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Objective:To investigate the safety and prognosis of partial nephrectomy (PN) in the treatment of highly malignant non-clear renal cell carcinoma (nccRCC).Methods:Clinical data of 47 patients with cT 1N 0M 0 high malignant nccRCC treated in Changhai Hospital from March 2016 to March 2022 were retrospectively analyzed. All patients received PN. There were 34(72.3%) males and 13(27.7%) females. The mean age was (53.5±15.0) years, and average BMI, was(23.7±3.4)kg/m 2.The maximum tumor diameter was (29.8±12.6) mm, and R. E.N.A.L. score was 7(5-9), with 37(78.7%) cases of T 1a and 10(21.3%) cases of T 1b. The mean estimated glomerular filtration rate (eGFR) before surgery was (96.3±25.5) ml/ (min·1.73m 2). All patients underwent PN, including 1 patient (2.1%) undergoing open surgery, 29 patients (61.7%) undergoing laparoscopic surgery, and 17 patients (36.2%) undergoing robotic surgery. There were a total of 22(46.8%) cases of papillary cell carcinoma(pRCC)type Ⅱ, 4(8.5%) cases of collecting duct carcinoma (cdRCC), 9(19.1%) cases of MiT family translocated renal cell carcinoma (tRCC), 5(10.6%) cases of mucoid tubular and spindle cell carcinoma (mtSCC)and 7(14.9%) cases of unclassified renal cell carcinoma (uRCC). The surgical conversion rate, positive margin rate, operative time, intraoperative blood loss, complications, and postoperative hospital stay were analyzed. Preoperative and postoperative eGFR were analyzed, and overall survival (OS) and cancer specific survival (CSS) were calculated. Results:All the operations were successfully completed. No radical operation or open operation was performed, with operation time of(100±60) min and intraoperative blood loss of(100±59) ml. There were no intraoperative complication and 1 case (2.1%) suffered from postoperative complication. Postoperative hospital stay were 5 (4-6) days. The mean eGFR after surgery was (86.5±27.1) ml/(min·1.73m 2), and the difference was statistically significant ( P=0.041). In this study, the mean follow-up time was (45.7±20.9)months, and no adjuvant therapy was used after surgery. During the follow-up period, 2 patients died, who all of them were kidney cancer-related death, and both OS and CSS were 95.7% (45/47). Conclusions:PN is safe, feasible and has a good prognosis in the treatment of high malignant T 1 nccRCC. For tumors with clear imaging boundaries and complete envelope, complete tumor resection is more likely, postoperative follow-up should be strict, and no remedial radical or systemic treatment was required.
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Objective:To investigate the clinical features of patients with local recurrence and secondary operation after partial nephrectomy for renal cancer.Methods:The clinical data of 14 patients who underwent secondary operation for local recurrence of renal cancer after partial nephrectomy in the First Affiliated Hospital and the Second Affiliated Hospital of Naval Medical University from January 2000 to January 2022 were retrospectively analyzed. There were 12 males and 2 females. Nine patients had a body mass index ≥24 kg/m 2. At first diagnosis of renal cancer, nine patients’ R. E.N.A.L. score of renal mass were at least 7. Partial nephrectomy was performed in the first operation of each patient, including 4 cases of open surgery, 6 cases of laparoscopic surgery, and 4 cases of robot-assisted laparoscopic surgery. The pathological stage of nine patients was pT 1aN 0M 0 and that of five patients was pT 1bN 0M 0. Twelve cases were clear cell carcinoma, 1 case was sarcomatoid carcinoma and 1 case was chromophobe cell carcinoma. The mean time from the first operation to local recurrence was (29.3±16.8) months. All recurrence lesions were found by abdominal CT or MRI. Thirteen patients had no clinical symptom at the time of tumor recurrence. The location of recurrence was clear. No sign of invasion of peripheral organs and tissues was observed. There was no other suspicious lesion. The tumor was considered to be completely resectable in all patients. All 14 cases underwent secondary operation. Ten patients underwent radical nephrectomy [tumor size was (2.8±0.9) cm]. Partial nephrectomy was performed in 4 cases [tumor size was (1.8±0.9) cm]after full evaluation by surgeons, including 2 cases of anatomic solitary kidney, and 2 cases of recurrent tumor less than 2 cm with clear tumor margin. Results:Eleven of the 14 cases underwent minimally invasive surgery, and no cases were converted to open surgery. The other 3 cases underwent open surgery. Seven patients had severe adhesions in the operation area. The blood loss in the partial nephrectomy group and the radical nephrectomy group was (100.0±70.7) ml and (143.0±81.2) ml, respectively. According to the Clavien-Dindo classification of surgical complications, Grade Ⅰ and Grade Ⅱ complication occurred in 1 patient respectively, and no patient had Grade Ⅲ or above complication. No tumor cell was found at the surgical margin. The pathological type and nuclear grade were the same as those in the first operation. There were 10 cases of pT 1aN 0M 0 stage, 3 cases of pT 3aN 0M 0 stage and 1 case of pT 3aN 1M 0stage. The follow-up time of 13 patients with complete follow-up data was (21.4±14.9) months after local recurrence resection. The tumor recurred in 3 patients and metastasized in 2 patients. The disease-free survival time of the above 5 patients was (13.2±8.8) months. Of the 4 patients who underwent partial nephrectomy, 3 had recurrence or metastasis. Among the 9 patients who underwent radical nephrectomy, 2 had postoperative recurrence or metastasis, and 7 patients survived without tumor until the last follow-up. Conclusions:For patients with local recurrence after partial nephrectomy who are in good condition and the recurrent lesions can be completely resected, the second operation is safe, feasible and effective. Patients with secondary radical nephrectomy have better prognosis. If the patient has a solitary kidney, the recurrent tumor is small and the margin is clear, partial nephrectomy can also be selected for the second operation. But the postoperative follow-up should be emphasized, and the adjuvant drug therapy should be given if necessary.
