The Security Assessment Of Retroperitoneal Laparoscopic Partial Nephrectomy

BackgroudKidney cancer, the most dangerous one, whose mortality in systemic cancer accounts forabout 2%, and survival rate in 5-year for 66%. With the popularity of ultrasound, CT/MRIimaging examinations, the early diagnosis of the asymptomatic renal benign tumor and evenrenal cell carcinoma could be come true, making surgical intervention ahead of time. Thetraditional radical nephrectomy (RN) need to remove the kidney, are likely to affect renalfunction, especially the carcinoma of solitary kidney, kidneys and the contralateral kidney renaldamage with renal cell carcinoma exist. In recent years, open partial nephrectomy (OPN) hasbeen gradually applied and widely accepted. With the statistics of follow-up, partial nephrectomy(PN) can not only retain the renal functional safely and effective, but also lead to fewercomplications, less local recurrence, and there is no significant difference for long-term survivalcompareing the PN to RN. PN is going to be the conventional treatment methods for the littlesize of renal cell carcinoma.With the development of minimally invasive technique, PN can be successfully completedwith the laparoscopy (LPN), clinical experience was accumulated. A new exploration ofretroperitoneal laparoscopy (RLPN) have come reality, to complete the same operation in alimits space established in manual. Compared to the LPN, RLPN lead to less stimulation ofabdominal, less invasion, faster recovery. Because of the narrow operating space and difficultiesof technical, there are just a few hospitals, in which RLPN can be carried out. But some detailsof the operations still keep controversial, such as the safety of the RLPN, the effetive method tosave the time of renal artery blocking and the most limit tumor margin. This study compareRLPN to OPN to evaluate the security in the details of operation, time for operation and clamping, estimated blood loss, sCr for Preoperative and postoperative, indicators forconvalescence and so on. At the same time ,we improved an new way to close the CollectionSystem with no-knot-sew. The innovation merit of this study to improve a no-knot-sew, wichican save the time for knoting in operation, reduce the warm ischemia time with clamping,especially for beginners, the technology can be proved to be effetive, it shortens the time ofclamping and protects the rest renal function from less warm ischemia. achieve the same effectas open surgery, it is worth the promotion of clinical application.Purpose1. With the data in the period of perioperation and follow-up of RLPN and OPN, thesecurity assessment will be maked for RLPN.2. To improve a skill in hemostasis and knoting for RLPN, and to Improve the efficacy ofoperation..Object of study1. standard for include:1. standard for include:①isolated tumor;②diameter <4cm;③CT / MR and other imaging studies are notprompted to distant metastasis, and limited to the lesions;④exogenous or part of the tumorwas exogenous;⑤sCr≤300umol/L..2. standard for exclude①surgical contraindications,②sC＞300umol/L,③severe bleeding tendency;④hematuria or pelvicaliceal invasion.Research methods1. Select the cases of renal tumors exogenous with diameter <4cm, were randomly dividedinto two groups. 21 cases for OPN, and 15 cases for RLPN, to finish nephron-sparing surgery ofpartial nephrectomy, with surgical margin set in 5mm~10mm.2. Put the new skill of hemostasis and knoting in practice for RLPN.3. To record and compare the 2 group for the difference of the operative time, time ofclamping for renal artery, blood loss, intraoperative transfusion, time of removal for drainage tube postoperative, volume of drainage, the days of consumption , active and hospital staypostoperative. With the data above, and to assess the safety of the two surgical methods.4. To observe and record each occurrence of cases of post-operative complications. Record ofthe cutting edge of each pathological positive rate, integrity of envelope.5. Follow-up to understand each cases of postoperative renal function in patients with tumorrecurrence rate and survival rate.6. Analyzing groups of related data,such as time of operation and clamping, estimated bloodloss, sCr for Preoperative and postoperative, indicators for convalescence and so on.Research resultsNephron-sparing partial nephrectomy is set for patients with renal cell carcinoma or a benigntumor with diameter<4cm. RLPN can be basically applied to all indications in OPN, would havea good degree of preservation of the greatest residual renal function, with obviously effect andsecurity. Comparing the RLPN and OPN, there is no significant difference in the tumor location(left and right kidney, the upper and lower pole renal), but in practice, the tumor located on theupper is more difficult to treat than the lower one. Bleeding contrast, OPN: 445.71±167.170 ml,RLPN: 118.67±58.171 ml, P<0.001; 10 cases of 36 patients were of blood transfusion (OPN:47.6%, RLPN: 0%), with the study of vascular clamping, this warm ischemic time groups weresignificantly different (OPN : RLPN , 29.24±4.847 min: 37.40±5.680 min, P<0.001), bothgroups were controlled within 40 min, while the use of renal protection measures intraoperative,it have reduced the injury of the warm ischemic, safe handling and well effection. The pathologyin all cases reported complete capsule in both 0.5 cm ~ 1cm margins of the kidney tumor. Wehave improved the previous "hemostasia after cutting" to "hemostasia while cutting" and"no-knot sew" skill to save hours of making knots, reduced the injury of tearing while knottingvertically; biological clamper can stimulate the proliferation of the wound and accelerated renalrepair granulation; with this new skill, the time of clamping can be shortened by about 5 to 6minutes, greatly reducing the warm ischemic renal injury. No postoperative urinary fistula,bleeding or other complications were found. By follow-up in more than 6 months, there nosignificant difference changes in renal function for both groups, and safety is worthwhile.Absolute rest in bed for 7 days, the drainage tube was pulled while it was less than 15 ml, the two groups showed significant difference (OPN : RLPN, 93.33±28.608 ml: 65.80±20.186 ml,P=0.003), the days for the indwelling drainage tube, OPN : RLPN, 4.05±0.740 days: 3.20±0.561 days, P=0.001). In comparison of the restoration of gastrointestinal function, the RLPNgroup shows more quickly than OPN; (OPN Group: RLPN group, 3.81±0.602 days: 2.80±0.676 days, P<0.001); the days stay in hospital postoperative shows that OPN : RLPN, 10.57±1.028 days: 8.93±1.100 days, P<0.001.Conclusion: Through the comparison of the data in perioperative period, RLPN lead to lessbleeding, shorter hospitalization, faster recovery, no stimulative of the gastrointestinal tract. Dueto operation of narrow vision, the operative of RLPN have become difficult, warm ischemia timehave extended. In case of that, we have improved "no-knot sew" technique, in the process ofcollection system's closing, shorten the total time of operation and warm ischemia effectively,with security well.