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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 assess the role of the arterial based complexity (ABC) scoring system in predicting clinically relevant outcomes of minimally invasive partial nephrectomy (MIPN). Methods: A retrospective review of 161 renal cell carcinoma patients who under-went MIPN at Tianjin Medical University Cancer Institute and Hospital from June 2016 to January 2018 was performed. The ABC score, including grades 1, 2, 3S, and 3H, were based on the patients'enhanced preoperative abdominal CT images. The reproducibility of the ABC scoring system was evaluated, and the relationship between the ABC score and patients'pathological features, surgery-related variables, postoperative complications, and renal function was analyzed. Results: Patients in grades 1, 2, 3S, and 3H in this study ac-counted for 20.5% (33/161), 60.2% (97/161), 11.8% (19/161), and 7.5% (12/161), respectively. The average Kappa value of the physi-cian's score was 0.523, and the average exact match percentage was 70.2%. The ABC score was significantly associated with operative time, warm ischemia time (WIT), estimated blood loss (EBL), and tumor size (P<0.001 for all) and was not associated with postopera-tive hospital stay, postoperative complications, preoperative estimated glomerular filtration rate (eGFR), and eGFR at 3 and 6 months postoperatively (P>0.05 for both). Conclusions: The ABC score is a scoring system with good repeatability and has certain predictive significance for the complexity of MIPN. However, further research is needed for its clinical application.
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OBJECTIVES: We designed the study to compare the oncologic and renal function outcomes of off-clamp, laparoscopic partial nephrectomy (OCLPN) and conventional laparoscopic partial nephrectomy (HCLPN) for renal tumors. METHODS: Between March 2008 and July 2015, 114 patients who underwent laparoscopic partial nephrectomy (LPN) of a renal neoplasm were studied. We performed LPN without hilar clamp on 40 patients (OCLPN, Group 1), and conventional LPN with hilar control and renorrhaphy on another 40 patients (HCLPN, Group 2). We retrospectively reviewed the medical records of each patient's age, sex, R.E.N.A.L. nephrometry score (RNS), operation time, complications, hospitalization period, tumor size, positive resection margin, histologic classification of tumor, pathologic stage, Fuhrman grade, estimated blood loss (EBL), warm ischemic time (WIT), and estimated glomerular filtration rate (eGFR) before and one year after surgery. RESULTS: There were no significant differences in age, sex, preoperative eGFR, EBL, surgical (anesthesia) time, and tumor size between the two groups. The mean eGFR was not significantly different between the OCLPN and HCLPN groups 1 month (95 and 86.2 mL/min/1.73 m², respectively; P = 0.106), 6 months (92.9 and 83.6 mL/min/1.73 m², respectively; P = 0.151) and 12 months (93.8 and 84.7 mL/min/1.73 m², respectively; P = 0.077) postoperatively. The change in eGFR after one year was 3.9% in the OCLPN group and −7.9% in the HCLPN group. CONCLUSIONS: OCLPN was superior to HCLPN in preserving renal function one year after surgery, and there was no statistically significant difference in tumor treatment results.
