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Objective To analyze the influencing factors of affected renal function after laparoscopic nephron-sparing nephrectomy with segmental renal artery blocking (SRPN) for low R.E.N.A.L.score small localized renal tumor with follow-up data.Methods The data of 33 patients was collected,who underwent SRPN for small renal tumor from January 2010 to April 2012,and were followed-up for 5 years successfully.In 33 integrated data of 5-year follow-up,there were 14 males and 19 females,aged(56.5 ± 11.8)years.The preoperative affected renal glomerular filtration rate (aGFRpre),postoperative affected renal glomerular filtration rate (aGFRpost),the residual ratio of aGFR (aGFRpost/aGFRpre),preoperative affected renal volume (aVolpre),postoperative affected renal volume (aVolpost) and the residual ratio of aVol (aVolpost/aVolpre) were collected at the postoperative 3rd,6th,12th,24th and 60th month in follow-up period.Preoperative and postoperative data were analyzed by paired-sample T test.Multivariate linear regression analysis determined the influence of body mass index,operation time,localized warm ischemia time and distance from tumor to renal collecting system.Compare the correlation between aGFRpost/aGFRpre and aVolpost/aVolpre.Results All 33 cases were performed successfully.The mean operation time was (108.4 ± 9.1) min,and the mean time of segmental renal artery blocking was (23.3 ± 3.0) min.Postoperative pathologic 17 (51.5％) of clear cell carcinoma,5 (15.2％) of papillary carcinoma,3 (9.1％) of chromophobe cell carcinoma.All of above margins were negative.8 (24.2％) of angiomyolipoma (9.1％).All 33 cases were followed up for more than 5 years.The 5-year overoll survival (OS) and cancer specific survival (CSS) were 100％.In the 3rd,6th,12th,24th and 60th month,aGFRpost were (34.6 ± 4.6) ml/min,(34.7 ± 4.8) ml/min,(34.9 ± 4.4) ml/min,(35.1 ± 4.4) ml/min,(35.2 ± 4.2) ml/min,decreased of (10.4 ± 2.4) ml/min,(10.4 ± 2.6) ml/min,(10.1 ± 2.4) ml/min,(9.9 ± 2.4) ml/min,(9.8 ± 2.5) ml/min compared with aGFRpre (P ＜ 0.05).Multivariate linear regression analysis showed that body mass index,operation time,localized warm ischemia time in SRPN and distance from tumor to renal collecting system were unable to influence aGFRpost (P ＞ 0.05).The correlation coefficients between aGFRpost/aGFRpre and aVolpost/aVolpre were 0.659,0.667,0.663,0.629,0.604 respectively,and the difference was statistically significant (P ＜ 0.05).Conclusions For low R.E.N.A.L.score small localized renal tumor with SRPN,the decrease of postoperative affected renal function is relevant to postoperative affected renal volume,not as to operation time,localized warm ischemia time in SRPN and distance from tumor to renal collecting system.
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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 evaluate the effect of selective segmental renal artery clamping ( SSRAC) on the solitary-kidney, providing a foundamental basis for the using of SSRAC in partial nephrectomy. Methods A total of 18 pigs were randomized equally into 2 groups according to the method of renal artery clamping such as main renal artery clamping ( MRAC) group or SSRAC group.Each case underwent right radical nephrectomy and either MRAC or SSRAC for 60 minutes on the left kidney.Serum creatinine ( SCr) and blood urea nitrogen (BUN) were measured before surgery and at 6 time points thereafter (the 1st, 7th, 14th, 21st, 28th, 90th day).Magnetic resonance imaging was performed before surgery and at 4 time points thereafter (the 1st, 7th, 28th, 90th day) and T2 relaxation time and apparent diffusion coefficient (ADC) were determined.Inflammatory cell infiltration and interstitial fibrosis were detected using renal histology on the 1st and 90th day after operation.Results SCr and BUN of the two groups increased to peak value on the 1st day, and then decreased gradually to normal on the 90th day after the operation.On the 1st day, SCr [(266.43 ±31.12)umol/l] and BUN [(13.63 ±2.54)mmol/l)] of SSRAC group were significantly lower than that of MRAC [(386.37 ±40.40)umol/l,(26.83 ±5.96)mmol/l] (P0.05) on the 7th, 14th, 21st, 28th, 90th day.In the MRAC group, the T2 relaxation time