机器人腹腔镜零缺血与肾动脉主干阻断肾部分切除术治疗T_(1a)期外生性肾脏肿瘤的临床研究
|
摘要
目的:对比机器人辅助腹腔镜零缺血与肾动脉主干阻断肾部分切除术治疗T_(1a)期外生性肾肿瘤的可行性、安全性与临床疗效。方法:回顾性分析2016年9月～2017年12月上海长征医院收治的99例使用零缺血或肾动脉主干阻断技术行机器人腹腔镜肾部分切除术患者的临床资料,其中21例采用零缺血技术(零缺血组),78例行肾动脉主干阻断(完全阻断组)。对两组患者资料进行倾向性匹配分析,按照1∶2最邻近匹配法,得到组间协变量均衡的样本,匹配后比较两组患者手术时间、术中出血量、热缺血时间、术后引流管留置时间、肾功能变化等指标。结果:匹配前,两组患者在肿瘤直径、R.E.N.A.L.评分等方面差异有统计学意义(P<0.05);匹配后,零缺血组有16例、完全阻断组有28例匹配成功,两组各基线指标比较差异均无统计学意义(P>0.05),两组在术中出血、手术时间、引流管留置时间、术后住院时间方面比较差异均无统计学意义(P>0.05)。零缺血技术避免了肾脏缺血,术后1个月肾功能保护效果较好,术后3个月肾功能无明显差异。结论:机器人辅助腹腔镜零缺血肾部分切除术这一新技术能安全、有效的应用于T_(1a)期外生性肾肿瘤的治疗,并不显著增加手术时间与术中失血,同时避免了肾实质热缺血再灌注损伤,术后短期肾功能保护较好。该技术的优势需要长期随访及大宗病例研究的验证,在应用过程中需要严格把握手术适应证。
Objective:To compare the safety,feasibility and efficacy between robot-assisted laparoscopic zeroischemia and complete renal artery clamping partial nephrectomy for exophytic T_(1a)renal tumor.Method:A total of99 patients with T_(1a)renal tumor who received robot-assisted laparoscopic zero-ischemia and complete renal artery clamping partial nephrectomy in Shanghai ChangZheng Hospital between September 2016 and December 2017 were retrospectively collected.The group covariates were balanced through propensity score matching(PSM)using 1:2 nearest neighbor matching method.After PSM,comparisons between two groups have been made in warm ischemia time,operation time,blood loss,rate of blood transfusion,postoperative hospital stay,incidence of complications and postoperative follow-up status.Result:Among all patients,diameter of tumor and R.E.N.A.L.scores were significantly different between zero-ischemia and complete renal artery clamping group(P<0.05).After PSM,patient distributions were closely balanced.Regarding operating time,blood loss,postoperative drainage and hospital stay did not differ between zero-ischemia(n=16)and complete renal artery clamping group(n=28),while zero-ischemia had contributed to better 1-month renal function conservation.Conclusion:Zero-ischemia robot-assisted laparoscopic partial nephrectomy is a new method of protecting renal function and can be performed safely for exophytic T_(1a)renal tumor.Patients in zero-ischemia group do not lose more blood or take more operational time than those in complete renal artery clamping group do,and postoperative short-term renal function injury caused by warm ischemia can be prevented.Further studies and a longer follow-up are warranted,but strict grasping the indications in the process of application is needed.