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Humans , Classification , Follow-Up Studies , Glomerular Filtration Rate , Hospitalization , Kidney Neoplasms , Medical Records , Nephrectomy , Retrospective Studies , Warm IschemiaABSTRACT
Objective To investigate the efficacy and safety of non-blocking renal artery laparoscopic partial nephrectomy in the treat-ment of renal cell carcinoma of stage T 1~T2.Methods From January 2012 to May 2016,the 140 patients with renal cell carcinoma of stage T1~T2 were selected ,and their clinical data were retrospectively analyzed .All the patients were equally divided into the observation group and the control group with 70 patients in each group according to the different treatment methods .Patients of the observation group were trea-ted with non-blocking renal artery laparoscopic partial nephrectomy ,while patients of the control group were treated with blocking renal artery laparoscopic partial nephrectomy .Recorded the postoperative complications ,postoperative recovery condition and renal function changes of the two groups.Results All the patients completed the surgery sucessfully and there was no conversion to laparotomy .The perative time,amount of bleeding ,gastrointestinal recovery time and postoperative hospital stay in the observation group were less than those of the control group (P0.05).One week after the operation , the incidence of secondary bleeding ,urinary leakage ,pulmonary infection ,incision infection ,renal infection and other complications in the observation group was 2.9%,which was significantly lower than 15.7%in the control group(P<0.05).The postoperative serum SCr values in the observation group and the control group were respectively (89.24 ±11.92)μmol/L and (137.24 ±11.49)μmol/L, which were significantly higher than (67.24 ±12.49)μmol/L and (68.14 ±13.11)μmol/L before the operation(P<0.05).In the mean time,the postoperative serum SCr values of the observation group was significantly lower than that of the control group (P<0.05).All the pa-tients were followed up to now , and the median survival time of the observation group and the control group were (25.32 ±3.14) months and (19.39 ±4.10) months respectively.That is to say,the median survival time of the observation group was significantly longer than that of the control group(t=4.209,P<0.05).Conclusion Non-blocking renal artery laparoscopic partial nephrectomy for treatment of renal cell car -cinoma of stage T1~T2 can avoid warm ischemia ,reduce postoperative complications ,protect renal function ,promote the patient ’ s recovery , and prolong the survival time ,which is a safe and effective method .
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Objective To explore the feasibility of 3D printing technique combined with intra-operative ultrasound for locating completely endophytic renal tumor in laparoscopic nephron-sparing surgery. Methods Fifteen patients with completely endophytic renal tumor, who underwent 3D printing technique combined with intra-operative ultrasound assisted localization of laparoscopic partial nephrectomy from Mar. 2014 to Mar. 2016, received CT image 3D reconstruction and 3D printing kidney model using Formlab Form1+ 3D printer before operation. Among 15 patients aging (55.7±10.5) years, 11 patients were male and 4 were female; the tumor diameter was (2.8±1.0) cm; and 3 cases were ventral and 12 were dorsal, all had solitary tumors. The clinical data, including intra-operative blood loss, warm ischemia time, post-operative pathology and surgical margins, and post-operative renal function, were statistically analyzed in this study. Results Laparoscopic partial nephrectomy was successfully carried out in all cases:the average operation time was (105.0±20.6) min, the average warm ischemia time was (22.8±3.5) min, and the mean intra-operative blood loss was (87.3±15.8) mL. No case received blood transfusion during or after operation, and the average post-operative hospital stay was (6.7±1.0) days. No obvious complication occurred after operation. The surgical margins were all negative. Post-operative pathology confirmed that 1 3 patients were with clear cell renal cell carcinoma, and 2 with papillary renal cell carcinoma. Patients were followed up for (23.7±11.8) months, and no continuous deterioration of renal function or tumor recurrence was found. Conclusion Pre-operative 3D printing technique for patients with completely endophytic renal tumor can help to determine the tumor location and adjacent relationship, reducing the risk of surgery by guiding operation scheme. Meanwhile, propaganda and education using 3D printing kidney model can improve patients’ cognition to surgery and simplify pre-operative conversation process. Furthermore, utilizing intra-operative ultrasound to optimize tumor resection scheme can reduce the damage to the renal vessels and collection system, maximizing the clinical benefit by ensuring negative margin and renal function reservation.
