A systematic review of robot-assisted partial nephrectomy outcomes for advanced indications:Large tumors(cT2-T3),solitary kidney,completely endophytic,hilar,recurrent,and multiple renal tumors

Objective:Robot-assisted partial nephrectomy(RAPN)has become widely used for treatment of renal cell carcinoma and it is expanding in the field of complex renal masses.The aim of this systematic review was to analyze outcomes of RAPN for completely endophytic renal masses,large tumors(cT2-T3),renal cell carcinoma in solitary kidney,recurrent tumors,completely endophytic and hilar masses,and simultaneous and multiple tumors.Methods:A comprehensive search in the PubMed,Scopus,Web of Science,and Cochrane Central Register of Controlled Trials databases was performed in December 2022 for English language papers.The primary endpoint was to evaluate the role of RAPN in the setting of each category of complex renal masses considered.The secondary endpoint was to evaluate the surgical and functional outcomes.Results:After screening 1250 records,43 full-text manuscripts were selected,comprising over 8500 patients.Twelve and thirteen studies reported data for endophytic and hilar renal masses,respectively.Five and three studies reported outcomes for cT2-T3 and solitary kidney patients,respectively.Four studies focused on redo-RAPN for recurrent tumors.Two studies investigated simultaneous bilateral renal masses and five reports focused on multiple tumor excision in ipsilateral kidney.Conclusion:Over the past decade,evidence supporting the use of RAPN for the most challenging nephron-sparing surgery indications has continuously grown.Although limitations remain including study design and lack of detailed long-term functional and oncological outcomes,the adoption of RAPN for the included advanced indications is associated with favorable surgical outcomes with good preservation of renal function without compromising the oncological result.Certainly,a higher likelihood of complication might be expected when facing extremely challenging cases.However,none of these indications should be considered per se an exclusion criterion for performing RAPN.Ultimately,a risk-adapted approach should be employed.

Surgical Video Review of Warm Ischemia Time during Laparoscopic Partial Nephrectomy and Impact on Positive Surgical Margins and Postoperative Complications

Introduction: A surgical video review is an emerging tool for quality improvement, especially in complex surgeries such as laparoscopic partial nephrectomy (LPN). Assessing and measuring the warm ischemia time (WIT) during LPN by dividing it into the time used for resection (ResT), time used for reconstruction (RecT) and intermediate time (IntT) has not been performed before. This study aimed to analyze the factors that can influence all these surgical times and assess their impact on positive surgical margins (PSM) and complication rates. Methods: We evaluated 36 surgical video recordings from patients who underwent LPN and measured WIT, ResT, RecT and IntT with a stopwatch. Factors such as tumor characteristics and surgeon experience were also recorded. SPSS software was used to identify the predictor factors for all these surgical times and to correlate the ResT with PSM and RecT with the complication rate. Results: We recorded a mean WIT of 887 seconds. The mean ResT, RecT and IntT were 240 (27.2% of WIT), 473 (52.6% of WIT) and 173 s (20.2% of WIT), respectively. We found a moderate correlation between the WIT (p = 0.030), IntT and the R.E.N.A.L. score (p = 0.019). The surgeon with less than 100 LPN had significantly longer WIT, ResT, and RecT values, with means of 977 (p = 0.015), 268 (p = 0.019) and 530 seconds (p = 0.015), respectively. No correlation was found between ResT and PSM (p = 0.418);however, a strong correlation was found between RecT and the probability of developing complications (p = 0.012). Conclusion: The surgeon’s experience influences WIT, ResT, and RecT, but not IntT, which depends on tumor complexity. RecT affects the probability of developing complications. IntT represents a fifth of the WIT and efforts to reduce the WIT should focus on reducing the IntT for complex tumors, by improving surgical planning.

