達文西機器手臂輔助腹腔鏡部分腎臟切除手術之術中及術後結果之經驗報告
李瑋涓1.2, 黃志平1,2, 張兆祥1,2, 吳錫金1,2,
中國醫藥大學附設醫院 泌尿部1
中國醫藥大學 醫學系 泌尿學科2
Robotic-Assisted Partial Nephrectomy in a Single Team Experience: Peri- and Post-Operative Outcomes at a Mean of 24 Months Follow-Up
Wei-Juan Li1,2 , Chi-Ping, Huang1,2 ,
Chao-Hsiang Chang1,2, His-Chin Wu1,2
Department of Urology, China Medical University Hospital1
Department of Urology, China Medical University2
Purpose: Partial nephrectomy was recommended to be managed for small renal tumor (diameter < 4cm). Among three surgical approaches (open, laparoscopic and robotic), robotic-assisted partial nephrectomy established a choice concerning the advantages of tumor resection and parenchymal suturing because of the delicate and flexible movements of the surgical instruments. As to evaluate the outcomes of robotic partial nephrectomy for larger and more complex renal tumor, this study retrospectively reviewed a single team experience as case series.
Materials and Methods: We retrospectively reviewed 68 cases who received robotic partial nephrectomy by a single surgeon between November 2012 and September 2017. Demographic, perioperative data and postoperative outcomes were collected and statistically analyzed.
Results: A total of forty men and twenty-eight women with mean age 53-years-old, body weight mass (BMI) 25±3.9 kg/m2 and mode of American Society of Anesthesiologists (ASA) scored 2 underwent robotic partial nephrectomy. The mean tumor size was 4.4cm (1.3-11cm) and the tumor complexity defined by R.E.N.A.L. (radius; exophytic/endophytic; nearness; anterior/posterior; location) includes 29 low risk (4-6 scores), 34 moderate risk (7-9 scores) and 5 high risk (10-12 scores) cases. Mean warm ischemia time (WIT) was 21 minutes (6-33 minutes) and blood loss was 237 mL. Ten patients (14.7%) received perioperative blood transfusion. The median postoperative hospital stay was 5 days (4-12 days). Three patients (4.4%) experienced postoperative complications including paralytic ileus and delayed renal bleeding and both of them received conservative managements. The other case was found to have asymptimatic arteriovenous malformation (AVM) during follow-up and received transarterial embolization (TAE) 6 months after surgery. Pathology revealed renal cell carcinoma in 43 patients (clear cell type 31 cases, papillary cell type 6 cases and chromophobe cell type 6 cases), angiomyolipoma in 20 cases, oncocytoma in 4 cases, and one chronic pyelonephritis. All resection margins were negative except one positive intraoperative frozen section margin with which the case converted to robotic radical nephrectomy. Follow-up ranged from 1 to 59 months and recurrence rate was 0%, respectively. The average change of renal function (eGFR) was only 8 ml/min/1.73 m2 (8%). Furthermore, within the 68 patients, 33 of them received preoperative and postoperative split renal function study (Tc-99m-MAG3 effective renal plasma flow) and the average split renal function change of operative side decreased 48.2 ml/min (26%).
Conclusion: This study showed optimal outcomes including ideal warm ischemia time (mean WIT was 21 min), all negative surgical margins and low postoperative complication rates (4.4%) for larger renal mass (mean tumor size > 4cm) and moderate complexity (mean nephrometry score was 7). Renal function was reserved as well. Larger case group and longer follow-up were necessary for further study.