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Objective To access the efficacy of the arterial based complexity (ABC) scoring system in predicting complexity of LPN.Methods A total of 70 patients underwent laparoscopic partial nephrectomy from January 2013 to November 2015 were enrolled in the retrospective analysis.Among those patients,53 (75.7％) were males and 17 (24.3％) were females.Their mean age was 52 years,ranged from 44 to 61 years.The average BMI was 28 kg/m2,ranged from 25 to 32 kg/m2.Before operation,the average creatinine was 70.5 μmol/L,ranged from 60.5 to 81.0 μmol/L.43 patients accepted the procedure via retro-peritoneal approach and 27 patients accepted the procedure via peritoneal approach.38 tumor located in the left kidney and 32 tumor located in the right kidney.By using ABC scoring system,four readers independently scored contrast-enhanced computed tomography images of 70 patients who underwent laparoscopic partial nephrectomy.Interobserver variability was assessed with kappa values and percentage of exact matches between each pairwise combination of readers.Logistics regression was used to evaluate the association between reference scores and ischemia time,estimated blood loss,operation time.Results The operative duration ranged from 100 to 180 min,mean 147 min.The mean ischemic time ranged from 15 to 37 min,mean 24 min.The average blood loss was 210 ml (ranging 50-380 ml).The mean hospitalization was 16 days (ranging 11-21 days).The urine leakage was noticed in 2 patients after the operation.The size of tumor ranged from 1.8 to 3.0 cm,mean 2.5 cm.The pathological classification included renal cell carcinoma in 65 cases,renal cell carcinoma with cystic changing in 2 cases,renal chromophobe cell carcinoma in 2 cases,right renal solitary fibroma in 1 case.Based on the ABC scorirng system,15 cases were in 1 degree,29 cases were in 2 degree,17 cases were in 3S degree and 9 cases were in 3H degree.Pairwise comparisons of readers' score assignments were significantly correlated;average kappa =0.492,across all reader pairs.The average proportion of exact matches was 65％,the average proportion that differ between a level or less than a level was 98.6％.Logistics regression between the complexity score system and surgical outcomes showed significant associations between reference category assignments and warm ischemia time and estimated blood loss (P ＜ 0.05),but showed no significant associations with operation time (P ＞ 0.05).Conclusions The ABC scoring system for LPN demonstrated good correlation with perioperative morbidity.This system is a novel anatomy-reproducible tool developed to help patients and doctors understand the complexity of renal masses and predict the outcomes of kidney surgery.
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Objective To explore the feasibility of 3D printing technique combined with intra-operative ultrasound for locating completely endophytic renal tumor in lapamscopic nephron-sparing surgery.Methods Fifteen patients with completely endophytic renal tumor,who undervwent 3D printing technique combined with intra-operative ultrasound assisted localization of laparoscopic partial nephrectomy from Mar.2014 to Mar.2016,received CT image 3D reconstruction and 3D printing kidney model using Fommlab Form1 + 3D printer before operation.Among 15 patients aging (55.7±10.5) years,11 patients were male and 4 were female;the tumor diameter was (2.8±1.0) cm;and 3 cases were ventral and 12 were dorsal,all had solitary tumors.The clinical data,including intra-operative blood loss,warm ischemia time,post-operative pathology and surgical margins,and post-operative renal function,were statistically analyzed in this study.Resuits Laparoscopic partial nephrectomy was successfully carried out in all cases:the average operation time was (105.0± 20.6) min,the average warm ischemia time was (22.8 ± 3.5) min,and the mean intra-operative blood loss was (87.3±15.8) mL.No case received blood transfusion during or after operation,and the average post-operative hospital stay was (6.7 ± 1.0) days.No obvious complication occurred after operation.The surgical margins were all negative.Post-operative pathology confirmed that 13 patients were with clear cell renal cell carcinoma,and 2 with papillary renal cell carcinoma.Patients were followed up for (23.7± 11.8) months,and nocontinuous deterioration of renal function or tumor recurrence was found.Conclusion Pre-operative 3D printing technique for patients with completely endophytic renal tumor can help to determine the tumor location and adjacent relationship,reducing the risk of surgery by guiding operation scheme.Meanwhile,propaganda and education using 3Dprinting kidney model can improve patients ' cognition to surgery and simplify pre-operative conversation process.Furthermore,utilizing intra-operative ultrasound to optimize tumor resection scheme can reduce the damage to the renalvessels and collection system,maximizing the clinical benefit by ensuring negative margin and renal function reservation.
