Comparative analysis of robot-assisted partial nephrectomy with off-clamp versus selective clamping in the management of cT1 kidney cancer
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摘要: 目的:比较肾动脉无阻断机器人辅助腹腔镜肾部分切除术与肾动脉分支阻断机器人辅助腹腔镜肾部分切除术治疗cT1期肾癌的临床疗效。方法:回顾性分析2014年5月—2018年9月我院同一手术团队完成的机器人辅助腹腔镜肾动脉无阻断和分支阻断肾部分切除术治疗58例cT1期肾癌患者的临床资料。肾动脉无阻断组31例,男19例,女12例,平均年龄(56.3±9.2)岁,平均BMI(24.3±3.3) kg/m2,平均美国麻醉师协会评分(ASA)(2.00±0.37)分,平均肿瘤最大径(2.7±1.6) cm,平均R.E.N.A.L.评分(5.7±1.6)分,经腹入路17例,经腹膜后入路14例,平均术前肾小球滤过率(eGFR)(94.0±13.7) mL/(min·1.73 m2);肾动脉分支阻断组27例,男21例,女6例,平均年龄(56.0±11.2)岁,平均BMI(24.8±4.1) kg/m2,平均ASA评分(1.96±0.44)分,平均肿瘤最大径(3.4±1.3) cm,平均R.E.N.A.L.评分(6.7±1.3)分,经腹入路16例,经腹膜后入路11例,平均术前eGFR(90.0±18.0) mL/(min·1.73 m2);以上指标两组比较差异均无统计学意义(P＞0.05)。比较两组患者的围手术期和随访资料,包括手术时间、术中出血量、手术输血率、手术中转率、手术并发症、切缘阳性率、病理学结果、术后住院天数、术后1个月血肌酐升高百分比、术后1个月eGFR下降百分比、术后1个月发射型计算机断层扫描检查肾小球滤过率(ECT-GFR)下降百分比、术后6个月ECT-GFR下降百分比等。结果:两组患者均顺利完成手术,均无中转开放手术或肾根治性切除术患者。两组手术时间[(131.0±54.5) min vs.(165.67±57.6) min,P=0.022]、术后并发症发生率[3.2%(1/31) vs.22.2%(6/27),P=0.042]比较,差异均有统计学意义。无阻断组与分支阻断组的术中出血量[(106.9±74.3) mL vs.(123.7±142.6) mL]、术后住院天数[(6.6±2.1) d vs.(6.7±3.5) d]、术后1个月血肌酐升高百分比[(2.6±19.4)%vs.(6.0±22.7)%]、术后1个月eGFR下降百分比[(0.1±13.6)%vs.(1.4±15.9)%]、术后1个月ECT-GFR下降百分比[(2.9±20.8)%vs.(3.4±25.0)%]、术后6个月ECT-GFR下降百分比[(4.5±12.8)%vs.(5.8±19.3)%]、术后病理恶性肿瘤比例[90.3%(28/31) vs.92.6%(25/27)]、手术切缘阳性率(0 vs.0)比较,差异均无统计学意义(P＞0.05)。结论:对于外生比例较高的cT1期肾癌,机器人辅助腹腔镜肾动脉无阻断肾部分切除术与肾动脉分支阻断肾部分切除术相比,总体手术时间短,术后并发症发生率低,短期随访两者肾功能保护效果相当。Abstract: Objective: To compare the clinical outcomes of off-clamp and selective renal artery clamping in robot-assisted partial nephrectomy(RAPN) for patients with cT1 kidney cancer.Methods: A total of 58 cT1 renal mass patients receiving RAPN with off-clamp or selective renal artery clamping in our center between May 2014 and September 2018 were retrospectively analyzed. There were 19 males and 12 females in off-clamp group(n=31), with a mean age of(56.3±9.2) years and a mean BMI of(24.3±3.3) kg/m2. The mean ASA score, tumor size, R. E. N. A. L. score and preoperative eGFR were(2.00±0.37),(2.7±1.6) cm,(5.7±1.6) and(94.0±13.7) mL/(min·1.73 m2). Seventeen procedures were performed via a transperitoneal approach and 14 procedures were performed via a retroperitoneal approach. There were 21 males and 6 females in selective clamping group(n=27), with a mean age of(56.0±11.2) years and a mean BMI of(24.8±4.1) kg/m2. The mean ASA score, tumor size, R. E. N. A. L. score and preoperative eGFR were(1.96±0.44),(3.4±1.3) cm,(6.7±1.3) and(90.0±18.0) mL/(min·1.73 m2). Sixteen procedures were performed via a transperitoneal approach and 11 procedures were performed via a retroperitoneal approach. There was no statistical difference between the two groups(P＞0.05). Intraoperative parameters and postoperative outcomes were compared between the two groups.Results: All cases of partial nephrectomy were successfully accomplished without intraoperative conversion to open surgery or radical nephrectomy. In the off-clamp group and selective clamping group, there was significant difference in operating time [(131.0±54.5) min vs.(165.67±57.6) min, P=0.022] and incidence of postoperative complications [3.2%(1/31) vs. 22.2%(6/27), P=0.042]. There was no significant difference in estimated blood loss [(106.9±74.3) mL vs.(123.7±142.6) mL], postoperative hospital stay [(6.6±2.1) d vs.(6.7±3.5) d], 1stmonth postoperative serum creatinine increase [(2.6±19.4)% vs.(6.0±22.7)%], 1stmonth postoperative eGFR reduction [(0.1±13.6)% vs.(1.4±15.9)%], 1stmonth postoperative ECT-GFR reduction [(2.9±20.8)% vs.(3.4±25.0)%] or 6thmonth postoperative ECT-GFR reduction [(4.5±12.8)% vs.(5.8±19.3)%]. According to the pathology results, the two groups' malignant outcomes were 90.3%(28/31) and 92.6%(25/27), and there was no case of positive surgical margin.Conclusion: Robot-assisted partial nephrectomy for treating more exophytic cT1 renal masses with off-clamp lead to shorter operating time, lower incidence of postoperative complications and comparative protective effects on short-term renal function compared with selective clamping RAPN.
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