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Objective:To analyze the correlation between R. E.N.A.L., PADUA, C-index, DAP scoring system and the efficacy and safety of nephron-sparing surgery (NSS) for T 1b renal tumors, and to construct a nomogram model to predict the efficacy and safety of surgery by combining multiple parameters. Methods:The data of 80 patients with stage T 1b renal tumor who received NSS from March 2020 to July 2021 in Changhai Hospital of Naval Military Medical University were retrospectively analyzed. There were 59 males and 21 females, aged (56.9±10.2) years old. The tumor diameter was (4.7±0.9) cm, with 40 cases on the left and 40 on the right sides. Tumors were located in the upper/lower pole in 46 cases and in the middle in 34 cases. The tumors were located in 59 cases laterally, 21 cases medially, and 74 cases were bulging, 16 cases endogenous. There were 53 round tumors, 18 lobular tumors, and 9 irregular tumors. One case underwent open surgery, 43 cases underwent laparoscopic surgery, and 36 cases underwent robotic surgery.42 cases underwent transperitoneal approach, and 38 cases underwent retroperitoneal approach. The composite outcome (MIC) achieved by all three indicators, including negative surgical margins, warm ischemia time <20 min, and no serious complications, was used as the main indicator to evaluate the efficacy and safety of surgery. Secondary indicators were operation time, intraoperative blood loss, postoperative hospital stay, postoperative creatinine changes and hemoglobin changes. Relevant risk factors were analyzed by logistic regression, and a nomogram model for predicting surgical efficacy and safety was constructed. Receiver operating characteristic(ROC) curves were used to compare the predictive power of the nomogram model with other scoring systems. Results:Univariate logistic regression analysis showed that PADUA and R. E.N.A.L. scores were risk factors for MIC achievement( OR=1.419, P=0.038; OR=1.358, P=0.038). However, C-index and DAP were not risk factors for MIC achievement( P>0.05). The results of correlation analysis showed that R. E.N.A.L. score was significantly correlated with postoperative hemoglobin decrease(R 2=0.197). PADUA score was significantly correlated with postoperative hospital stay(R 2=0.186). C-index was significantly correlated with postoperative creatinine increase(R 2=-0.221). DAP was significantly associated with operation time (R 2=0.192). The results of univariate logistic regression analysis showed that body mass index ( OR=1.257, P=0.025), tumor morphology ( OR=18.741, P=0.005), longitudinal location of tumor ( OR=1.992, P=0.038), the relationship between tumor and collection system ( OR=4.886, P=0.002) were risk factors for MIC attainment. A nomogram prediction model was constructed by combining these indicators with the Mayo adhesive probability (MAP) index. The ROC curve showed that the area under the curve (AUC) of the nomogram model and R. E.N.A.L. score, PADUA score, C-index, and DAP were 0.834, 0.645, 0.643, 0.526, and 0.593, respectively. The nomogram model had the highest predictive power for T 1b renal tumors achieving MIC. Conclusions:In the renal tumor scoring system, PADUA and R. E.N.A.L. scores can predict whether the MIC of T 1b renal tumor NSS is achieved or not. The nomogram model composed of patient body mass index, tumor shape, longitudinal position of tumor, relationship between tumor and collecting system and MAP can better predict whether the MIC of T 1b renal tumor NSS is achieved or not.
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Objective:To investigate the feasibility and safety of a novel single-port robotic surgical system with flexible 3D endoscope and deformable surgical instruments in zero ischemic partial nephrectomy.Methods:From May 2021 to October 2021, a prospective study on patients with renal tumor who plan to receive zero ischemic partial nephrectomy was conducted. Inclusion criteria included over 18 years old, body index between 18.5 to 30.0 kg/m2, American Society of Anesthesiologists Score ranged from 1 to 3 points, cooperation with the follow-up and related examinations, voluntary in participating the clinical trial and signing the informed consent. Exclusion criteria included patients with other co-existed malignant tumors or a medical history of other malignant tumors, the patients who have received the same urological surgery in the past, the patients who underwent or plan to undergo other major operations 3 months before or after the surgery, the patients with active pulmonary tuberculosis or severe systemic diseases, the patients to be considered not suitable to enroll in by the researchers. A novel single-port robotic surgical system was used to perform the surgery. The system consiststed of a remote control console, a surgical equipment cart, a four-arm operation cart and deformable robotic instruments which were reusable. The two-section deformable robotic instruments were able to bend in four directions and carried different surgical instruments such as unipolar scissors, bipolar grasping forceps and needle holders. The deformable robotic instruments entered the body through a special trocar with single hole and multi-channel, and then unfolded in a triangle. By bending instruments, surgeons could perform single-port robotic surgery without the trouble of "chopstick effect" or "reverse direction" . Four cases of single-port partial nephrectomy were carried out. Under general anesthesia, the patients were taken the lateral recumbent position, with elevated waist and lowered head and feet. A 3-4 cm incision was taken layer by layer along the lateral edge of the rectus abdominis at the umbilicus level. A special 2.5 cm robotic trocar was set into the cavity, and a high-definition 3D laparoscopic lens and a snake shaped mechanical arm were then put into the abdominal cavity through the trocar. All operations were performed by transperitoneal approach with an auxiliary port through the same or a different skin incision if necessary. Tumor resection and renal reconstruction were performed by the way of zero ischemia. The perioperative parameters such as tumor size, operation time, intraoperative bleeding and postoperative complications were analyzed.Results:Four patients were involved, including 2 males and 2 females, with 2 of them having a history of hypertension. The ECOG scores were all 0, and KPS score was 100 in 3 cases and 90 in 1 case. Preoperative mean serum creatinine was (76.8±18.8)μmol/L (range 70-104 μmol/L). The tumors were located on the left in 3 cases and on the right in 1 case. The diameter of the tumor ranged from 1.1 to 2.8 cm, with the TNM classification of T 1a. The R. E.N.A.L. scores were 4a, 7p, 6p and 4P respectively. The first operation was performed by pure single-port surgery, and the other 3 cases were performed with the help of an auxiliary port to ensure the safety .The operation time ranged from 155 min to 210 min, and the intraoperative bleeding ranged from 20 ml to 170 ml. Postoperative pathology showed 2 cases of renal clear cell carcinoma with negative margin and 2 cases of angiomyolipoma. No severe complications, such as bleeding or urinary leakage, were observed during the perioperative period, and the change of serum creatinine was insignificant before discharge and before operation( P=0.24). Conclusions:A robotic single-port partial nephrectomy can be successfully carried out by using this novel single-port robotic surgical system with flexible 3D endoscope and deformable surgical instruments.