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PURPOSE: To compare the 5-year oncologic and functional outcomes of robot-assisted laparoscopic partial nephrectomy (RALPN) and laparoscopic partial nephrectomy (LPN) as treatment for localized renal cell carcinoma (RCC). MATERIALS AND METHODS: We analyzed the records of 181 patients with localized RCC who underwent RALPN (n=97) or LPN (n=84) between 2007 and 2011. Demographic and preoperative data with estimated glomerular filtration rate (eGFR), intraoperative data including warm ischemic time (WIT) and complications, oncologic outcomes (recurrence, metastasis), and rate of eGFR preservation at most recent follow-up were examined. RESULTS: WIT was shorter in the RALPN group (27±9.1 minutes) than the LPN group (31±10 minutes, p=0.019). Intraoperative complication rates were also lower in RALPN patients than LPN patients (4.1% vs. 14.3%). The eGFR preservation rate was higher in the RALPN group (84.6%) than in the LPN group (81.5%, p=0.049). Particularly, a relatively high difference in the eGFR preservation rate was observed in the RALPN group compared with the LPN group according to R.E.N.A.L. score 7–10 values (RALPN, 86.5±12.9 vs. LPN, 76.7±16.0; p=0.003). During the follow-up period, there was no local recurrence in either group and distant metastases only occurred in one patient in the RALPN group and in 2 patients in the LPN group. CONCLUSIONS: RALPN and LPN showed similar 5-year oncologic outcomes, but RALPN was superior to LPN in terms of WIT, intraoperative complications, and long-term eGFR preservation rate, especially in complex cases.
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Humans , Carcinoma, Renal Cell , Follow-Up Studies , Glomerular Filtration Rate , Intraoperative Complications , Neoplasm Metastasis , Nephrectomy , Recurrence , Warm IschemiaABSTRACT
Objective To evaluate the safety and efifcacy of Laparoscopic partial nephrectomy (LPN) versus 1aparoscopic cryoablation (LCA) for the small renal tumors (SRMs).Methods The databases of PubMed, SCI, Ovid, the Cochrane Library, CNKI, CBM, VIP and Wangfang Data were searched to controlled clinical trial about LPN versus LCA for the treatment of small renal tumor. The retrieval time span was from inception to Apr 2016. The studies were screened according to the inclusion and exclusion criteria, the date were extracted and the quality was evaluated by 2 reviewers independently. And then the Meta-analysis was conducted using RevMan 5.3 software.Results 9 studies were included, and 748 cases were involved. The meta-analysis showed that comparing with LPN, the operation time of LCA was shorter [MD = 42.75, 95 % CI (12.19~73.31),P = 0.006], less intraoperative blood loss [MD = 190.73, 95 % CI (126.67~254.78),P = 0.000], shortening hospital stay [MD = 2.23, 95 % CI (0.17~4.28),P = 0.030], lower transfusion rate [OR
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Objective To evaluate the safety,efficiency of retroperitoneal laparoscopic partial nephrectomy combined with four points location in 3D model or 3Dimensional CT for completely endophytic tumors,and summarize the surgical experience.Methods From Jan 2015 to Jan 2016,5 patients with completely endophytic tumors,who underwent retroperitoneal laparoscopic partial nephrectomy were recruited.one patient underwent 3D printing kidney model,and another 4 patients underwent 3Dimensional CT and locating four projection positions of the tumor on the surface,in order to guide the tumor resection in laparoscopic partial nephrectomy.Perioperative,operative,and postoperative,as well as oncological outcomes were analyzed.Results In all 5patients,preoperative four points location in 3D model or 3Dimensional CT for completely endophytic tumors is feasible and accurate in term of locating the tumor.The mean operative time was(129.0 ± 19.5) min,mean warm ischaemia time was (19.6 ± 5.4) min and mean estimated blood loss was(100 ± 83) ml.Pathological examination showed cell renal cell carcinoma.All the patients had a negative surgical margin,and no tumor recurrence or metastasis during 6-18months of follow up.Conclusions In experienced institutes,retroperitoneal laparoscopic partial nephrectomy combined with four points location in 3D model or 3Dimensional CT for completely endophytic tumors is a feasible and safe procedure in terms of accurate locations,low complication rates,reasonable functional and oncologic outcomes after an intermediate-term follow-up
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Objective To compare the safety and clinical effect of laparoscopic partial nephrectomy ( LPN) on small renal cell carcino-ma. Methods The records of 65 patients who underwent partial nephrectomy in our hospital from March 2008 to March 2013 were retrospec-tively analyzed. 35 patients were given open partial nephrectomy and the other 30 patients were given LPN. Compared the operative time,blood loss,warm ischemia time,length of stay,positive marginrate,and occurance rate of complications between the two groups. Results There was no statistical difference in the mean size of tumor in the two groups. Compared to the OPN group,there was less blood loss,operative time, hospital stays and warm ischemia time in the LPN group. There was neither positive surgical margin nor renal function damage in the two groups. And during the follow-up period ranged from 6 to 18 months,there was no local recurrence. Conclusion Laparoscopic partial ne-phrectomy has a shorter operation time,less blood loss,shorter length of hospital stay compared with open partial nephrectomy,and it wouldn 't extend the time of warm ischemia,while the clinical effect of the two methods are similar.