Absence of asymptomatic unruptured renal artery pseudoaneurysm on contrast-enhanced computed tomography after robot-assisted partial nephrectomy without parenchymal renorrhaphy

Objective:To assess the incidence of asymptomatic unruptured renal artery pseudoaneurysm(RAP)on contrast-enhanced computed tomography(CE-CT)after robot-assisted partial nephrectomy(RAPN)without parenchymal renorrhaphy.Methods:From May 2016 to December 2017,78 patients underwent RAPN for renal tumors.Inner suture was performed in the opened collecting system or renal sinus,whereas parenchymal renorrhaphy was not.For hemostasis,the soft coagulation system was used,and absorbable hemostats were placed on the resection bed.CE-CT was carried out within 7 days after surgery.Data on these patients were prospectively collected.A single radiologist determined the diagnosis of RAP.Results:Median(range)data were as follows:Patient age,65(19-82)years;radiographic tumor size,30(12-95)mm;operating time,166(102-294)min;warm ischemic time,16(7-67)min;and blood loss,15(0-4450)mL.One patient(1.6%)required a perioperative blood transfusion.No patient required conversion to open surgery or nephrectomy.CE-CT was carried out at median 6(3-7)days after surgery.CE-CT showed no RAP development in all 61 patients.Urinary leakage was not observed.One patient had acute cholecystitis,a postoperative complication classified as Clavien-Dindo grade higher than 3,which was treated with cholecystectomy.Positive surgical margin was identified in four patients(6.6%).Conclusion:RAPN using soft coagulation and absorbable hemostats without renorrhaphy appears to be feasible and safe.Our technique could eliminate the risk of RAP.

Retroperitoneal laparoscopic partial nephrectomy for unilateral synchronous multifocal renal carcinoma with different pathological types:A case report

BACKGROUND The majority of renal cell carcinomas are single lesions;unilateral synchronous multifocal renal carcinoma(USMRC)is rarely reported and poses a treatment challenge for urological oncologists.CASE SUMMARY A 56-year-old man was hospitalized for pain and discomfort in the right kidney area for 6 d.Contrast-enhanced computed tomography demonstrated cT1a renal tumors at the lower pole of the right kidney and a cT1b renal tumor at the middle dorsal portion of the right kidney.The patient underwent retroperitoneal laparoscopic partial nephrectomy(RLPN).There were no complications peri-operatively.Histopathology revealed a low-grade,pathologic stage T1a(pT1a),clear cell renal cell carcinoma at the lower pole of the right kidney and a pT1b,chromophobe renal cell carcinoma at the middle dorsal portion of the right kidney.No tumor bed recurrence or metastasis was observed on imaging and his renal function remained stable during the 12-mo follow-up period.CONCLUSION RLPN is a safe,effective,and feasible for the management of USMRC,which can obtain equivalent oncological results with optimal renal function preservation.

Pneumothorax during retroperitoneal laparoscopic partial nephrectomy in a lupus nephritis patient:A case report

BACKGROUND Downgrading target treatment and laparoscopic partial nephrectomy have become increasingly popular in patients with renal cell carcinomas.Rare as it is,pneumothorax is one of the most severe intraoperative complications which needs immediate recognition.On the other hand,as a rheumatological disease,lupus nephritis requires a long period of hormone therapy.Cases of pneumothorax in hormone-consuming renal cancer patients are even fewer.CASE SUMMARY A 39-year-old woman was admitted to our department to take a laparoscopic partial nephrectomy.The patient had a medical history of lupus nephritis and renal clear cell carcinoma with hormone and target treatment.Her blood oxygen saturation dropped to 92%during the operation,and pneumothorax was detected by ultrasound.O2 inhalation and lung dilation were performed.Her vital signs were monitored closely throughout the operation.The operation was accomplished,and she regained consciousness smoothly.A postoperative bedside chest X-ray was conducted after she was transferred to the urosurgery ward,while no evidence of further pneumothorax or lib injury was observed.CONCLUSION Pneumothorax is a severe complication in laparoscopic or robotic-assisted laparoscopic operations,especially in retroperitoneal ones.It is easily neglected unless the injury of the diaphragm is found.Low insufflation pressure and shorter operation time are necessary for patients with a history of long-term hormone consumption or chronic immune system disease.