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Objective:To explore the surgical technique and efficacy of pure retroperitoneoscopic extravesical standardized seeable (P.R.E.S.S.) technique for bladder cuff excision (BCE).Methods:Ninety five patients with UTUC from five domestic centers (30 cases from Changzheng Hospital, 21 cases from Peking University First Hospital, 20 cases from Yuhuangding Hospital, 21 cases from Dalian Medical University affiliated No.2 Hospital and 3 cases from General Hospital of Eastern Theater Command)between August 2017 and December 2020 were retrospectively analyzed. There were 57 males and 38 females with a mean age of (67.7±10.0) years and median tumor size of 3.0 cm. All patients underwent pure retroperitoneoscopic radical nephroureterectomy with a single surgical position and four (36 cases) or five (59 cases) trocar layout according to the surgeon’s prefer habit and experience. The demographics of the two groups were the age of [(66.3±11.2)years vs. (68.6±9.1)years], male/female ratio of (25/11 cases vs. 32/27 cases), body mass index of [(25.0± 3.0)kg/m 2 vs. (24.8±3.4)kg/m 2], tumor maximum diameter of [2.8(1.6, 3.5)cm vs. 3.0(2.0, 4.0)cm], left/right side tumor of(19/17 cases vs. 34/25 cases), T 1-2/T 3-4/Tis stage of(25/10/4 cases vs. 49/10/0 cases), and multifocal tumors of(3 cases vs. 2 cases), and the difference was not statistically significant( P>0.05). On the other hand, the differences of hydronephrosis of the operated kidney(13 cases vs. 39 cases, P=0.004), and tumor location (in renal pelvis or calyx or upper/middle/lower ureter being 23/9/4 cases vs. 35/4/20 cases, P=0.005), were statistically significant. The umbilical artery cord was used as anatomical landmark in the process of P. R.E.S.S. bladder cuff excision. The pelvic floor and extraperitoneal space around the ureter were expanded, the bladder wall was opened to form pneumovesicum, and a sufficient bladder cuff resection and exact bladder cuff closure was performed. Perioperative outcomes and follow-up data were analyzed, and the clinical outcomes between the four and five trocars were compared to evaluate the impact of trocar layout on the surgical outcomes. Results:There were 91(95.8%) cases successfully undergoing P. R.E.S.S. BCE technique, with one case converted to open BCE due to bleeding and three cases converted to distal ureter Hem-o-lok clipping because of poor exposure. Median operative time was 180(125, 230)min, and estimated blood loss was 100(50, 100)ml. The overall complication rate was 10.5%(10/95), including 2 cases(2.1%) of intraoperative bleeding, with 1 case treated by transfusion (400 ml), the other case converted to open surgery without transfusion. There were 8 cases of postoperative complications(8.4%), including 7 cases of Clavien-Dindo grade Ⅱ(3 cases of secondary hemorrhage, one case for each of drug allergy, acute renal insufficiency, blood creatinine increased to 490 μmol/L, or lung infection with lymphatic leakage), 1 case of grade Ⅲa(intestinal obstruction treated with insertion of the intestinal obstruction catheter under local anesthesia), and all these patients were discharged smoothly. The difference between the four and five trocars was not statistically significant in the following variables, including the rate of surgical conversion(8.3% vs. 1.7%), estimated intraoperative blood loss(100 ml vs. 60 ml), ratio of intraoperative lymph node dissection (25.0% vs.20.3%), P. R.E.S.S. bladder cuff excision success rate(91.7% vs.98.3%), the incidence of intraoperative and postoperative complications (13.8% vs.8.5%), pT 1-2/pT 3-4/pTis stage(22/11/3 cases vs.37/19/3 cases) and the proportion of recurrence or metastasis(8.3% vs.3.4%)(all P>0.05). However, the differences in the operation time(190 min vs.170 min, P=0.011)and postoperative hospital stay(5 d vs.6 d, P=0.005) were statistically significant. Conclusions:P. R.E.S.S. bladder cuff resection technique is safe and feasible during the procedure of pure retroperitoneoscopic radical nephroureterectomy by a single surgical position and facilitates seeable adequate bladder cuff excision by establishing an enlarged pelvic lateral extraperitoneal space and pneumovesicum. Five-trocar technique is more suitable for patients with lower ureteral tumors but may be associated with a longer postoperative hospital stay compared with the four-trocar technique.
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Objective:To evaluate the safety and efficacy of Toumai ? endoscopic robotic system in radical prostatectomy. Methods:This study was a single-center phase Ⅲ randomized controlled study. From June 2020 to January 2021, patients with prostate cancer who met the inclusion criteria in Changhai Hospital Affiliated to Naval Military Medical University were divided into the experimental group and the control group by random table method. Inclusion criteria included aged 18 to 80 years, pathologically diagnosed as prostate cancer, clinical stage ≤T 2N 0M 0. Exclusion criteria included patients requiring emergency surgery, having serious cardiovascular diseases and cannot tolerate surgery, having participated in other investigational drug or device clinical trials within the last 3 months. The experimental group used Toumai ? laparoscopic robotic system, and the continence group used the Da Vinci robotic system. The patients in both groups underwent radical prostatectomy via a transabdominal approach, which was performed by two surgeons. The clinical characteristics between the two groups were compared, related adverse events were recorded, and PSA and urinary continence were followed up one month after the operation. Results:A total of 44 patients were enrolled in this study, including 22 cases in the experimental group and 22 cases in the control group. The mean age of patients in the trial group and the control group was (67.7±7.5) years and (66.4±6.3) years, respectively. The median PSA at diagnosis was 10.5 (7.7, 23.7) ng/ ml and 13.5 (8.9, 24.7) ng/ ml, respectively. Biopsy Gleason score of 6, 7, 8 and 9 in experimental group were 13.6% (3/22), 68.2% (15/22), 4.5% (1/22) and 13.6% (3/22), respectively, and in the control group were 4.5% (1/22), 59.1% (13/22), 22.7% (5/22) and 13.6% (3/22) respectively. The middle risk and high risk group in the experimental group was 50.0% (11/22), 50.0% (11/22), and the control group was 36.4% (8/22), 63.6% (14/22). There was no statistical difference between the two groups.The operations in both groups were successfully performed. There were no conversions to open or laparoscopic surgeries, and no Clavien-Dindo grade Ⅲcomplications. There was no significant difference in the estimated blood loss during the operation [(109.1±51.6)ml vs.(94.5±51.6)ml] and the blood transfusion rate [9.1%(2/22)vs. 4.5%(1/22)] in both groups. The operation time was significantly higher in the experimental group than that in the control group [164.5(130.5, 214.3) min vs. 88.0(65.3, 110.5)min, P<0.001]. The positive rate of surgical margin was 13.6% (3/22) in the experimental group and 36.4% (8/22) in the control group, respectively, showing no significant difference. The pathologic stages of pT 2, pT 3a and pT 3bin experimental group were 63.6% (14/22), 13.6% (3/22) and 22.7% (5/22), respectively, while those in control group were 36.3% (8/22), 40.9% (9/22) and 22.7% (5/22), respectively, showing no significant difference. The recovery rates of urine control in the experimental group and the control group were 22.7% (5/22) and 22.7% (5/22), respectively. The median PSA in the experimental group and the control group were 0.055 (0.021, 0.103) ng/ ml and 0.032 (0.010, 0.089) ng/ ml, respectively, with no statistical difference. Conclusions:The Toumai ? endoscopic robotic system can successfully perform radical prostatectomy, based on insignificant difference from Da Vinci robotic system in safety and efficacy. The short-term follow-up showed that tumor control and urinary continence have recovered well in the test group. The long-term effect of the new system on tumor control and functional recovery after radical prostatectomy needs further multi-center studies.
