Ekrem İSLAMOĞLU, Çağatay ÖZSOY, Kaan KARAMIK, İbrahim EROL, Mutlu ATEŞ, Murat SAVAŞ

ROBOT YARDIMLI PARSİYEL NEFREKTOMİ: İLK 56 HASTAMIZDA CERRAHİ TEKNİK VE ONKOLOJİK SONUÇLARIN DEĞERLENDİRİLMESİ

AmaçKliniğimizde böbrek tümörü nedeniyle robot yardımlı parsiyel nefrektomi (RYPN) yapılan ilk 56 hastamızda cerrahi teknik ve onkolojik sonuçların değerlendirilmesi.Materyal ve Metod Mart 2015 ile Şubat 2018 tarihleri arasında RYPN yapılan 56 hastanın prospektif olarak toplanan verileri geriye dönük olarak analiz edildi. Preoperatif kan parametrelerinde hemoglobin, serum üre/kreatinin ve karaciğer fonksiyon testleri bakıldı. Perioperatif parametrelerde; ameliyat ve iskemi süreleri ile kan transfüzyonları kaydedildi. Postoperatif olarak hemoglobindeğerleri ve patolojik sonuçlar incelendi.BulgularYaşları ortalama 59 yıl (32-84) olan 44 erkek ve 12 kadın hastaya transperitoneal yaklaşımla RYPN uygulandı. Ortalama tümör çapı 3.8 cm (1.5-8) olan 27 sağ,29 sol renal ünite opere edildi. Ortalama operasyon süresi 151 dk (90-250), ortalama sıcak iskemi süresi 24.5 dk (18-35), ortalama kan kaybı 63 ml (25-100)idi. Bir hastada (% 1.7) transfüzyon gerektiren perirenal hematom gözlendi. Hiçbir hastada açık cerrahiye dönülme ihtiyacı olmadı ve hiçbir hastada nefrektomigerekmedi. Sekiz hastada pelvikaliksiyel sistem açıldığı için onarım yapıldı ancak hiçbirisine üreteral stent yerleştirme ihtiyacı duyulmadı. Böbrekteki kitlelerin %78.5’i primer renal hücreli karsinom olarak raporlandı ve 4 hastada (% 9.0) cerrahi sınır pozitif olarak belirtildi. Hastaların ortalama takip süresi 13(4-36) aydı vehiçbir hastada lokal rekürrens ya da uzak metastaz görülmedi. Hiçbir hastada insizyonel herni gibi geç dönem komplikasyon izlenmedi.SonuçRYPN, iyi seçilmiş evre 1 böbrek tümörlerinde güvenle uygulanabilen bir cerrahi yöntemdir. Cerraha sağladığı sütür atma kolaylığı ve hareket serbestliği sayesinde sıcak iskemi süresini makul düzeylerde tutarak, öngörülen onkolojik ve fonksiyonel sonuçlara, düşük morbidite ile ulaşılmasını sağlar.

ROBOT-ASSISTED PARTIAL NEPHRECTOMY: EVALUATION OF SURGICAL TECHNIQUE AND ONCOLOGICAL OUTCOMES OF OUR FIRST 56 PATIENTS

Objective To evaluate the surgical technique and oncologic results of our first 56 patients who underwent robot-assisted partial nephrectomy (RAPN) for kidney tumor in our clinic. Materials and Methods Prospectively collected data from 56 patients who underwent RAPN between March 2015 and February 2018, was retrospectively analyzed. Hemoglobin,serum urea/creatinine and liver function tests were evaluated in preoperative blood parameters. In perioperative parameters; surgery and ischemic times and blood transfusions were recorded. Hemoglobin values and pathological results were analyzed postoperatively. Results RAPN was applied to 44 male and 12 female patients with a mean age of 59 years (32-84) with the transperitoneal approach. There were 27 right and 29 left renal units with a mean tumor diameter of 3.8 cm (1.5- 8). Mean duration of operation was 151 min (90-250), mean warm ischemia time was 24.5 min (18-35) and mean blood loss was 63 ml (25-100). In one patient (1.7%) a perirenal hematoma requiring transfusion was observed. None of the patients needed to convert to open surgery and none of the patients needed nephrectomy. Eight patients underwent repair due to the opening of the pelvicalyceal system, but no ureteral stenting was needed. Pathologically, primary renal cell carcinoma was reported in 78.5% of the masses in the kidney and the surgical margin was positive in 4 patients (9.0%). The mean follow-up period of the patients was 13 months (4-36) and no local recurrence or distant metastasis was observed in any patient. No late complications such as an incisional hernia were observed in any patient. Conclusion RAPN is a safe surgical procedure for well-selected stage 1 renal tumors. With the ease of suturing and freedom of movement provided by robotic system, the warm ischemia time is kept at reasonable levels, ensuring predicted oncologic and functional outcomes with low morbidity