Prediction of Intraoperative Trifecta Achievement during Laparoscopic Partial Nephrectomy

Purpose: We introduce the concept of intraoperative Trifecta during laparoscopic partial nephrectomy (LPN) as the simultaneous achievement of estimated blood loss (EBL) < 500 ml, warm ischemia time (WIT) < 20 minutes and minimal changes of the intraoperative course. The study’s aim was to find preoperative factors that could predict the likelihood of achieving intraoperative Trifecta and build a surgical nomogram. Methods: We retrospectively evaluated 122 patients who underwent LPN. Preoperative factors like age, sex, body-mass index (BMI), kidney function, tumor characteristics (R.E.N.A.L. score) and Charlson-Comorbidity-Index (CCI) were recorded. Intraoperative complication (IOC) was graded according to the Rosenthal classification. R software was used to find a predicting model for achievement of Trifecta using preoperative variables and a nomogram was built. Results: The surgical features include median EBL of 100 ml having 6.5% bleed > 500 ml, median WIT of 12 minutes having 7.3% more than 20 minutes. There was recorded a 12.3% IOC with a mean Rosenthal’s grade of 0.2. Intraoperative Trifecta was achieved in 105 patients (86%) and three preoperative factors were chosen for the predictive model: BMI (p = 0.041), CCI (p = 0.037) and RENAL score (p = 0.002). A nomogram was generated and the ROC-AUC of the model was 75.8%. Conclusion: We have defined an intraoperative Trifecta concept as the achievement of EBL < 500 ml, WIT < 20 minutes and minimal changes of the intraoperative course. A nomogram was developed from preoperative factors like BMI, CCI and R.E.N.A.L. score. It can be used to estimate the probability of Trifecta achievement in patients treated with LPN.

Single-site laparoscopic partial nephrectomy: Where are we going?

AIM:To review an evolution of laparoscopic surgery,there has been a growing interest in laparoendoscopic single-site surgery(LESS).METHODS:A comprehensive electronic literature search was conducted using PubM ed database to identify all publications relating to LESS-partial nephrectomy(PN).The research includes articles published from April 2008 to January 2014.We focused our attention only on articles in which were cited the single-site surgical technique(laparoscopic and robotic),tumour stage and grade,mean tumour size,intraoperative variables,blood loss and transfusion rate,length of postoperative stay and complication rates,Clavien classification,positive of surgical margins,pain assessment at discharge.RESULTS:A total of 9 studies were collected with 221patients included.The mean patients age was 62 years.The mean tumor size was 2.35 cm with a mean operative time of 181 min(range 111-270 min)and 58.3%were done by robot.The mean ischemia time was 23.6min.The 25.8%of patients underwent an unclamp LESS-PN.Mean estimated blood loss was 296 mL and median length of hospital stay was 4 d.The rate of severe post-operative complications(≥Clavien gradeⅢ)was 5.4%.Not all surgical series of LESS-PN or Robotic-LESS-PN shows conversion in Multiport Laparoscopic or Open Surgery.Regarding oncologic outcomes,surgical margins were positive 4%of patients(9/221),no distant or port-site metastases were recorded.CONCLUSION:LESS-PN and RLESS-PN are feasible and associated with reduced postoperative pain,shorter median hospital stay,shorter recovery time,and better cosmetic satisfaction without compromising surgical and oncological safety.

Robotic-assisted laparoscopic partial nephrectomy: A comparison of approaches to the posterior renal mass