Objective:To compare the safety,feasibility and efficacy between robot-assisted laparoscopic zeroischemia and complete renal artery clamping partial nephrectomy for exophytic T_(1a)renal tumor.Method:A total of99 patients with T_(1a)renal tumor who received robot-assisted laparoscopic zero-ischemia and complete renal artery clamping partial nephrectomy in Shanghai ChangZheng Hospital between September 2016 and December 2017 were retrospectively collected.The group covariates were balanced through propensity score matching(PSM)using 1:2 nearest neighbor matching method.After PSM,comparisons between two groups have been made in warm ischemia time,operation time,blood loss,rate of blood transfusion,postoperative hospital stay,incidence of complications and postoperative follow-up status.Result:Among all patients,diameter of tumor and R.E.N.A.L.scores were significantly different between zero-ischemia and complete renal artery clamping group(P<0.05).After PSM,patient distributions were closely balanced.Regarding operating time,blood loss,postoperative drainage and hospital stay did not differ between zero-ischemia(n=16)and complete renal artery clamping group(n=28),while zero-ischemia had contributed to better 1-month renal function conservation.Conclusion:Zero-ischemia robot-assisted laparoscopic partial nephrectomy is a new method of protecting renal function and can be performed safely for exophytic T_(1a)renal tumor.Patients in zero-ischemia group do not lose more blood or take more operational time than those in complete renal artery clamping group do,and postoperative short-term renal function injury caused by warm ischemia can be prevented.Further studies and a longer follow-up are warranted,but strict grasping the indications in the process of application is needed.
引文
1 Scosyrev E,Messing E M,Sylvester R,et al.Renal function after nephron-sparing surgery versus radical nephrectomy:results from EORTC randomized trial30904[J].Eur Urol,2014,65(2):372-377.
2 Campbell S,Uzzo R G,Allaf M E,et al.Renal Mass and Localized Renal Cancer:AUA Guideline[J].J Urol,2017,198(3):520-529.
3 Hung A J,Cai J,Simmons M N,et al."Trifecta"in partial nephrectomy[J].J Urol,2013,189(1):36-42.
4陈绪龙,陈方敏,石家齐,等.保留肾单位手术中肾缺血损伤和肾功能保护的研究热点[J].临床泌尿外科杂志,2017,32(2):144-147.
5王林辉,叶华茂,吴震杰,等.机器人辅助腹腔镜肾部分切除术与传统腹腔镜肾部分切除术适应证选择及临床疗效对比研究[J].第二军医大学学报,2013,34(7):719-726.
6 Chen W,Zheng R,Baade P D,et al.Cancer statistics in China,2015[J].CA Cancer J Clin,2016,66(2):115-132.
7 Siegel R L,Miller K D,Jemal A.Cancer Statistics,2017[J].CA Cancer J Clin,2017,67(1):7-30.
8 Thompson R H,Lane B R,Lohse C M,et al.Every minute counts when the renal hilum is clamped during partial nephrectomy[J].Eur Urol,2010,58(3):340-345.
9 Shao P,Qin C,Yin C,et al.Laparoscopic partial nephrectomy with segmental renal artery clamping:technique and clinical outcomes[J].Eur Urol,2011,59(5):849-855.
10 Gill I S,Patil M B,Abreu A L,et al.Zero ischemia anatomical partial nephrectomy:a novel approach[J].JUrol,2012,187(3):807-814.
11 Desai M M,de Castro Abreu A L,Leslie S,et al.Robotic partial nephrectomy with superselective versus main artery clamping:a retrospective comparison[J].Eur Urol,2014,66(4):713-719.
12吴震杰,王坚超,刘承宗,等.区域血流荧光可视化成像在机器人肾部分切除术中的初步应用体会[J].中华泌尿外科杂志,2017,38(7):489-492.
13刘承宗,时佳子,吴震杰,等.术中荧光在机器人辅助腹腔镜下肾部分切除术中的应用初探[J].临床泌尿外科杂志,2018,33(6):446-449.
14 Rassweiler J J,Autorino R,Klein J,et al.Future of robotic surgery in urology[J].BJU Int,2017,120(6):822-841.
15 Ukimura O,Nakamoto M,Gill I S.Three-dimensional reconstruction of renovascular-tumor anatomy to facilitate zero-ischemia partial nephrectomy[J].Eur Urol,2012,61(1):211-217.
16刘溪,王德胜,曲发军,等.预留缝线法在零缺血腹腔镜下肾部分切除术中的应用[J].临床泌尿外科杂志,2017,32(2):118-121.
17 Zhou L,Wei X,Sun W J,et al.Selective Versus Hilar Clamping During Minimally Invasive Partial Nephrectomy:A Systematic Review and Meta-Analysis[J].J Endourol,2015,29(8):855-863.