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Objective To evaluate the feasibility and safety of superselective renal artery clamping technique in laparoscopic partial nephrectomy and to assess its short-term effect on postoperative renal function. Methods Totally 23 patients, who were diagnosed as having renal malignant tumor and treated with transperitoneal laparoscopic partial nephrectomy by the same doctor at department of urology, Changhai Hospital from June 2013 to May 2014, were included in the present study. Superselective technique and traditional renal artery clamping technique were employed in group A (10 cases) and group B (13 cases), respectively. The operation time, intraoperative blood loss, postoperative renal function and other clinical parameters were compared between the two groups. Results Compared with group B, group A had significantly increased operation time ([257.60 ± 22.03] min vs [199.08 ± 36.70] min, P<0.05), intraoperative blood loss ([220 ± 57.01] mL vs [71.54 ± 30.51] mL, P<0.05) and postoperative incision drainage ([113.33 ± 24.82] mL vs [68.08 ± 28.88] mL, P<0.05), and there were no Grade III- complications such as massive bleeding or urinary leakage in the two groups. But patients in group A had slighter renal function damage postoperatively in the early stage compared with group B, as demonstrated by slighter eGFR decrease ([3.14 ± 7.22]% vs [15.26 ± 9.53]%, P<0.05) for a similar ischemic time ([28.60±8.17]) min vs ([27.85±6.16] min). Conclusion Superselective renal artery clamping does less harm to the kidney than traditional main renal artery clamping in laparoscopic partial nephrectomy, and it is worth further research for its benefit in early-stage renal function recovery postoperatively.
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Objective To evaluate whether the unidirectional barbed suture is safety and efficiency enough for laparoscopic partial nephrectomy.Method From March 2013 to March 2014,27 patients with renal mass have been involved into this study and divided into 2 groups wsing a lottery.Group A used Coated Vicryl in renorrhaphy after LPN,and group B used unidirectional barbed suture.All patients underwent LPN preformed by single group of surgeons.Perioperative and postoperative indicators were compared in two groups.Result It is identical in age,BMI,tumor size,R.E.N.A.L nephrometry scoring system between 2 groups.However,using barbed suture has significantly shortened in warm ischemia time (WIT).The postoperative indicators,such as blood loss,hospital stay and surgery complication has no significantly difference in two groups.Conclusion The unidirectional barbed suture is safety and efficiency using in LPN which can shorten WIT significantly.
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Con el fin de disminuir el tiempo de isquemia durante la nefrectomía parcial, se han diseñado distintas opciones como clampeo arterial selectivo, técnica sin clampeo con hipotermia corporal y técnica de des clampeo precoz (DP). El objetivo del presente trabajo es analizar el resultado y complicaciones de un grupo de pacientes sometidos a nefrectomía parcial laparoscópica (NPL), aplicando la técnica de DP. Materiales y métodos: A través de una base de datos que se mantiene prospectivamente, se analizó los datos clínicos de los pacientes sometidos a nefrectomía parcial laparoscópica con técnica de desclampeo precoz entre los años 2010 y 2011.Resultados: Once pacientes fueron sometidos a NPL con técnica de DP entre agosto de 2010 y diciembre de 2011. Seis hombres y 5 mujeres, mediana de edad 59 (43-76) años. El tiempo operatorio fue de 180 min (180-220), con tiempo de clampeo 19,5 min (11-23). El sangrado total fue 300 ml (180-2.500). No hubo necesidad de conversión a cirugía abierta, pero un paciente requirió nefrectomía radical por sangrado importante. Márgenes positivos se encontró en un solo caso. Conclusión: El desclampeo precoz permite disminuir el tiempo de isquemia en la nefrectomía parcial laparoscópica, sin aumentar el riesgo de sangrado. Además, podría disminuir las complicaciones vasculares. Sin embargo, técnicamente es una cirugía compleja que requiere entrenamiento adecuado...