AIM: To evaluate outcomes of robotic-assisted laparoscopic partial nephrectomy performed for posterior renal tumors via a transperitoneal or retroperitoneal approach.METHODS: Retrospective review was performed for patients who underwent robotic-assisted laparoscopic partial nephrectomy(RALPN) for a posterior renal tumor between 2009-2015. Patient demographic characteristics, operative factors, pathology, oncologic outcomes, renal function, and tumor complexity were obtained. Radius of the tumor, exophytic/endophytic properties of the tumor, nearness of tumor to the collecting system, anterior/posterior position, location relative to the polar line(RENAL) nephrometry scores were calculated. nephrometry scores were calculated. The operative approach was determined by the primary surgeon. RESULTS: A total of 91 patients were identified who underwent RALPN for a posterior renal tumor. Fifty-four procedures were performed via the retroperitoneal(RP) approach, and 37 via the transperitoneal(TP) approach. There were no significant differences in patient factors(race, sex, age and body mass index), RENAL nephrometry scores, tumor size, conversion rates, or margin status. Among procedures performed on-clamp, therewas no significant difference in warm ischemia times. Total operative time(180.7 min for RP vs 227.8 min for TP, P < 0.001), robotic console time(126.9 min for RP vs 164.3 min for TP, P < 0.001), and median estimated blood loss(32.5 m L for RP vs 150 mL for TP, P < 0.001) were significantly lower via the RP approach. Off-clamp RALPN was performed for 31(57.4%) of RP procedures vs 9(24.3%) of TP procedures. Oncologic and renal functional outcomes were equivalent.CONCLUSION: The RP approach to RALPN for posterior renal tumors is superior with regard to operative time and blood loss and the ability to be performed off-clamp.

Harmonic scalpel versus traditional scissors in laparoscopic partial nephrectomy:A propensity score-based analysis

Objective:The present study aims to compare the clinical efficacy of laparoscopic partial nephrectomy using a harmonic scalpel versus traditional scissor.Methods:A retrospective review was conducted in patients with localized renal tumors and scheduled for laparoscopic partial nephrectomy from January 2015 to December 2019.Eventually,225 patients joined this retrospective study.Patients were divided into the harmonic scalpel group or scissor group based on the method used,with 71 cases and 154 cases respectively.Propensity score matching(1:1)was performed to adjust for potential baseline confounders,and each group had 57 cases.Patient characteristics,perioperative clinical results,complications,and oncological results were compared between the two groups.Results:After matching,patient characteristics were not significantly different between the two groups.The scissor group was associated with a significantly shorter operative time(105 min vs.130 min,p<0.001),shorter warm ischemia time(19.35 min vs.22.07 min,p?0.005).However,the harmonic scalpel group was associated with significantly less estimated blood loss(20 mL vs.30 mL,p?0.013)and shorter length of stay(8 d vs.10 d,p?0.040).There was no significantly difference in indwelling time of drainage tube,perioperative complication,oncological outcomes or recurrence rates.Conclusions:The harmonic scalpel is used safely and effectively in laparoscopic partial nephrectomy,and has benefits in intraoperative blood loss and length of stay.

Heminephrectomy for a large renal mass in a horseshoe kidney: A case report outlining a robotic assisted laparoscopic approach

With an incidence of 1/500,a horseshoe kidney is not uncommon.Tumours discovered in horseshoe kidney however are quite rare,and prove difficult to surgically manage due to complex vascular anatomy.With variable surgical approaches previously described,only a select few robot-assisted cases have been reported.This case describes one such robot-assisted laparoscopic heminephrectomy,with the use of indocyanine green and an endovascular stapler to successfully demarcate ischemia and achieve hemostasis intraoperatively.No complications were encountered,and pathology revealed a pT1bN0 clear cell renal cell carcinoma with negative surgical margins,demonstrating the feasibility of our approach.

Current strategies to diagnose and manage positive surgical margins and local recurrence after partial nephrectomy

Objective:No standard strategy for diagnosis and management of positive surgical margin(PSM)and local recurrence after partial nephrectomy(PN)are reported in literature.This review aims to provide an overview of the current strategies and further perspectives on this patient setting.Methods:A non-systematic review of the literature was completed.The research included the most updated articles(about the last 10 years).Results:Techniques for diagnosing PSMs during PN include intraoperative frozen section,imprinting cytology,and other specific tools.No clear evidence is reported about these methods.Regarding PSM management,active surveillance with a combination of imaging and laboratory evaluation is the first option line followed by surgery.Regarding local recurrence management,surgery is the primary curative approach when possible but it may be technically difficult due to anatomy resultant from previous PN.In this scenario,thermal ablation(TA)may have the potential to circumvent these limitations representing a less invasive alternative.Salvage surgery represents a valid option;six studies analyzed the outcomes of nephrectomy on local recurrence after PN with three of these focused on robotic approach.Overall,complication rates of salvage surgery are higher compared to TA but ablation presents a higher recurrence rate up to 25%of cases that can often be managed with repeat ablation.Conclusion:Controversy still exists surrounding the best strategy for management and diagnosis of patients with PSMs or local recurrence after PN.Active surveillance is likely to be the optimal first-line management option for most patients with PSMs.Ablation and salvage surgery both represent valid options in patients with local recurrence after PN.Conversely,salvage PN and radical nephrectomy have fewer recurrences but are associated with a higher complication rate compared to TA.In this scenario,robotic surgery plays an important role in improving salvage PN and radical nephrectomy outcomes.