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There are few reports on the study of extraperitoneal robotic single-port laparoscopic radical prostatectomy in China. In this study, patients with localized prostate cancer were treated with extraperitoneal robotic single-port laparoscopic radical prostatectomy extraperitoneal robot-assisted single-port laparoscopic radical prostatectomy(EpRA-spRP)from April 2019 to June 2019.All patients performed EpRA-spRP successfully without adding additional auxiliary port. The operation time and blood loss were controllable, and hospitalization time was short. It is safe and feasible to perform EpRA-spRP for medium and low-risk prostate cancer. The short-term tumor control and functional recovery are satisfactory.However, the long-term effect needs further follow-up and observation.
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Objective:To assess the safety and feasibility of single-port robotic radical cystectomy.Methods:During May 2019 and August 2019, nine patients (8 males, 1 female) received single-port robotic radical cystectomy by the same surgeon. The average age was 65.6(56-78)years. After a 4.5-5.5 cm trans-umbilical incision was made, Lagiport was inserted. Da Vinci Si system 1 #, 2 # arms and 30° lens were applied. Radical cystectomy and bilateral pelvic lymphadenectomy were performed without additional ports. Urinary diversion was completed outside the body. Uterus and vaginal anterior walls were also resected for female patient. Results:All 9 surgeries were successfully conducted without additional ports or conversion to laparoscopic and open surgery. The average operation time was 437.8(280-600)min. Urinary diversion methods included 2 orthotopic ileal neobladder, 5 ideal conduit and 2 cutaneous ureterostomy. Average estimated blood loss was 227.8(100-450)ml, without blood transfusion. Average intestinal recovery time was 3.1(2-4)days, drainage duration was 8.3(3-16) days, and postoperative hospital stays was 7.7(6-13) days. Pathological TNM stage: T 2aN 0M 0 6 cases, T 2bN 0M 0 1 case, T 3aN 3M 0 1 case, T isN 0M 0 1 case. All surgical margins were negative. One bowel obstruction was cured with fasting and indwelling gastric tube. During 9-12 months’ follow-up, no tumor recurrence and metastasis were observed. There was no hydronephrosis or ureterostenosis. All surgical incision healed well. Conclusions:For experienced surgeons, single-port robotic radical cystectomy is safe and feasible with small incision and fast recovery. Short-term clinical result is satisfied.
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Since the introduction of laparo-endoscopic single-site surgery(LESS) in China in 2008, this technique has developed rapidly in the domestic urology field. This paper systematically reviews and summarizes the historical process of the development of single-site laparoscopy technique in domestic urology. From the exploration period, the rapid development period, the rational thinking period to the current breakthrough development period, the technology has made great progress in related theoretical foundations, surgical operation skills, device development and clinical norms. It has many advantages such as less postoperative pain, minor damage in body surface, and rapid recovery. But the limitations including narrow operating space and great instrument interference are still remain. At present, the development of domestic single-site laparoscopy technique is generally stable and standardized. The robotic single-site surgery system may be able to effectively solve the problem of instrument interference, but the clinical advantages and application value of the robotic single-site surgery system still need to be further clarified by prospective, multi-center, large sample and high-quality clinical research.
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Renal cell carcinoma(RCC) is one of the most common urological tumors. In the present study, 623 RCC-related articles were searched in Chinese Journal of Urology during 1980 and 2019. Based on these articles, we looked back in the history of RCC diagnosis and therapy in China and analyzed current situations.
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Objective:To investigate the factors related to the prognosis of patients with metastatic renal cell carcinoma after bone metastasectomy and to provide a reference for the clinical treatment of renal cell carcinoma.Methods:The clinical data of 143 patients with metastatic renal cell carcinoma in our center from January 2008 to December 2018 were retrospectively collected. Among 143 patients, 121 were male and 22 were female, with the average age of (54.8±12.5) year-old(from 18 to 85 year-old). The KPS scores of 138 patients were no higher than 80%. According to International Metastatic RCC Database Consortium (IMDC) risk model for metastatic renal cell carcinoma, the patients were divided into intermediate risk group (92 patients) and poor risk group (51 patients). The patients who had received complete resection for both primary lesion and metastatic tumor were regarded as tumor-free (47 patients). Otherwise, the patients with unresectable primary tumor or incomplete resection of the metastatic tumor were defined as the patients surviving conversely bone metastases were the only metastatic site, and the other 57 patients also experienced concomitant metastases comparatively. Sixty-two patients only had solitary bone metastasis lesion and 81 patients had multiple bone metastases. Kaplan-Meier survival analysis was used to calculate the 1-year, 3-year and 5-year survival rate. The impacts of different variables on the prognosis were examined by log-rank test. Univariate analysis and multivariable Cox proportional hazards regression models were used to identify the independent risk factors.Results:The median follow-up time was 49.0 months. The overall survival was 1-115 months, with the median OS was 24.0 months. The 1-year, 3-year and 5-year survival rate were 79.2%, 59.4% and 31.6%, respectively. All the patients underwent bone metastasectomy and 72 of them were treated with targeted therapy. The pathology results of metastasectomy were clear cell carcinoma for 132 patients and non-clear cell carcinoma for the 11 patients. In tumor-free group, the median OS was 30.0 months and in survival with tumor group, the median OS was 19.4 months, with a significant difference between the two groups ( P=0.030). In IMDC intermediate risk group, the prognosis was improved among the patients who received post-surgical targeted therapy after metastasectomy (24.3 months vs. 16.8 months, P=0.027), whereas the difference was not significant for IMDC poor risk group ( P=0.449). Age ≥60 years and multiple bone metastases sites were proved to be the independent risk factors for the prognosis of patients with metastatic renal cell carcinoma after bone metastasectomy. Conclusions:The prognosis of RCC patients with bone metastases was generally poor. Metastasectomy could prolong the OS of the patients who had undergone primary nephrectomy and had solitary bone metastasis. Metastasectomy combined with targeted therapy could significantly improve the prognosis of the IMDC intermediate risk patients. However, the effect of targeted therapy among IMDC poor risk patients remained to be further proved.
