ABSTRACT
Objective To investigate the principles of diagnosis and treatment of non-hereditary bilateral synchronous renal cell carcinoma.Methods This retrospective study analyzed 36 cases of non-hereditary bilateral synchronous renal cell carcinoma in our hospital from January 2008 to December 2016,including 30 males and 6 females.A total of 74 renal tumors were found,in which 34 patients had bilateral single kidney tumor and 2 patients had two tumors in one kidney.The diameter of tumors ranged from 1 cm to 11 cm,with an average of (6.8 ±4.1)cm.The patients that underwent nephron-sparing surgery(NSS) got 4-12 points,with an average of (6.1 ±3.4) points in R.E.N.A.L.score and 3-13 points,with an average of (6.9 ± 3.7) points in Zhongshan score.The patients are classified into 4 groups according to operation methods.In group A,16 patients underwent bilateral NSS,which the preoperative creatinine was 63-103 μmol/L with an average of (80.9 ± 11.4) μmol/L.In group B,7 patients underwent one side of NSS before contralateral radical nephrectomy (RN),which preoperative creatinine was 59-87 μmol/L with an average of (75.7 ± 8.9)μmol/L.In group C,7 patients underwent one side of RN before contralateral NSS,preoperative creatinine was 57-107 μmol/L,with an average of (77.6 ± 19.2) μmol/L.In group D,6 patients underwent one side of NSS or RN and spare the contralateral side,2 of which shifted from NSS to RN after finding tumor invaded pelvis and upper ureter during surgery.Of all the 16 patients with bilateral NSS,4 patients underwent surgery on the side where tumor had a higher score in the first phase and then the side where tumor had a lower score in the second phase,11 underwent surgeries in an opposite order.One patient underwent bilateral NSS simultaneously.Group A,B and C are taken into final analysis.Result All the 30 patients underwent surgery successfully.The operation time of NSS ranged from 60 to 110 min with an average of (88.6 ± 23.6) min and RN ranged from 40 to 90 min with an average of (72.3 ± 21.4) min.The warm ischemia time of NSS was 12-40 mins with an average of (29.5 ± 9.7)min.The creatinine of Group A was 62-117 μmol/L with an average of (89.4 ± 15.8) μmol/L and 57-392 μmol/L with an average of (129.6 ±74.9)μmol/L one month after the first and second surgery respectively.The creatinine of Group B was 64-115 μmol/L with an average of (94 ± 14.4) μmol/L and 93-453 μmol/L with an average of (190.4 ± 117.2)μ mol/L one month after the first and second surgery respectively.The creatinine of Group C was 84-113 μmol/L with an average of (90.1 ± 12.1) μ mol/L and 88-156 μmol/L with an average of (121.4 ± 24.8)μmol/L one month after the first and second surgery respectively.One patient in Group B and C developed lung metastases.One patient in Group B occurred oliguria after the second stage of surgery,and gradually improved after one week of hemodialysis.The creatine showed no significant difference among Group A,B and C before operation,after the first and second stage (P ＞ 0.05).Postoperative hospital stay after the first stage surgery was 3-16 days with an average of (6.7 ± 3.4) d,and 3-16 d with an average of (6.2 ± 3.2)d after the second stage,respectively.Conclusions In principle,bilateral renal tumors should be treated with NSS,wbich can protect renal functions as much as possible.Among patients who can undergo bilateral NSS,the first-stage surgery should be operated on the simpler and easier side to preserve the kidney of one side as much as possible to lay a good foundation for the second stage surgery.Among patients who undergo one side of RN and the other side of NSS,NSS is recommended for the first stage,and RN for the contralateral second stage after the renal function of the operated side was restored.
ABSTRACT
Objective To evaluate the efficacy of zero ischemia index (ZⅡ) in predicting the complexity and perioperative outcomes of off-clamp nephron-sparing surgery (NSS).Methods The patients between June 2016 and June 2017 in our institution who underwent off-clamp NSS were prospectively evaluated.ZⅡ was defined as the product of the tumor diameter and depth within renal parenchyma.The ZⅡ ＞6 defined as higher risk while ZⅡ ≤ 6 defined as low risk.The operating time,estimated blood loss,hospital stay,drainage,and complication rate were analyzed.Results There were 35 males and 10 females with average age of 42 y(range 23-76y).Mean tumor size was 2.4 cm (range 0.8-4.2 cm).Mini-flank approach open NSS was performed in 33 cases and laparoscopic NSS was performed in 12 cases.Off-clamp NSS was successfully performed in 44 patients except for renal artery occlusion in 1 case.Mean operative time was (95.0± 17.5) min (range 50-150 min);The average estimated blood loss was (152.4 ± 134.2) ml (range 20-600 ml);Mean postoperative drainage was (97.3 ± 59.7) ml (range 50-300 md);Mean postoperative hospital stay was (6.1 ± 1.3) d (range 5-8 d).Not severe post operative complication was observed.There were 37 patients in low risk group and 8 patients in high risk group.Operating time was significantly longer in high risk group [(118.8 ± 14.6 min) vs.(89.9±13.4) min,P＜0.01].EBL [(375.0±158.1) ml vs.(104.3 ±61.4) ml,P＜0.01] and drainage [(161.2±91.3)ml vs.(83.5 ±40.4)ml,P ＜ 0.01] were also significantly higher in high risk group.But there was no significant difference in hospital stay between two groups.The postoperative pathology indicated that 35 cases of clear cell carcinomas,2 cases of chromophobe renal cell carcinomas,one case of papillary carcinoma and seven cases of angiomyolipomas.Conclusions The ZⅡ is a novel and effective measurable criterion which can help predict the risk of perioperative outcomes of off-clamp NSS.ZⅡ =6 is established as a preliminary threshold for patient selection of off-clamp NSS.