右美托咪定对腹腔镜肾部分切除术患者远期肾功能的保护作用

目的观察右美托咪定(DEX)对腹腔镜肾部分切除术(LPN)患者术后远期肾功能的保护作用。方法选取2021年5月至2022年12月安徽医科大学第二附属医院择期行LPN患者80例,根据随机对照表法将患者随机分为右美托咪定组和对照组,每组40例。右美托咪定组在肾动脉阻断前30 min给予DEX负荷量0.6 mg/kg,之后改为维持剂量0.5μg/(kg·h)并持续到手术结束前30 min。对照组静脉泵注相同剂量和时间的生理盐水。记录患者麻醉诱导前(T_(0))、插管即刻(T_(1))、肾动脉阻断即刻(T_(2))、肾动脉开放即刻(T_(3))和拔管即刻(T_(4))的平均动脉压(MAP)和心率(HR)。监测患者术前以及术后1、6个月^(99m)Tc-DTPA肾小球滤过率(GFR)、血清胱抑素C(Cys-C)和血清肌酐(SCr),并根据公式计算出基于SCr的估计GFR(eGFRcr)、基于SCr和Cys-C的估计GFR(eGFRcr-cys)和基于Cys-C的估计GFR(eGFRcys)。观察患者术前以及术后24 h和48 h血清中性粒细胞明胶酶相关载脂蛋白(NGAL)和尿肾损伤分子-1(KIM-1)含量。结果T_(1)、T_(4)时,右美托咪定组MAP低于对照组(P<0.05),T_(2)时,MAP高于对照组(P<0.05);T_(1)时,右美托咪定组HR低于对照组(P<0.05)。术后24 h和48 h,右美托咪定组血清NGAL和尿KIM-1低于对照组(P<0.05)。术后1、6个月,右美托咪定组手术侧^(99m)Tc-DTPA GFR值高于对照组(P<0.05),而两组对侧^(99m)Tc-DTPA GFR和总^(99m)Tc-DTPA GFR值比较,差异无统计学意义(P>0.05)。术后1、6个月,右美托咪定组eGFRcr-cys和eGFRcys值高于对照组(P<0.05),但两组eGFRcr值比较,差异无统计学意义(P>0.05)。结论DEX可对LPN术后远期肾功能产生保护作用,是防治LPN术后慢性肾脏病发生和发展的潜在治疗药物。

国产Agibot^(■)腔镜机器人首次人体试验手术3例报道

本文回顾性分析了我院2023年12月实施国产Agibot^(■)腔镜机器人人体试验的患者3例,均为男性,前列腺癌2例,肾癌1例。年龄44.8~75.4岁,其中根治性前列腺切除术2例(受试者编号Y01001、Y01002)、肾部分切除术1例(受试者编号Y01003)。手术均顺利完成,无中转开放或普通腹腔镜手术,无术中及术后并发症,无输血。2例根治性前列腺切除术的术前机器安装时间4~8 min,手术时间132~141 min,引流管引流时间3d,术后住院时间3~5 d,术后病理诊断为前列腺腺癌,术后30 d随访前列腺特异性抗原(PSA)均<0.1μg/L。1例肾部分切除术的术前机器安装时间6min,手术时间87 min,热缺血时间24 min,引流管引流时间3 d,术后住院时间7 d,术后病理诊断为肾透明细胞癌,切缘阴性。术中指标及术后结果表明国产Agibot^(■)腔镜机器人手术效果良好,患者康复顺利。长期影响有待通过大样本、多中心、长期随访研究进一步验证。

