Polascik T J, Pound C R, Meng M V, Partin A W, Marshall F F
James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, Maryland 21287-2101, USA.
J Urol. 1995 Oct;154(4):1312-8. doi: 10.1016/s0022-5347(01)66845-9.
We evaluate whether partial nephrectomy can be performed safely and efficaciously for renal tumors.
The results of 67 partial nephrectomies performed between 1977 and 1994 for renal cell carcinoma (51), oncocytoma (9), angiomyolipoma (3), transitional cell carcinoma (3) and other nonneoplastic lesions (2) were analyzed retrospectively in detail.
Diminished complication rates were noted after 1988, and were attributed to improvements in surgical technique and an increased incidence of smaller, serendipitously discovered tumors. Although 35.5% of the patients had preoperative renal impairment (mean serum creatinine 2.1 mg./dl.), there were minimal changes in renal function and no patient required acute hemodialysis following partial nephrectomy. Among 42 patients with clinical stage T1 to T2 renal cell carcinoma undergoing partial nephrectomy local recurrence was identified in 8.3% of those with primary neoplasms. All 6 patients with local recurrence had negative surgical margins, recurrence often, distant from the operative site and multifocal disease, implicating multicentricity as the etiology of local recurrence. Five patients (83.3%) with local recurrence were alive and asymptomatic at a mean of 138 months after partial nephrectomy. Since capsular penetration was identified in 5 of 27 renal cell carcinomas (18.5%) with a diameter of 3.5 cm. or less, aggressive surgical resection with adequate tumor-free parenchymal and perinephric margins is necessary even for small lesions.
With improved surgical techniques, including regional hypothermia, intraoperative sonography, meticulous dissection and injection of the collecting system with methylene blue, partial nephrectomy is safe and effective in properly selected patients.
我们评估对肾肿瘤进行部分肾切除术是否能够安全有效地实施。
对1977年至1994年间因肾细胞癌（51例）、嗜酸细胞瘤（9例）、血管平滑肌脂肪瘤（3例）、移行细胞癌（3例）及其他非肿瘤性病变（2例）而施行的67例部分肾切除术的结果进行了详细的回顾性分析。
1988年后并发症发生率降低，这归因于手术技术的改进以及偶然发现的较小肿瘤的发生率增加。尽管35.5%的患者术前存在肾功能损害（平均血清肌酐2.1mg/dl），但部分肾切除术后肾功能仅有轻微变化，且无患者需要进行急性血液透析。在42例临床分期为T1至T2的肾细胞癌患者接受部分肾切除术后，原发性肿瘤患者中有8.3%出现局部复发。所有6例局部复发患者的手术切缘均为阴性，复发常远离手术部位且为多灶性疾病，提示多中心性是局部复发的病因。5例（83.3%）局部复发患者在部分肾切除术后平均138个月时存活且无症状。由于在直径3.5cm或更小的27例肾细胞癌中有5例（18.5%）发现有包膜侵犯，因此即使对于小病变，也需要进行积极的手术切除并获得足够的无瘤肾实质和肾周切缘。
随着手术技术的改进，包括局部低温、术中超声检查、细致的解剖以及用亚甲蓝注入集合系统，部分肾切除术在经过适当选择的患者中是安全有效的。
