不阻断肾蒂技术在后腹腔镜肾部分切除术的应用

The clinical analysis of off-clamp retroperitoneal laparoscopic partial nephrectomy for T_1N_0M_0 renal tumor

目的:探讨经腹膜后入路腹腔镜不阻断肾蒂肾部分切除术的手术效果、安全性及可行性。方法:2013年3月~2015年9月,同一术者对27例T_1N_0M_0期肾肿瘤行后腹腔镜不阻断肾蒂肾部分切除术(不阻断肾蒂组)。以同期36例T_1N_0M_0期肾肿瘤后腹腔镜全阻断肾蒂肾部分切除术(阻断肾蒂组)为对照进行临床数据分析。结果:全部患者手术均顺利完成,无一例中转开放手术。阻断组平均热缺血时间为(21.6±5.3)min。不阻断组术中出血量显著多于阻断组(113.6±26.3)/(46.2±12.5)ml,(P<0.05)、而且肿瘤切除时间更长(5.3±3.2)/(4.3±1.2)min,(P<0.05)。两组间的肾实质缺损缝合时间、切缘阳性率、术中输血、并发症及术后住院时间均差异无统计学意义(P>0.05)。不阻断组较阻断组术后1周和6个月的患肾eGFR恢复更好(62.1±8.3)/(46.8±9.1)ml·min^(-1)·1.73m^(-2)、(72.5±5.7)/(59.5±7.8)ml·min^(-1)·1.73 m^(-2)(P<0.05);两组术后12个月患肾eGFR差异无统计学意义(76.5±7.9)/(68.8±9.7)ml·min^(-1)·1.73m^(-2)(P>0.05);但术后不阻断组患肾eGFR平均变化率较阻断组(-2.3/-7.6)小,差异有统计学意义(P<0.05)。术后随访12个月内全部患者均未见肿瘤复发及转移。结论:T_1N_0M_0期肾肿瘤行后腹腔镜不阻断肾蒂肾部分切除术安全可行、有利于保护患肾功能,但技术难度更大、更具挑战性。

Objective:To investigate the effect and feasibility of off-clamp retroperitoneal laparoscopic partial nephrectomy(RLPN)for T_1N_0M_0 renal tumors.Methods:Retrospective comparative study was performed for two groups of patients with T_1N_0M_0 renal tumors enrolled from March 2013 to September 2015.Off-clamp group was consisted of 27 cases who underwent RRLPN without renal hilar control,and on-clamp group included 36 cases who underwent RRLPN with total hilar control by the same surgeon(Fu Bin).Results:All procedures were performed successfully without conversion.The mean warm ischemia time for on-clamp group was(21.6±5.3)min.Off-clamp group had more bleeding,and longer tumor resection time than on-clamp group(113.6±26.3/46.2±12.5 mL;5.3±3.2/4.3±1.2 min,respectively,P <0.05).There were no significant differences between the two groups in suturing time for renal mesenchymal defect,positive surgical margins,transfusion,complications and postoperative hospital stay time(P>0.05).Compared with on-clamp group,the results of eGFR 7days and six months after surgery for off-clamp group were better(46.8±9.1/62.1±8.3)mL·min^(-1)·1.73m^(-2),(59.5±7.8/72.5±5.7)mL·min^(-1)·1.73m^(-2),respectively,(P<0.05);while the results of postoperative 1-year-eGFR were similar between two groups(76.5±7.9/68.8±9.7 mL·min^(-1)·1.73 m^(-2),P>0.05).Furthermore,the average postoperative change rate of eGFR was statistically significant between off-clamp group and on-clamp group(-2.3/-7.6,P <0.05).No tumor recurrence and metastasis were occurred during 12-months follow-up for these patients.Conclusions:Off-clamp RRLPN is safe and feasible for T_1N_0M_0 renal tumor with better renal function preservation,but more technically challenging.