MDA、AOPP、Nrf2、GSH水平与肾细胞癌患者腹腔镜肾部分切除术后急性肾损伤的相关性

目的分析丙二醛(MDA)、人晚期氧化蛋白产物(AOPP)、血浆核因子E2相关因子(Nrf2)和谷胱甘肽(GSH)水平与肾细胞癌患者腹腔镜肾部分切除术(LPN)后急性肾损伤(AKI)的相关性。方法纳入2022年2-8月解放军总医院第三医学中心泌尿外科收治的110例肾细胞癌患者。依据国际肾病改善全球预后(KDIGO)标准分为AKI组(n=30)和非AKI组(n=80),再依据年龄分为老年AKI(>65岁,n=14)、中年AKI(50~65岁,n=16)与老年非AKI(>65岁,n=30)、中年非AKI(50~65岁,n=50)4个亚组。收集患者的临床资料和实验室检查结果,并于手术开始前(T_(1))、手术结束后(T_(2))、术后24 h(T_(3))采集静脉血,检测MDA、AOPP、Nrf2、GSH水平,比较各亚组不同时间点MDA、AOPP、Nrf2、GSH水平,并分析其与LPN术后AKI发生的相关性,采用单因素和多因素logistic回归分析LPN术后发生AKI的危险因素。结果Spearman相关分析显示,老年患者各时间点MDA水平与LPN术后AKI的发生无明显相关性(P>0.05),AOPP-T_(3)水平与LPN术后AKI的发生呈正相关(r=0.315,P=0.037),Nrf2-T_(3)、GSH-T_(2)水平与LPN术后AKI的发生呈负相关(r=-0.365,P=0.015;r=-0.338,P=0.025)。中年患者各时间点MDA、AOPP、Nrf2、GSH水平与LPN术后AKI的发生无明显相关性(P>0.05)。多因素logistic回归分析显示,BMI、手术切除肾体积是老年患者LPN术后AKI发生的独立危险因素(OR=2.724,P=0.040;OR=1.309,P=0.049),GSH-T_(2)是老年患者LPN术后AKI发生的独立保护因素(OR=0.271,P=0.042);术中胶体液入量是中年患者LPN术后AKI发生的独立危险因素(OR=1.006,P=0.007),术中尿量是中年患者LPN术后AKI发生的独立保护因素(OR=0.104,P=0.007)。结论老年患者LPN术后AKI的发生可能与术后AOPP水平升高和Nrf2、GSH水平降低有关,且术后GSH是老年患者LPN术后AKI发生的独立保护因素,而中年患者LPN术后AKI的发生则与围手术期MDA、AOPP、Nrf2、GSH水平变化无明显相关性。

经腹腔入路与经腹膜后入路行腹腔镜肾部分切除术治疗肾肿瘤的效果比较

目的比较经腹腔与经腹膜后入路行腹腔镜肾部分切除术治疗肾肿瘤的临床效果。方法选取2020年1月至2022年12月于我院行腹腔镜肾部分切除治疗的86例肾肿瘤患者,以手术入路方式不同分成腹膜后入路组(n=43)和腹腔入路组(n=43)。比较两组患者的围手术期指标、并发症发生率及生活质量。结果腹膜后入路组手术时间、肠道恢复时间、住院时间均短于腹腔入路组,术中出血量低于腹腔入路组(P<0.05)。腹膜后入路组术后并发症发生率为6.98%,低于腹腔入路组的23.26%(P<0.05)。术后1个月,两组的WHOQOL-BREF评分均升高,且腹膜后入路组WHOQOL-BREF评分高于腹腔入路组(P<0.05)。结论与经腹腔入路相比,经腹膜后入路行腹腔镜肾部分切除术治疗肾肿瘤的手术创伤更小,可加速肾肿瘤患者术后恢复,明显降低并发症发生率,提升生活质量。