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Objective To explore the application of three-dimensional intelligent qualitative and quantitative analysis system (IQQA) in the planning,simulation and implementation of precise surgery for bilateral renal tumors.Methods A retrospective analysis a total of 7 patients with bilateral kidney tumors in our center from June 2017 to August 2018 was performed.There were 5 males and 2 females,with an average age of (54.6 ± 6.0) years,ranging 47.0-63.0 years.The average BMI index was (23.4 ± 2.4) kg/m2,ranging 21.2-28.0 kg/m2.The average diameter of 14 renal tumors in 7 patients was (3.8 ± 1.1) cm,ranging 1.9-5.3 cm.The average R.E.N.A.L score was 6.6 ± 1.2,ranging 5.0-9.0.The tumor stage was T1N0M0.The mean preoperative hemoglobin,albumin,creatinine and GFR were (138.6 ± 17.0)g/L and (47.3 ± 2.5 g/L),(51.6 ± 19.1) μmol/Land (56.9 ± 6.7) ml/min,respectively.Before operation,the original data of CT were input into IQQA system.Then we reconstructed kidney,blood vessel,collecting system and tumors using system.And the structure of kidney,tumors and vessels was visualized directly.The systematic analysis of the operation is carried out at terminals vary from various angles,and the surgical resection simulation.The position,angle and curvature of the cut surface are adjusted according to the effect.The plan of partial nephrectomy is designed.The resection area,remaining area of kidney is calculated.In this way,we can construct individualized and accurate laparoscopic partial nephrectomy planning before operation.Last,we carried out the operation according to the designed plan.The laparoscopic standard partial nephrectomy was performed in 11 cases.The laparoscopic selective partial nephrectomy was performed in 2 cases.One underwent laparoscopic partial nephrectomy without obstruction.We achieved precise resection of tumors and rapid suture of wounds according to the preoperative planning of excision and suture.We collected of the surgical success rate,conversion to opening rate,operation time,warm ischemia time,intraoperative bleeding volume,complications and hospitalization after operation.The related laboratory indicators such as eGFR and creatinine were followed up for 3 months,and the prognostic indicators such as renal CT and pulmonary CT for 6 months after operation were evaluated and analyzed.Result 14 renal tumors were successfully reconstructed by IQQA in 7 patients.The operations were completed successfully without conversion to open surgery or radical nephrectomy.The average operative duration was (68.9 ± 9.2) minutes,ranging 50.0-80.0 minutes.The average renal artery occlusion duration was (20.7 ± 4.1) minutes,ranging 15.0-29.0 minutes.The average intraoperative bleeding volume was (70.7 ± 29.7) ml,ranging 30.0-120.0 ml.The average indwelling time of drainage tube was (5.5 s0.7) days,ranging 5.0-7.0 days.The average hospitalization time was (6.3 ± 0.5) days,ranging 6.0-7.0 days.There were no perioperative complications such as bleeding,urinary leakage,infection,incision dehiscence and pulmonary infection.Postoperative pathology revealed 13 clear cell renal carcinoma and 1 renal angiomyoma.No recurrence or metastasis was found in chest CT and lung CT after 6 months follow-up.The creatinine and GFR in 3 months after operation were (52.0 ± 15.2) μmol/L(36.0-72.0 μmol/L) and (56.7 ± 5.3) ml/min(46.7-66.3 ml/min).There was no significant difference of creatinine and GFR with the preoperative (P ＞ 0.05).The mean Hb and albumin levels in 3 months after operation were (120.9 ± 17.0) g/L(90.0-147.0 g/L) and (41.4 ± 2.6) g/L (38.0-46.0 g/L),which were significantly lower than those before operation (P ＜ 0.05).Conclusions The three-dimensional intelligent qualitative and quantitative analysis system (IQQA) can visualize the kidney,tumor and the vasculature of bilateral kidney tumors by preoperative three-dimensional reconstruction.The optimal surgical plan of partial nephrectomy can be designed by preoperative operation planning and computer terminal in order to enhance the safety of partial nephrectomy for bilateral kidney tumors and preserve the possibility of kidney,and protect the renal function to the greatest extent.To accurately predict the retention of renal function after operation,so that patients with bilateral renal tumors can get the greatest benefit in partial nephrectomy.