To decrease the time of ischemia during partial nephrectomy, various options were designed as selective arterial clamping, unclamping technique with body hypothermia and early unclumping technique (EU). The aim of this paper is to analyze the results and complications of a group of patients undergoing laparoscopic partial nephrectomy (LPN), using the EU technique. Materials and Methods: Using a prospective database, the clinical data of patients undergoing laparoscopic partial nephrectomy with early uncclamping technique between 2010 and 2011 is analyzed. Results: 11 patients underwent LPN with EU technique between August 2010 and December 2011. 6men and 5 women, median age 59 (43-76) years. The operative time was 180 min (180-220), with clamping time 19.5 min (11-23). The total estimated bleeding was 300 ml (180-2500). There was no need for conversion to open surgery, but one patient required radical nephrectomy due major bleeding. Positive margins were found in one case Conclusion: Early unclamping technique decreases the ischemia time in laparoscopic partial nephrectomy without increasing the risk of bleeding. Furthermore, it may reduce vascular complications. However, this is a technically demanding surgery that requires proper training...
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Humans , Male , Female , Adult , Middle Aged , Ischemia/prevention & control , Laparoscopy/adverse effects , Nephrectomy/adverse effects , Kidney Neoplasms/surgery , Postoperative Complications , Time Factors , Laparoscopy/methods , Nephrectomy/methods , Blood Loss, Surgical/prevention & control , Operative Time , Length of StayABSTRACT
Advanced imaging techniques have resulted in increasing use of minimally invasive approaches for nephron sparing surgeries of kidney. Need for precise knowledge of normal and variant anatomy of vascular pedicle of kidney is thus justified. Ample literature is available on the variations in the intrarenal vascular pattern of the kidney, which are seen frequently. But the variation in arrangement of structures at the renal hilum has not gained much interest up till now. One hundred (51 right and 49 left) embalmed kidneys were utilized for the present study. Careful dissection of renal hilar structures was carried out to observe antero-posterior relationship of structures at the hilum of the kidney. In majority (73 percent), the arrangement was not according to the normal textbook description i.e. renal vein, renal artery and pelvis arranged antero-posteriorly. In 31 percent anterior division of renal artery was seen in front of renal vein at the hilum, whereas, in 50 percent cases the pelvis was not the posterior most relation. The variable patterns observed were classified into five types. In cases of renal hilar tumors laparoscopic partial nephrectomy is being done with a limited field of vision. Knowledge of these variations is useful for operating surgeons to identify and individually clamp the hilar structures, which is advantageous over en-bloc clamping.
Las técnicas avanzadas de imagen han permitido aumentar el uso de abordajes mínimamente invasivos para la cirugía conservadora del nefrón. Por esto, se justifica la necesidad de un conocimiento preciso de la anatomía normal y las variaciones anatómicas del pedículo vascular del riñón. Es amplia la literatura disponible sobre variaciones en el patrón vascular intrarrenal, lo que se observa con frecuencia. Sin embargo, hasta ahora, la variación en la disposición de las estructuras en el hilio renal no ha generado mucho interés. Se utilizaron 100 riñones fijados (51 derechos y 49 izquierdos) para el estudio. Una cuidadosa disección de las estructuras hiliares renales se llevó a cabo para observar la relación antero-posterior de las estructuras en el hilio del riñón. En la mayoría de los casos (73 por ciento), las características no estaba de acuerdo con la descripción normal de la vena renal, es decir, con la arteria renal y la pelvis renal dispuestos en sentido anteroposterior. Los patrones de las variables observadas fueron clasificadas en cinco tipos. En el 31 por ciento de los casos la división anterior de la arteria renal estaba anterior a la vena renal en el hilio, mientras que, en el 50 por ciento de los casos, la pelvis no estaba posterior. En los casos de tumores renales hiliares la nefrectomía parcial laparoscópica se realiza con un limitado campo de visión. El conocimiento de estas variaciones es útil para un adecuado desempeño de los cirujanos al identificar y separar individualmente las estructuras hiliares, que es una ventaja sobre la separación en bloque.