Long-term oncologic outcomes of laparoscopic versus open partial nephrectomy

Background Most of the literatures on laparoscopic partial nephrectomy （LPN） versus open partial nephrectomy （OPN） focus on technical details and early or mid-term oncologic outcomes, reflecting that the approach is safe and provides mid- term benefits compared with traditional open surgery. However, the difference of long-term oncologic outcome between LPN and OPN remains unclear. The aim of this meta-analysis was to evaluate the long-term oncologic outcome of LPN in the treatment of localized renal tumors compared with that of OPN. Methods A systematic search of electronic databases including Medline, Embase, and Cochrane library was conducted. Comparative studies reporting on long-term oncologic outcome of LPN versus OPN were regarded eligible. The odds ratio （OR） and its corresponding 95% confidence intervals （CO were calculated for the oncologic outcomes. The methodologic quality of the included studies was evaluated using the strict criteria of the Newcastle-Ottawa scale. Results Six comparative studies （1495 participants including 555 LPN and 940 OPN） were included in the present study. There was no significant difference between LPN and OPN in 5-year overall survival （OS） rates （OR=1.83, 95% Cl （0.80, 4.19））, 5-year cancer specific survival （CSS） rates （OR=1.09, 95% CI （0.62, 1.92））, and 5-year recurrence free survival （RFS） rates （OR=0.68, 95% CI （0.37, 1.26））. Conclusion The results of this meta-analysis revealed that there was no significant difference in long-term oncologic outcome between LPN and OPN for treatment of localized renal tumors.

Comparison of two different renorrhaphy techniques in retroperitoneal laparoscopic partial nephrectomy for complex tumor

Background Partial nephrectomy is currently the standard treatment for clinical T1 renal neoplasms, as it can provide oncologic outcomes equivalent to radical nephrectomy. The aim was to evaluate the efficacy of self-retaining suture （SRS） in renorrhaphy technique in retroperitoneal laparoscopic partial nephrectomy （LPN） for a single renal mass of moderate or high complexity by assessing peri-operative outcomes. Methods A retrospective analysis was done of 64 patients between 2010 and 2012 for complex renal mass （RENAL score 〉7） in whom retroperitoneal LPN was performed with two layers using continuous knotless barbed suture （Quill PDO SRS group; n=34） and absorbable vicryl （non-SRS group; n=30）, respectively. Cases were matched for RENAL score. All the surgical procedures were performed by the same surgeon with experience of more than 500 cases of LPN. Comparisons were made in patients and preoperative outcomes and peri-operative complications between SRS group and non-SRS group. Results Mean warm ischemia time （WIT） in SRS group was less than non-SRS group （18.0 vs. 24.8 minutes, P=-0.021）. Renorrhaphy suture cost in SRS group was lower than non-SRS group （$269.6 vs. $335.8, P=0,001）. There were no significant differences between the two groups for postoperative changes in creatinine and estimated glomerular filtration rate and the rate of peri-operative complications. Conclusion SRS was safe for complex renal tumor with two layers, continuous and unknot suture, during LPN and would reduce the WIT and renorrhaphy suture cost significantly.

改良加速康复外科在腹腔镜肾部分切除术中的应用

目的探讨改良加速康复外科(ERAS)在腹腔镜肾部分切除术中的可行性和安全性。方法回顾性分析2019年5月至2021年6月北京协和医院泌尿外科采用腹腔镜肾部分切除术治疗的肾肿瘤患者临床资料,根据围术期是否采用改良加速康复外科策略分为常规组和改良ERAS组,比较两组患者的术后恢复情况和并发症发生情况。结果共纳入243例患者,其中改良ERAS组142例,常规组101例,两组患者所在地域、年龄、性别和肿瘤分期等基线指标差异无统计学意义。改良ERAS组患者术后首次饮水时间、首次排气时间、首次下床活动时间、导尿管拔除时间、引流管拔除时间、术后住院天数等均早/短于常规组,住院总花费、住院期间术后总并发症发生率均低于常规组(P<0.05)。结论腹腔镜肾部分切除术围术期应用改良ERAS有助于加速患者术后康复,相比常规手术更加安全有效,值得临床推广。

