Analysis of the efficacy of early unclamping of the renal artery in robot-assisted laparoscopic partial nephrectomy
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摘要: 目的 探讨机器人辅助腹腔镜肾部分切除术(robot-assisted partial nephrectomy，RAPN)术中肾脏肿瘤切除创面基底层缝合后早期开放肾动脉的安全性，以及与传统双层缝合后开放肾动脉对术后肾功能影响的差异。方法 回顾性分析2023年12月—2024年6月因肾肿瘤于中山大学孙逸仙纪念医院行RAPN并完成肿瘤切除创面双层缝合的91例患者的临床资料。所有患者均完善了术前1个月内CT及血清肌酐，以及术后5~7 d、术后3个月的血清肌酐。传统双层缝合指阻断肾动脉后，连续缝合关闭基底层再缝合皮质层，早期开放肾动脉指缝合基底层后松开血管夹，再缝合皮质层。独立样本t检验用于比较连续性的临床基线数据，而分类变量采用χ2及精确检验。结果 91例患者中，27例行早期开放肾动脉(早期开放肾动脉组)，64例患者为传统双层缝合后再开放肾动脉(传统双层缝合组)。2组患者的术前基线数据[R.E.N.A.L.评分、体重指数(body mass index，BMI)及年龄]比较均差异无统计学意义，患者平均年龄为(50.2±13.3)岁，平均BMI为(24.3±3.8) kg/m2，平均R.E.N.A.L.评分为(8.2±2.0)分。2组患者热缺血时间比较差异有统计学意义[(12.9±5.2) min vs (22.3±9.2) min，P < 0.001]。早期开放肾动脉组出血量与传统双层缝合组相当[(43.7±91.2) mL vs (67.8±76.0) mL，P=0.198]，2组患者术前估算的肾小球滤过率(estimated glomerular filtration rate，eGFR)比较差异无统计学意义[(100.7±25.0) mL/min/1.73 m2 vs (96.6±31.2) mL/min/1.73 m2，P=0.546)，早期开放肾动脉组患者术后eGFR及下降率显著优于传统双层缝合组[(99.3±22.2) mL/min/1.73 m2 vs (84.2±29.1) mL/min/1.73 m2，P=0.018；(-0.2±14.2)% vs (12.0±21.9)%，P=0.009]。1例双层缝合组患者术后1个月内返院行介入治疗，1例早期开放肾动脉组患者术后输注血小板，术中无肿瘤破裂及术后病理切缘阳性。早期开放肾动脉组患者术后3个月新基线eGFR仍优于传统双层缝合组[(97.6±19.0) mL/min/1.73 m2 vs (83.7±29.0) mL/min/1.73 m2，P=0.034)]，但二者下降率差异无统计学意义[(4.3±14.1)% vs (9.8±21.8)%，P=0.341]。结论 早期开放肾动脉法可以显著降低RAPN的热缺血时间，实现术后早期的肾功能获益，同时未增加手术相关并发症。Abstract: Objective To investigate the impact of early unclamping technique employed in robot-assisted partial nephrectomy(RAPN) on renal function and safety, and to compare the differences in postoperative renal function outcomes between early-unclamping and double-layer renorrhaphy.Methods This study retrospectively enrolled 91 patients who underwent RAPN for renal tumors at Sun Yat-sen Memorial Hospital from December 2023 to June 2024. Preoperative CT scans and serum creatinine levels within one month before surgery were available for all patients, as well as serum creatinine assessments during their hospital stay postoperatively and 3 months after surgery. Double-layer renorrhaphy involved continuous suturing of the base layer followed by the cortical layer after renal artery clamping, whereas early unclamping technique involved releasing the clamp after suturing the base layer, prior to suturing the cortical layer. The standard t-test was used to compare continuous clinical baseline data, and Chi-square and exact tests were applied for categorical variables.Results A total of 91 patients were included, with 27 undergoing early unclamping and 64 undergoing double-layer closure. There were no significant differences in preoperative baseline characteristics(R.E.N.A.L. score, body mass index[BMI], and age) between the two groups. The mean age was (50.2±13.3) years, mean BMI was (24.3±3.8) kg/m2, and mean R.E.N.A.L. score was (8.2±2.0). Significant differences were observed in warm ischemia time([12.9±5.2] min vs [22.3±9.2] min, P < 0.001) between the groups. Blood loss was comparable between the early unclamping group and the double-layer closure group([43.7±91.2] mL vs [67.8±76.0] mL, P=0.198). Preoperative eGFR did not differ significantly between the groups([100.7±25.0] mL/min/1.73 m2 vs [96.6±31.2] mL/min/1.73 m2, P=0.546). However, postoperative eGFR and the percentage decline in eGFR were significantly better in the early unclamping group compared to the double-layer renorrhaphy group([99.3±22.2] mL/min/1.73 m2 vs [84.2±29.1] mL/min/1.73 m2, P=0.018;[-0.2±14.2]% vs [12.0±21.9]%, P=0.009). One patient in the double-layer suture group returned to the hospital for interventional therapy within one month after surgery, and one patient in the early unclamping group received platelet transfusion postoperatively. Intraoperative tumor rupture, or positive surgical margins were observed in any patients. Patients in the early unclamping group exhibited a superior postoperative new baseline eGFR compared to those in the double-layer renorrhaphy group([97.6±19.0] mL/min/1.73 m2 vs [83.7±29.0] mL/min/1.73 m2, P=0.034), with no significant difference observed in the percentage of decline([4.3±14.1]% vs [9.8±21.8]%, P=0.341).Conclusion Early unclamping of the renal artery during RAPN significantly reduces warm ischemia time, resulting in functional benefits without increasing complications.
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Key words:
- kidney tumor /
- partial nephrectomy /
- early unclamping of the renal artery
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表 1 早期开放肾动脉组与传统双层缝合组的基线数据比较
例(%)，X±S 指标 总例数(91例) 早期开放肾动脉组(27例) 传统双层缝合组(64例) P值 年龄/岁 50.2±13.3 48.3±13.9 51.0±13.2 0.383 男性 55(60.4) 16(59.3) 39(60.9) 0.314 肿瘤直径/mm 45.4±16.2 45.2±11.7 45.5±17.9 0.935 BMI/(kg/m2) 24.3±3.8 24.2±3.8 24.3±3.8 0.869 R.E.N.A.L.评分/分 8.2±2.0 7.7±2.0 8.4±2.0 0.166 手术时间/min 129.0±37.3 117.3±38.0 134.0±36.1 0.052 热缺血时间/ min 19.6±9.2 12.9±5.2 22.3±9.2 < 0.001 术中出血量/mL 60.7±81.3 43.7±91.2 67.8±76.0 0.198 术后住院时间/d 5.0±1.8 4.6±1.6 5.2±1.8 0.151 术前eGFR/(mL/min/1.73 m2) 97.8±29.4 100.7±25.0 96.6±31.2 0.546 术后5~7 d eGFR/(mL/min/1.73 m2) 88.7±28.0 99.3±22.2 84.2±29.1 0.018 术后5~7 d eGFR下降率/% 11.3±28.0 -0.2±14.2 12.0±21.9 0.009 新基线eGFR/(mL/min/1.73 m2) 87.6±27.2 97.6±19.0 83.7±29.0 0.034 新基线eGFR下降率/% 8.3±20.0 4.3±14.1 9.8±21.8 0.341 
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表 2 早期开放肾动脉组与传统双层缝合组并发症比较
例(%) 项目 早期开放肾动脉组(27例) 传统双层缝合组(64例) P值 发生并发症 13(48.1) 38(59.4) 0.324 Clavien-Dindo Ⅲ级 0(0) 1(1.6) 0.514 术后输血 1(3.7) 0(0) 0.122 术后3个月内返院 0(0) 1(1.6) 0.514
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