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 ...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.展开更多
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) d...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.展开更多
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...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.展开更多
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 ...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.展开更多
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 ...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.展开更多
<strong>Purpose:</strong> We introduce the concept of intraoperative Trifecta during laparoscopic partial nephrectomy (LPN) as the simultaneous achievement of estimated blood loss (EBL) < 500 ml, warm i...<strong>Purpose:</strong> 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. <strong>Methods:</strong> 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. <strong>Results: </strong>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%. <strong>Conclusion:</strong> 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.展开更多
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 datab...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.展开更多
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 pat...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.展开更多
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 l...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.展开更多
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 surgic...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.展开更多
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 c...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.展开更多
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 ...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.展开更多
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-...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.展开更多
文摘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.
文摘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.
文摘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.
基金Supported by the Incubation Project of Outstanding Young Scientist Fund of Sichuan Province,No.2019JDJQ0039the Key Research Foundation of Sichuan provincial health commission,No.19ZD015the Interdisciplinary Program of Shanghai Jiao Tong University,No.YG2021QN102.
文摘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.
文摘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.
文摘<strong>Purpose:</strong> 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. <strong>Methods:</strong> 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. <strong>Results: </strong>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%. <strong>Conclusion:</strong> 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.
文摘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.
文摘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.
基金This study was funded by Medical Health Science and Technology Project of Zhejiang Provincial Health Commission(2020375998).
文摘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.
文摘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.
文摘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.
文摘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.
文摘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.