery it was 72.8+/-21.6 (p<0.001) and 72.01+/-16.6 (p=0.025), respectively. A simple enucleation was performed in 41 cases, while enucleoresection was done in 70 cases. A collection system was opened in 22 cases (13.5%+/-9.8). The suturing and clipping were performed in 20 and 2 patients, respectively. In 2 cases a stenting was performed. In 2 cases there was hemoglobin drop requiring blood transfusion (1.2%+/-3). An embolization due to refractory bleeding was required in 3 cases (1.8%+/-3.7). There was no conversion to open surgery or nephrectomy. Of the 163 tumors, a malignancy was diagnosed in 151 (92.6%+/-7.5) cases. There was no positive surgical margin and recurrence of the tumor.
Laparoscopic partial nephrectomy can be successfully performed under zero ischemia. The intervention without clamping of renal blood vessels contributes to significant preservation of the renal function.
根据临时和确定性止血的类型，对接受保留肾单位手术的肾肿瘤患者的治疗结果进行比较分析。
2015年1月至2018年7月，由一名外科医生共进行了163例腹腔镜肾部分切除术。根据以下参数对肾肿瘤患者的治疗结果进行比较分析：肿瘤分期、肿瘤部位特征、手术持续时间、失血量、并发症发生率和分级以及功能和肿瘤学结局，具体取决于临时和确定性止血的类型。术前规划采用普遍接受的肾测量量表R.E.N.A.L.以及肿瘤的三维重建。
163例患者中，64例为女性（39.3%）。患者的平均年龄为56.7±11.1岁（25 - 80岁）。分别在77、20、2和64例中诊断出临床分期T1a、T1b、T2和T3a。平均肿瘤大小为34.8±1.1（11 - 78mm）。平均手术时间为84.5±32.2分钟（30 - 180分钟）。90例患者（55.21%）采用腹腔镜经腹入路，73例患者（44.79%）选择后腹腔镜入路。110例患者（67.5%）肿瘤呈外生性生长，53例患者（32.5%）肿瘤呈内生性生长，59例患者（36.2%）肿瘤位于肾窦。零缺血组和肿瘤床双极电凝组的手术时间明显更短（分别为72.2±29.02 [p<0.001]和60.8±31.7 [p<0.001]）。平均失血量为160.8±142.7ml（30 - 900ml）。术后第二天和术后6个月通过MDRD方程计算的肾小球滤过率（平均水平为75.7ml/min/1.73m²）显示，与其他组相比，零缺血组略有下降：术后第二天和术后6个月分别为72.8±21.6（p<0.001）和72.01±16.6（p = 0.025）。41例患者进行了单纯剜除术，70例患者进行了剜除切除术。22例患者（13.5%±9.8）打开了集合系统。分别有20例和2例患者进行了缝合和夹闭。2例患者进行了支架置入术。2例患者出现血红蛋白下降需要输血（1.2%±3）。3例患者（1.8%±3.7）因难治性出血需要进行栓塞。没有转为开放手术或肾切除术。163个肿瘤中，151个（92.6%±7.5）被诊断为恶性。没有手术切缘阳性和肿瘤复发。
腹腔镜肾部分切除术可在零缺血情况下成功进行。不夹闭肾血管的干预有助于显著保留肾功能。