18 Cacciamani G E,Medina L G,Gill T S,et al.Impact of Renal Hilar Control on Outcomes of Robotic Partial Nephrectomy:Systematic Review and Cumulative Meta-analysis[J].Eur Urol Focus,2018.
19 Wang H K,Qin X J,Ma C G,et al.Nephrometry scoreguided off-clamp laparoscopic partial nephrectomy:patient selection and short-time functional results[J].World J Surg Oncol,2016,14(1):163-163.
2 Campbell S,Uzzo R G,Allaf M E,et al.Renal Mass and Localized Renal Cancer:AUA Guideline[J].J Urol,2017,198(3):520-529.
3 Hung A J,Cai J,Simmons M N,et al."Trifecta"in partial nephrectomy[J].J Urol,2013,189(1):36-42.
4陈绪龙,陈方敏,石家齐,等.保留肾单位手术中肾缺血损伤和肾功能保护的研究热点[J].临床泌尿外科杂志,2017,32(2):144-147.
5王林辉,叶华茂,吴震杰,等.机器人辅助腹腔镜肾部分切除术与传统腹腔镜肾部分切除术适应证选择及临床疗效对比研究[J].第二军医大学学报,2013,34(7):719-726.
6 Chen W,Zheng R,Baade P D,et al.Cancer statistics in China,2015[J].CA Cancer J Clin,2016,66(2):115-132.
7 Siegel R L,Miller K D,Jemal A.Cancer Statistics,2017[J].CA Cancer J Clin,2017,67(1):7-30.
8 Thompson R H,Lane B R,Lohse C M,et al.Every minute counts when the renal hilum is clamped during partial nephrectomy[J].Eur Urol,2010,58(3):340-345.
9 Shao P,Qin C,Yin C,et al.Laparoscopic partial nephrectomy with segmental renal artery clamping:technique and clinical outcomes[J].Eur Urol,2011,59(5):849-855.
10 Gill I S,Patil M B,Abreu A L,et al.Zero ischemia anatomical partial nephrectomy:a novel approach[J].JUrol,2012,187(3):807-814.
11 Desai M M,de Castro Abreu A L,Leslie S,et al.Robotic partial nephrectomy with superselective versus main artery clamping:a retrospective comparison[J].Eur Urol,2014,66(4):713-719.
12吴震杰,王坚超,刘承宗,等.区域血流荧光可视化成像在机器人肾部分切除术中的初步应用体会[J].中华泌尿外科杂志,2017,38(7):489-492.
13刘承宗,时佳子,吴震杰,等.术中荧光在机器人辅助腹腔镜下肾部分切除术中的应用初探[J].临床泌尿外科杂志,2018,33(6):446-449.
14 Rassweiler J J,Autorino R,Klein J,et al.Future of robotic surgery in urology[J].BJU Int,2017,120(6):822-841.
15 Ukimura O,Nakamoto M,Gill I S.Three-dimensional reconstruction of renovascular-tumor anatomy to facilitate zero-ischemia partial nephrectomy[J].Eur Urol,2012,61(1):211-217.
16刘溪,王德胜,曲发军,等.预留缝线法在零缺血腹腔镜下肾部分切除术中的应用[J].临床泌尿外科杂志,2017,32(2):118-121.
17 Zhou L,Wei X,Sun W J,et al.Selective Versus Hilar Clamping During Minimally Invasive Partial Nephrectomy:A Systematic Review and Meta-Analysis[J].J Endourol,2015,29(8):855-863.
18 Cacciamani G E,Medina L G,Gill T S,et al.Impact of Renal Hilar Control on Outcomes of Robotic Partial Nephrectomy:Systematic Review and Cumulative Meta-analysis[J].Eur Urol Focus,2018.
19 Wang H K,Qin X J,Ma C G,et al.Nephrometry scoreguided off-clamp laparoscopic partial nephrectomy:patient selection and short-time functional results[J].World J Surg Oncol,2016,14(1):163-163.