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Objective To compare the perioperative parameters and renal function in patients,whose aged was 65 year-old or above,with clinical T1-2 renal tumors undergoing partial nephrectomy (PN) or radical nephrectomy (RN).Methods A retrospective review of 469 patients,who underwent RN and PN in our center,was conducted from January 2012 to November 2018,icluding 247 in the RN group and 222 in the PN group.The RN group consisted of 170 male and 77 female patients,with the mean age of (70.96 ± 5.21) year-old.126 cases were found that the tumor located on the fight side,with the median diameter of (4.93 ± 2.03) cm.The median BMI,median R.E.N.A.L.score and pre-operation eGFR of the RN group were (24.4 ± 3.1) kg/m2,8.39 ± 1.45) and (80.23 ± 15.14) ml/(min · 1.73 m2),respectively.The PN group consisted of 150 male and 72 female patients,with the mean age of (70.23 ± 4.62) years old.108 patients had tumors on the left side while 114 on the right side,with the median diameter of (3.17 ± 1.41) cm.The median BMI,median R.E.N.A.L score and pre-operation eGFR of the PN group were (23.5 ± 3.2) kg/m2,(6.69 ± 1.81) and (82.83 ± 14.36) ml/(min · 1.73m2),respectively.No statistical difference was noticed in the age,gender,tumor location and BMI between RN group and PN group(P ＞ 0.05).The PN group had smaller tumors and lower R.E.N.A.L.scores than the RN group (P ＜ 0.05).Various parameters were compared between the PN and RN groups,including operative duration,surgical procedure,intraoperative blood loss,perioperative blood transfusion,drainage tube removal time,postoperative duration of hospitalization,pathological results,the renal function immediately after surgery and at 1 month,1 year,2 years,3 years,4 years,5 years after surgery,and the incidence of chronic renal dysfunction.Results Significant differences were found in multiple variables between the two cohorts,such as operative duration [(115.70 ± 39.69) min in RN vs.(132.26 ± 49.02) min in PN],estimated intraoperative blood loss [(45.85 ± 55.93) days in RN vs.(66.60 ± 61.55) ml in PN],drainage tube removal time [(4.38 ± 1.71) days in RN vs.(4.86 ± 1.61) days in PN],duration of postoperative hospitalization [(5.14 ± 1.65) days in RN vs.(5.52 ± 1.32) days in PN] (P ＜ 0.05).Furthermore,higher proportion of RCC was detected in the RN cohort (93.5％ in RN vs.86.5 ％ in PN,P ＜ 0.05).There was no significant difference in perioperative blood transfusion rate between the two cohorts (10.93％ vs.9.01％,P ＞ 0.05).Compared with the RN cohort,the PN cohort had higher eGFR immediately after surgery [(74.08 ± 18.31) ml/(min · 1.73m2) vs.(52.58 ± 14.21) ml/(min · 1.73m2)],1 month after surgery [(76.11 ± 18.34) ml/(min · 1.73m2) vs.(53.78 ± 15.03)ml/(min · 1.73m2)] and at the last follow-up [(73.92 ± 18.59) ml/(min · 1.73m2) vs.(52.35 ± 16.13) ml/(min · 1.73m2)] (P ＜ 0.001).Compared with those of the RN cohort,the incidences of eGFR ＜ 45 ml/(min · 1.73m2) of the PN cohort were lower immediately after surgery [9.01％ (20/222) vs.31.9％ (79/247)],1 month after surgery [7.87％ (14/178) vs.27.31％ (62/227)],1 year after surgery [8.96％ (13/145) vs.38.75％ (62/16 0)],2 years after surgery [9.89％ (9/91) vs.31.57％ (42/133)],3 years after surgery [13.21％ (7/53) vs.30.61％ (30/98)],4 years after surgery [16.21％ (6/37) vs.30.26％ (23/76)] and 5 years after surgery [18.18％ (4/22) vs.31.11％ (14/45)] (P ＜ 0.001).Conclusion The perioperative risk of PN in the treatment of elderly patients aged 65 and above with clinical cT1-2 renal tumor is controllable.PN could better retain renal function for those patients and reduce the risk of postoperative chronic renal insufficiency.
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Objective To investigate the clinical feasibility and effectiveness of 3-D printing (3DP) combined with 3-D laparoscopic nephron-sparing surgery (LNSS) for partial endogenous renal cell carcinoma.Methods A retrospective analysis was made of the clinical data of 79 patients with partial endogenous renal cell carcinoma who were admitted to our department from July 2015 to October 2018.There were 46 males and 33 females.Their average age was (50.9 ± 7.9) years old,ranged from 33 to 68 years old.Tumor stages were T1aN0M0 in 53 cases and T1bN0M0 in 26 cases.The preoperative serum creatinine ranged from 40 to 107 μmol/L,with an average of (72.4 ± 14.2) μmol/L.The preoperative GFR ranged from 19 to 54 ml/min,with an average of (40.2 ± 6.2) ml/min.Thirty-four patients underwent 2-D laparoscopic nephron-sparing surgery (2DLNSS) based on preoperative enhanced CT scans.Forty-five patients underwent 3-D printing (3DP) based on three-dimensional reconstruction of renal CT scans.Seventeen patients underwent 2-D laparoscopic nephron-sparing surgery guided by 3-D printing model(3DP-2DLNSS),and 28 patients underwent 3-D laparoscopic nephron-sparing surgery guided by 3-D printing (3DP-3DLNSS).Serum creatinine levels ranged from 42 to 122 μmol/L with an average of (86.3 ± 14.8) μmol/L,and creatinine levels ranged from 8 to 66 μmol/L with an average of (19.1 ± 14.1) μmol/L.Six months after operation,the GFR of the kidney was 9-36 ml/min with an average of (21.4 ± 6.4)ml/min,and the fluctuation range was 6-40 ml/min with an average of (19.2 ± 8.8) ml/min.There was no statistical difference in the incidence of complications and pathological types after operation.Results There was no statistical difference in general data of preoperative patients.In intraoperative and post-operative statistics,the time of exploring renal artery was shorter than that of 2DLNSS (33.7 ± 7.5) min in 3DP-2DLNSS (28.3 ± 8.2,P =0.015) min and 3DP-3DLNSS (27.8 ± 6.5,P =0.002) min.In tumor detection time,3 DP-2DLNSS was shorter than 2DLNSS group (41.2 ± 6.6 vs.46.5 ± 6.9 min,P =0.012),and 3 DP-3DLNSS was shorter than 3DP-2DLNSS (35.4 ± 7.3 vs.41.2 ± 6.6 min,P =0.009).In warm ischemia time,3DP-2DLNSS min was shorter than 2DLNSS (23.5 ±9.7 vs.33.9 ±7.5 min P ＜0.001),and 3DP-3DLNSS was shorter than 3DP-2DLNSS (18.3 ± 4.6 vs.23.5 ± 9.7,P =0.023).In surgical time,3DP-2DLNSS (115.7 ± 23.0) min and 3DP-3DLNSS (103.3 ± 22.8) min were shorter than 2DLNSS (132.4 ± 28.9) min (P =0.031,P ＜ 0.001).In intraoperative bleeding volume,3 DP-3 DLNSS was less than 2DLNSS (117.9 ± 17.9 vs.130.6 ± 16.8,P =0.009) ml.Fasting for 1 to 4 days after operation,with an average of (1.7 ± 0.8) days.The indwelling catheterization ranged from 1 to 8 days after operation,with an average of (3.9 ± 1.3) days.Negative pressure drainage was removed 2-9 days after operation,with an average of (4.9 ± 1.4) days.And the hospitalization 5-11 days after operation,with an average of (7.3 ± 1.5) days.Conclusions Preoperative 3D printing combined with intraoperative 3D laparoscopic nephron sparing surgery for partial endogenous renal tumors is safe and effective,which is superior to the previous CT scan alone and intraoperative 2D laparoscopic treatment.