of upper, middle and lower pole of the left kidney increased and the ADC decreased on the 1st day after operation.It arrived to the peak value on the 7th day, and decreased or increased respectively from then on to normal level on the 90th day.In the SSRAC group, there were no significant changes of T2 relaxation time and ADC in the upper and middle pole of left kidney (P>0.05), but it was similar to that in the MRAC group for lower pole.On the 1st, 7th, 28th day after operation, the T2 relaxation time of upper and middle pole of the left kidney in the MRAC group [(45.50 ±1.87),(51.82 ±2.27), and(40.37 ±1.93)ms ) ] were significantly higher than those in the SSRAC group [(36.67 ± 1.33),(35.15 ±1.27), and(37.48 ±1.37)ms](P0.05).On the 1st, 7th, 28th day after operation, the ADC of upper and middle pole of the left kidney in the MRAC group [(2.29 ±0.08) ×10 -3 mm2/s, (2.10 ±0.08) ×10 -3 mm2/s, (2.41 ±0.09) ×10 -3 mm2/s] were significantly lower than that of the SSRAC group [(2.69 ± 0.08) ×10 -3 mm2/s, ( 2.63 ±0.06 ) ×10 -3 mm2/s, ( 2.68 ±0.05 ) ×10 -3 mm2/s ] ( P <0.05 ) . However, on the 1st,7th, 28th, 90th day after operation, the ADC of lower pole of the left kidney in the SSRAC group [(1.93 ±0.08) ×10 -3mm2/s,(1.91 ±0.09) ×10-3mm2/s,(2.33 ±0.07) ×10 -3mm2/s, and (2.43 ±0.07) ×10 -3 mm2/s] were significantly lower than those of the MRAC group [ (2.37 ±0.05) ×10 -3 mm2/s, (2.06 ±0.07) ×10 -3 mm2/s, (2.46 ±0.09) ×10 -3 mm2/s, (2.61 ±0.08) ×10 -3 mm2/s](P<0.05).The whole left kidney in MRAC group experienced extensive tubular hydropic degeneration and limited inflammatory cell infiltration on the 1st day after operation.Moreover, renal tubular hydropic degeneration alleviated and no glomerular changes, fibrous tissue hyperplasia or inflammatory cell infiltration was found on the 90th day after operation.In SSRAC group, no changes were found in upper and middle pole of left kidney at the two time points, while the pathological injury of the lower pole of left kidney was more severe.Conclusions SSRAC has obvious protective effect on renal function in the early stage. However, compared with MRAC, the renal tissue injury in the ischemic area was more serious.Therefore, to protect renal function in partial nephrectomy, the ischemic renal area should be reduced as much as possible, even to zero-ischemic, when adopting SSRAC.
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Objective To establish a risk assessment model for laparoscopic partial nephrectomy (LPN) with segmental renal artery clamping (SRAC).Methods In the first stage,107 patients who underwent LPN with SRAC from December 2009 to September 2011 were retrospectively reviewed.There were 63 men and 44 women,aged from 11-80 years,mean (58.1 ±10.1) years.The blocking program of target arteries was dependent on the experience of the surgeon and CTA.After multiple Logistic regression analysis,variables used to build a nomogram were selected using a backward elimination scheme.Then,a model for a clamping program customized to the patient was designed.In the second stage,the surgical outcomes of 141 patients who subsequently underwent LPN-SRAC with the applied model from October 2011 to June 2014 were compared with those of the first stage patients.There were 84 men and 57 women,aged from 51-75years,mean (59.9 ± 8.6) years.Outcomes of two stages were compared.Results Five potential predictors were initially assessed including segmental renal artery angle,target artery diameter,and distance to the abdominal aorta,renal hilum,and kidney midline.The regression equation was then set up with Logistic regression analysis.Compared with the patients in the first stage,success rate of clamping in the second stage,with the help of the new SRAC model,was improved from 74.8％ (175/234) to 94.2％(227/241) (P ＜ 0.001),the total operative time was decreased from (88.6 ± 10.9) min to (80.2 ±16.6) min (P＜O.001),and operative blood loss was reduced from (198.7 ±111.6) ml to (168.5 ±117.8) ml (P =0.042).No obvious differences were observed in warm ischemia time,postoperative hospitalization,R.E.N.A.L nephrometry score,or number of final clamped branches.Conclusion The model for assuring clamping success was helpful in designing an SRAC program.