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Humans , Renal Artery/anatomy & histology , Kidney/blood supply , Renal Veins/anatomy & histologyABSTRACT
Introducción: Avances técnicos y la experiencia acumulada hacen que la nefrectomía parcial laparoscópica sea una opción viable en el tratamiento de masas renales pequeñas (<4 cm), debido a su efectividad oncológica y la asociación entre la nefrectomía radical y la insuficiencia renal crónica y la morbilidad cardiovascular asociada a ésta. Las terapias ablativas surgen como alternativa en el tratamiento de las masas renales pequeñas, entre éstas la radiofrecuencia. Reportes recientes sugieren que las terapias ablativas no ofrecen un adecuado control oncológico y que la imagenología actual no puede llevar a cabo seguimientos de forma segura. Material y método: presentamos una serie de casos de 13 pacientes portadores de 16 tumores renales, sometidos a nefrectomía parcial laparoscópica asistida por radiofrecuencia entre abril de 2008 y junio de 2009. El procedimiento fue realizado por vía transperitoneal en 11 pacientes y vía retroperitoneal en dos. La radiofrecuencia fue administrada por vía percutánea bajo control visual laparoscópico y la tumorectomía realizada sin necesidad de clampear los vasos renales. Resultados: el tiempo quirúrgico promedio fue de 93 mins. (45-135).No hubo sangrado importante intraoperatorio ni complicaciones postoperatorias. De 16 tumores, 13correspondieron a carcinoma de células renales, uno oncocitoma y uno angiomiolipoma. Los márgenes quirúrgicos fueron informados negativos y todos los pacientes están en remisión completa con un seguimiento promedio de 8 meses (1-15 meses). Conclusiones: la radiofrecuencia es una excelente ayuda a la nefrectomía parcial laparoscópica. Permite realizar el procedimiento sin clampear los vasos renales sometiendo parénquima renal sano a isquemia y con escaso sangrado.
Introduction: Technical advances and accumulated experience have done laparoscopic partial nephrectomy a viable option in the treatment of small renal masses (<4 cm), because of its oncologic effectiveness and the association between radical nephrectomy and chronic renal failure and cardiovascular morbidity associated. Ablative therapies arise like a valid alternative in the treatment of small renal masses, between these radiofrequency. Recent reports suggest that ablative therapies do not offer an adequate oncological control and that current imagenology cant carry out follow-ups of sure form. Materials and methods: we present a case series of 13 patients diagnosed of 16 small renal masses, treated by laparoscopic partial nephrectomy with radiofrequency assistance between April 2008 and June 2009. Procedure was realized by a transperitoneal approach in eleven patients and by retroperitoneal approach in two. Radiofrequency was administrated by percutaneous way under visual laparoscopic control and partial nephrectomy realized without needing of renal vascular clamping. Average surgical time was 93 minutes (45-135). There was no important bleeding during surgery and no surgical complications associated. Thirteen of total sixteen tumors corresponded to renal cell carcinomas, one to angiomiolypoma and the last one to oncocytoma. All surgical margins were informed as negatives and at present, all the patients have no evidence of disease with a follow up average time of 8 months (1-15 months). Conclusions: radiofrequency can be an excellent tool assisting laparoscopic partial nephrectomy. It allows surgery without need of clamping renal vein and artery avoiding warm ischemia and with no bleeding.