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Objective To compare the clinical outcomes of selective artery (SAC) with main artery (MAC) clamping of robotic partial nephrectomy (RPN) in patients with early-stage (cTiN0M0) renal masses.Methods Between October 2016 and September 2018,a total of 343 cT1 renal mass patients receiving RPN with SAC (n =21) or MAC (n =322) in our center,were retrospectively analyzed.There were 13 males and 8 females in SAC group with a mean age of (53.1 ± 10.6) years old,mean tumor size of (2.5 ±0.7)cm,and mean R.E.N.A.L.score of 6.2 ± 1.5.There were 149 males and 173 females in MAC group,with a mean age of (51.6 ± 12.3) years old,mean tumor size of(3.5 ± 1.4)cm,and mean R.E.N.A.L.score of 7.9 ± 1.6.There was statistical significance between two groups in tumor size and R.E.N.A.L score(P ＜ 0.001).The group covariates were balanced through propensity score matching (PSM) using 1:2 nearest neighbor matching method.After matching,mean age,tumor size,R.E.N.A.L.score and preoperative eGFR in the SAC and MAC groups were (3.1 ± 10.6) vs.(52.7 ± 10.2) years,(2.5 ± 0.7) vs.(2.6±0.7) cm,6.2 ±1.5 vs.6.2 ±0.9,and (101.7 ± 19.8)vs.(101.6 ±20.3) ml/(min · 1.73m2),respectively (P ＞ 0.05).Perioperative outcomes and follow-up data were compared between the two matched groups.Results There was no significant differences resulted regarding operating time [(127.0 ±54.8)min vs.(130.0 ±49.9) min],blood loss[(166.0 ± 173.5)ml vs.(124.0 ± 101.0)ml],ischemia time [(18.9 ± 6.4) vs.(18.1 ± 5.8) min],hospital stay [(8.7 ± 3.4) d vs.(8.5 ± 2.5) d],incidences of complications (28.6％ vs.19.0％),surgical conversions (0 vs.2.4％),transfusions (4.8％ vs.2.4％) or positive surgical margin(0 vs.0) and malignant pathological outcomes(95.2％ vs.92.9％).The follow-up durations ranged from 3 to 24 months with a mean duration of 9.1 and 12.4 months in SAC and MAC,respectively.At the end of follow-up,the two groups had similar decrease in estimated glomerular filtration rate [(7.5 ± 17.2) ％ vs.(12.1 ± 18.2) ％,P =0.466],but the difference was statistically significant with ECT-GFR both of function reduction in the operated kidney [(21.6 ± 14.6) ％ vs.(38.4 ± 20.7)％,P =0.001] and in two kidneys [(2.5 ±16.4)％ vs.(14.8 ±20.0)％,P =0.002].Conclusions Robotic partial nephrectomy with selective vascular control lead to better postoperative renal function compared with main vascular clamped PN techniques and does not lead to a higher surgical risk following a strict patient selection criteria.
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Objective To analyze the value of early sequential unclamping method in laparoscopic partial nephrectomy.Methods From April 2017 to October 2017,a total of 8 cases of renal tumor patients by early sequential unclamping method of laparoscopic partial nephrectomy (LPN) were reviewed,with 5 males and 3 females and average age of 56.4 years (43-70 years).Three cases of renal tumor were located on the left side,5 cases on the right side.The mean tumor diameter was 5.6 (4.6-6.4) cm.The preoperativeR.E.N.A.L.score was 8.8 (7-10),and the mean ASA score was 1.4 (1-2).Preoperative serum creatinine level was 89.5 (72.1-104.2) μmol/L,and the GFR level of the kidney with tumor before operation was 55.5 (40.4-62.3) ml/min.The early sequential unclamping method was used for retroperitoneal laparoscopic partial nephrectomy:according to the preoperative CTA results,the main branches and branches of the renal artery were routinely separated.Before the tumor resection,the branches of renal artery and the main renal artery were sequentially blocked.After removal of the tumor,the first layer of bare kidney wound blood vessels and collection system were sutured and repaired.Then released the main renal artery occlusion clamp,restored most of the blood supply to the kidney,but kept the tumor-specific segmental renal artery blocked.Continuous suture of the kidney created a rough combination of the renal wound.After second layers of suture completed,unclamped the segmental renal artery and sutured the renal wound again,made the third layers of suture intersecting with the second seam suture to strengthen the hemostatic effect.Results All the 8 patients were performed LPN with early sequential unclamping method successfully.The average operative time was 132.5 (90-180) min,the intraoperative blood loss was 142.5 (100-200) ml,the completely warm ischemia time was 15.5 (12.0-20.0) min,and no blood transfusion was performed intraoperatively and postoperatively.The operative margin was negative.The postoperative pathology showed that 7 cases were clear cell carcinoma and 1 cases of papillary cell carcinoma.Postoperative complications such as urinary leakage,incision infection and fever were not found.Drainage tube removal time was 3.5 (3-5) days and the time of postoperative hospitalization was 4.8 (4-6) days.At 1 months after operation,the serum creatinine level was 94.0 (83.6-101.2) μmol/L and the GFR level of one side kidney with tumor was 52.3 (43.2-59.6) ml/min.After 2-9 months of follow-up,there was no recurrence of the tumor.Conclusions Early sequential unclamping method could shorten the warm ischemia time and reduce the risk of bleeding during the operation.It also maintains a clear operative field,which could reduce the difficulty of laparoscopic partial nephrectomy and make a more accurate tumor resection in the complex renal tumor patients.
