Department of Urology, Keimyung University School of Medicine, Dongsan Hospital, Daegu, Korea.
Department of Urology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
Int J Urol. 2020 May;27(5):457-462. doi: 10.1111/iju.14224. Epub 2020 Apr 16.
To investigate whether differences in surgical details during robot-assisted partial nephrectomy impact postoperative renal function.
Patient, tumor and perioperative characteristics of 751 patients who underwent robot-assisted partial nephrectomy were analyzed with respect to the difference in ipsilateral glomerular filtration rate measured by diethylenetetramine pentaacetic acid renal scan. Detailed surgical methods defined for tumor excision (cutting vs splitting), hemostasis (suturing vs clipping) and renorrhaphy (continuous vs interrupted) were analyzed for early glomerular filtration rate decline and long-term recovery.
The glomerular filtration rate of the entire cohort decreased by 9.8 mL/min/1.73 m (22%) at 3 months postoperatively, gradually increasing thereafter. The recovery slope was 1.7 mL/min/1.73 m /year during a median follow-up period of 23.0 months. Early glomerular filtration rate decline was more pronounced in the cutting group (23.5 vs 20.1%, P = 0.009). Clipping was associated with less glomerular filtration rate decline throughout the observation period, and the recovery slope was also significantly higher (2.7 vs 1.1 mL/min/1.73 m /year). In multivariate analysis, early decline was associated with age, preoperative glomerular filtration rate, parenchymal volume loss and ischemia >25 min. With respect to long-term recovery, suturing had the greatest adverse impact (β = -5.060, P < 0.0001, 95% confidence interval -7.709, -2.411) in addition to parenchymal volume reduction and early decline. In the propensity-matched cohort accounting for differences in tumor size and complexity, suturing was persistently associated with a significant glomerular filtration rate decline until >2 years after surgery.
Hemostatic sutures during robot-assisted partial nephrectomy might interfere with long-term renal function recovery irrespective of parameters that determine the initial function change. As the splitting method reduces the use of sutures, modifying these details might help preserve renal function.
研究机器人辅助部分肾切除术过程中的手术细节差异是否会影响术后肾功能。
分析 751 例接受机器人辅助部分肾切除术患者的患者、肿瘤和围手术期特征，根据二乙三胺五乙酸肾扫描测量的对侧肾小球滤过率差异。分析肿瘤切除（切割与分割）、止血（缝合与夹闭）和肾缝合（连续与间断）的详细手术方法，以评估早期肾小球滤过率下降和长期恢复情况。
整个队列的肾小球滤过率在术后 3 个月时下降了 9.8 mL/min/1.73 m（22%），此后逐渐增加。在中位数为 23.0 个月的随访期间，恢复斜率为 1.7 mL/min/1.73 m /年。在切割组中，早期肾小球滤过率下降更为明显（23.5%比 20.1%，P=0.009）。夹闭在整个观察期间与较低的肾小球滤过率下降相关，恢复斜率也显著更高（2.7 比 1.1 mL/min/1.73 m /年）。在多变量分析中，早期下降与年龄、术前肾小球滤过率、肾实质体积损失和缺血>25 min 有关。关于长期恢复，缝合对肾功能恢复有最大的不利影响（β= -5.060，P <0.0001，95%置信区间 -7.709，-2.411），除了肾实质体积减少和早期下降外。在考虑肿瘤大小和复杂性差异的倾向匹配队列中，缝合术一直与手术后>2 年的显著肾小球滤过率下降相关。
机器人辅助部分肾切除术中的止血缝合可能会干扰长期肾功能恢复，而与决定初始功能变化的参数无关。由于分割方法减少了缝合的使用，因此修改这些细节可能有助于保护肾功能。