基于静脉解剖基础的标准化手术流程对机器人辅助肾部分切除学习曲线的影响

目的探讨以静脉解剖理论为基础制定机器人辅助腹腔镜肾部分切除术的标准化手术流程对手术者学习曲线的指导作用和临床价值。方法2021年1月~2022年3月间单一术者连续完成的机器人辅助腹腔镜肾部分切除术病人40例。40例连续病例依手术时间先后顺序分为A、B、C、D四组,每组各10例。手术均由同一位主刀医生完成。术者和第一助手在开始实施首例手术前,对我单位制定的基于静脉解剖基础的机器人辅助腹腔镜肾部分切除术标准化手术流程进行系统学习考核。术中通过对生殖静脉、下腔静脉、肾静脉和腰静脉的解剖辨认,引导整个手术流程。对比四组病人在总手术时间、肾脏热缺血时间、术中出血量、引流管拔除时间、病理切缘阳性率和术中及围术期并发症等指标之间的差异。结果40例病人均顺利完成手术,平均手术时间(114.25±30.65)分钟,平均热缺血时间(22.5±7.42)分钟,术中平均出血量(290±314.44)ml。随着手术例数的积累,A、B、C、D组病人的总手术时间逐渐缩短,分别为142分钟,122分钟,107分钟和87分钟。肾脏热缺血时间逐渐缩短,分别为30分钟,23分钟,22分钟和18分钟。D组病人术中出血量明显少于前三组,分别为335 ml,330 ml,335 ml和160 ml。引流管拔除时间分别为5.9天,6.1天,5.6天和5.1天;病人总的并发症发生率为17.5%,四组病人并发症的数量分别为2例、2例、2例和1例;差异无统计学意义。结论在积累10例手术后,术者已能独立完成机器人辅助腹腔镜肾部分切除术。完成20例手术后,术者能逐渐熟练掌握该手术方式。完成30例手术后,术者的技术水平达到并维持稳定状态。建立以静脉解剖理论为基础的标准化手术流程,能帮助术者缩短总手术时间和肾脏热缺血时间,减少术中出血量,提高手术的安全性,缩短术者的学习曲线。

腹腔镜下肾部分切除术后出现急性肾损伤的影响因素分析

目的探讨腹腔镜下肾部分切术后出现急性肾损伤的影响因素。方法回顾性分析2019年1月至2022年4月郑州大学第一附属医院泌尿外科收治的79例接受腹腔镜下肾部分切除术(LPN)的肾细胞癌(RCC)患者的临床资料,按照术后是否发生急性肾损伤(AKI)分为AKI组(n=20),和非AKI组(n=59)。通过病历系统收集患者年龄,性别,体质量指数(BMI),合并疾病(高血压、糖尿病),术前尿酸、尿素氮、热缺血时间(WIT)、肿瘤最大径以及术前、术后48 h内血清肌酐(Scr)等临床资料。采用单因素、多因素Logistic回归分析LPN术后AKI的发生因素,并采用受试者工作特征(ROC)曲线分析危险因素对LPN术后AKI发生的预测价值。结果79例接受LPN的RCC患者中,术后诊断为AKI的有20例(25.3%)。AKI组和非AKI组年龄(t=2.149,P=0.036)、BMI(t=2.221,P=0.029)、术前尿素氮(Z=3.734,P<0.001)、WIT(Z=4.300,P<0.001)、肿瘤最大径(Z=3.191,P<0.001)、术前Scr(t=3.628,P=0.001)、术后48 h内的Scr(t=8.474,P<0.001)比较差异均有统计学意义。而多因素logistic回归分析结果显示,WIT(P<0.001)、BMI(P=0.021)是LPN术后发生AKI的独立危险因素。ROC曲线分析结果示,BMI、WIT的截断值依次为25.15 kg/m 2、25.50 min,曲线下面积分别为0.651、0.822。结论BMI和WIT是LPN术后发生AKI的危险因素,并且具有一定的预测价值。