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Objective To summarize our clinical experience of cryoablation for renal cancer and to analyze the therapeutic indication,security,selection of cryoablation and outcomes.Methods Sixty-four patients suffered with T1a renal cell carcinoma were enrolled in this study from March 2012 to March 2018.Among them,5 cases were senile patients (≥ 80 years),5 cases complicated with other cancers,3 cases complicated with renal insufficiency,4 cases complicated with decompensated cirrhosis,3 cases with bilateral renal cancer,4 cases with solitary kidney cancer and 39 cases with some other complications.The preoperative serum creatinine level was(80.5 ± 38.2)μmol/L.The patients underwent laparoscopic singlesite (LESS) renal cryoablation,conventional laparoscopic renal cryoablation,or percutaneous image-guided cryoablation according to individual situation.Contrast-enhanced CT scan or MRI were used during the procedures and follow-up was performed.Results All operations were completed successfully and technical success was achieved as well in all cases.Blood transfusion was necessary for 2 cases because of hemorrhage.The mean diameter of the mass was (2.6 ± 0.90) cm,the median volume of blood loss was 50ml(10-110 ml),and the mean operation time was(96.0 ± 24.5) min.The median inpatient hospital stay was 3 d (1-6 d).In one case,digital subtraction angiography (DSA) embolization was performed due to hemorrhage after surgery.None of the other cases had intraoperative or postoperative complications.The serum creatinine level after surgery was not significantly decreased [postoperative (83.8 ±42.1) μmol/L,P =0.64].The contrast-enhanced CT or MRI of the kidneys one week postoperatively showed uniform low density in all lesion areas,which represented complete ablation and regression of the tumor.All cases were followed up regularly.One case showed relapse at the 6 th month follow-up and underwent cryoablation again.Another case,who was not regularly followed up,relapsed at 69th month after surgery.No relapse was observed in the other cases during the follow-up.Conclusions Renal cancer cryoablation is a safe,feasible and efficacious therapy for the patients who suffered from unresectable T1a renal cell carcinoma because of high surgical risk or multifocal lesions.
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Objective To investigate the safety and efficiency of robot-assisted partial nephrectomy (RAPN) for totally intrarenal tumors (TITs).Methods Thirty-eight patients who underwent RAPN for treating TITs by one experienced surgeon were included between August 2012 and December 2017.There were 25 males and 13 females,aged 26-72 years(mean 51.6 years).Tumors of 24 cases were in right kidney,and 14 cases in left kidney.The diameter of tumor was(3.12 ± 0.92) cm,the R.E.N.A.L.score was(9.76 ± 1.00),and the Scr was (74.82 ± 20.32) μmol/L.Patients' peri-operative and oncological outcomes were analyzed.Results All the tumors were successfully resected without conversion to open surgery or radical nephrectomy.Mean operative time and ischemia time were (188.47 ± 46.75) min and (24.32 ± 7.69) min.Mean blood loss was (115.79 ± 43.66) rrd.One-week postoperative Scr was (85.97 ± 28.33) μmol/L.Postoperative hemorrhage was successfully treated by DSA or drug therapy in 3 patients.The pathological examination showed 28 clear cell renal cell carcinomas,3 chromophobe renal cell carcinomas,3 TFE-3 infusion related renal cell carcinomas,2 metanephric adenomas,1 acidophile adenoma and 2 angioleiomyolipomas.One positive surgical margin occurred in RAPN group for cystic components.No evidence of tumor progression observed during follow-up.Conclusions RAPN is safe and effective in treating TITs when performed by an experienced surgeon at a high-volume institution.Further prospective and large-scale study was warranted to evaluate the long-term outcomes.
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Objective To analyze the safety and effectiveness of robot-assisted laparoscopic partial nephrectomy(RLPN) for cT2 renal tumors in international multi-centers.Methods This study was conducted to collect information on surgical procedures performed by RLPN and robot assisted laparoscopic radical nephrectomy (RRN) in nineteen international urological centers from January 2012 to December 2017.RLPN were performed in 159 patients (118 males and 41 females),with the average age of (59.3 ± 13.2) years,body mass index(BMI) of (28.7 ± 5.4)kg/m2,preoperative GFR of (77.3 ± 22.1) ml/min.RRN were performed in 219 patients,with the average age of (62.0 ± 12.9) years,BMI of (28.7 ±6.1) kg/m2,preoperative GFR of (71.4 ± 20.3) ml/min.There was no statistical difference between the two groups in gender and BMI.The age of the patients in RLPN group was younger than that in RRN group,and the preoperative GFR was better.The patient's baseline demographics,perioperative data,tumor pathology,oncologic outcomes,and renal function (GFR) were recorded.Results All 378 cases underwent successful surgery.The operation time of RLPN was 150 min(65-353 min),which was shorter than that of RRN [180 min(85-361 min),P ＜ 0.001].The intra-operative blood loss of RLPN was more than that of RRN [150 ml (40-3 000 ml) vs.100 ml (10-1 100 ml),P ＜ 0.001].The incidence of intra-operative complications were not statistically different between the two groups [5.7％ (9/159) vs.3.2％ (7/219),P =0.240].The incidence of postoperative complications was higher in the RLPN group than that in RRN group [19.5％ (31/159) vs.10.5％ (23/219),P =0.014],but there was no significant difference in the incidence of complications of grade 3 or above [4.4％ (7/159) vs.2.3％ (5/219),P =0.246].The recurrence-free survival rate of RLPN group was higher than that of RRN group [91.4％ (117/128) vs.81.9％ (167/204),P =0.013],and RLPN group was more conducive to renal function protection (P ＜ 0.001).Conclusions RLPN for cT2 tumors can obtain effective tumor control rate and better renal function preservation.It could be an acceptable alternative for surgical management of cT2 tumors.
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Partial nephrectomy (PN) enables surgeons to obtain both radical resection of renal tumor and maximal preservation of normal kidney,which brings benefits on survival time and life quality for patients with early stage kidney cancer.Nevertheless,how to select the patients suitable for PN still remains a clinical challenge.In this article,by analyzing the domestic and overseas application status of PN,we summarized the advantages and disadvantages of PN for patients at different stages as well as difficulties and risks in PN on complicated renal tumor.The appropriate surgical indications could benefit more patients with kidney cancer through PN.