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1. Gültekin M, Boztaş G. Türkiye kanser istatistikleri. Sağlık Bakanlığı, Türkiye Halk Sağlığı Kurumu, 2014; 43.
2. Chawla S.N., Crispen P.L., Hanlon A.L., Greenberg R.E., Chen D.Y., Uzzo R.G. The natural history of observed enhancing renal masses: meta-analysis and review of the world literature. The Journal of urology, 2006; 175(2), 425-431.
3. Gill I.S., Kavoussi L.R., Lane B.R., Blute M.L., Babineau D., Colombo J.R., Kattan M.W. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. The Journal of urology, 2007; 178(1), 41-46.
4. Weight C.J., Lieser G., Larson B.T., Gao T., Lane B.R., Campbell S.C., Fergany A. F. Partial nephrectomy is associated with improved overall survival compared to radical nephrectomy in patients with unanticipated benign renal tumours. European urology, 2010; 58(2), 293-298.
5. Mitchell R.E., Gilbert S.M., Murphy A.M., Olsson C.A., Benson M.C., McKiernan J.M. Partial nephrectomy and radical nephrectomy offer similar cancer outcomes in renal cortical tumors 4 cm or larger. Urology, 2006; 67(2), 260-264.
6. Touijer K., Jacqmin D., Kavoussi L.R., Montorsi F., Patard J.J., Rogers C.G., Van Poppel H. The expanding role of partial nephrectomy: a critical analysis of indications, results, and complications. European urology, 2010; 57(2), 214-222.
7. Novick A.C., Derweesh I. Open partial nephrectomy for renal tumours: current status. BJU international, 2005; 95(s2), 35-40.
8. Ljungberg B., Cowan N.C., Hanbury D.C., Hora M., Kuczyk M.A., Merseburger A.S., Sinescu I.C. EAU guidelines on renal cell carcinoma: the 2010 update. European urology, 2010; 58(3), 398-406.
9. Marszalek M., Meixl H., Polajnar M., Rauchenwald M., Jeschke, K., Madersbacher S. Laparoscopic and open partial nephrectomy: a matched-pair comparison of 200 patients. European urology, 2009; 55(5), 1171-1178.
10. Benway B.M., Bhayani S.B., Rogers C.G., Dulabon L.M., Patel M.N., Lipkin M., Stifelman M.D. Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes. The Journal of urology, 2009; 182(3), 866-873.
11. Link R.E., Bhayani S.B., Allaf M.E., Varkarakis I., Inagaki T., Rogers C., Kavoussi L.R. Exploring the learning curve, pathological outcomes and perioperative morbidity of laparoscopic partial nephrectomy performed for renal mass. The Journal of urology, 2005; 173(5), 1690-1694.
12. Kural A.R., Atug F. The applications of robotic surgery in urology. Turkish Journal of Urology, 2010; 36(3), 248-258.
13. Ljungberg B., Albiges L., Bensalah K., Bex A., Giles R.H., Hora M., Powles T. EAU Guidelines on renal cell carcinoma. European Association of Urology 2017. Update March.
14. Simmons M.N., Weight C.J., Gill I.S. Laparoscopic radical versus partial nephrectomy for tumors> 4 cm: intermediate-term oncologic and functional outcomes. Urology, 2009; 73(5), 1077-1082.
15. Van Poppel H., Da Pozzo L., Albrecht W., Matveev V., Bono A., Borkowski A., Marreaud S. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. European urology, 2011; 59(4), 543-552.
16. Thompson R.H., Frank I., Lohse C.M., Saad I.R., Fergany A., Zincke H., Novick A.C. The impact of ischemia time during open nephron sparing surgery on solitary kidneys: a multi-institutional study. The Journal of urology, 2007; 177(2), 471-476.
17. Muramaki M., Miyake H., Sakai I., Fujisawa M. Prognostic factors influencing postoperative development of chronic kidney disease in patients with small renal tumors who underwent partial nephrectomy. Current urology, 2012; 6(3), 129-135.
18. Benway B.M., Bhayani S.B. Surgical outcomes of robot-assisted partial nephrectomy. BJU international, 2011; 108(6b), 955-961.
19. Cho C.L., Ho K.L., Chu S.S., Tam P.C. Robot-assisted versus standard laparoscopic partial nephrectomy: comparison of perioperative outcomes from a single institution. Hong Kong Medical Journal 2011; v. 17 n. 1, p. 33-38
20. Deane L.A., Lee H.J., Box G.N., Melamud O., Yee D.S., Abraham J.B.A., Ornstein D.K. Robotic versus standard laparoscopic partial/wedge nephrectomy: a comparison of intraoperative and perioperative results from a single institution. Journal of endourology, 2008; 22(5), 947-952.
21. DeLong J.M., Shapiro O., Moinzadeh A. Comparison of laparoscopic versus robotic assisted partial nephrectomy: one surgeon’s initial experience. The Canadian journal of urology, 2010; 17(3), 5207-5212.
22. Yossepowitch O., Thompson R.H., Leibovich B.C., Eggener S.E., Pettus J.A., Kwon E.D., Russo P. Positive surgical margins at partial nephrectomy: predictors and oncological outcomes. The Journal of urology, 2008; 179(6), 2158-2163.
23. Scoll B.J., Uzzo R.G., Chen D.Y., Boorjian S.A., Kutikov A., Manley B.J., Viterbo R. Robot-assisted partial nephrectomy: a large single-institutional experience. Urology, 2010; 75(6), 1328-1334.
24. Mottrie A., De Naeyer G., Schatteman P., Carpentier P., Sangalli M., Ficarra V. Impact of the learning curve on perioperative outcomes in patients who underwent robotic partial nephrectomy for parenchymal renal tumours. European urology, 2010; 58(1), 127-133.
25. Rogers C.G., Menon M., Weise E.S., Gettman M.T., Frank I., Shephard D.L., Bhayani S.B. Robotic partial nephrectomy: a multi-institutional analysis. Journal of robotic surgery, 2008; 2(3), 141-143.
26. Benway B.M., Bhayani S.B., Rogers C.G., Dulabon L.M., Patel M.N., Lipkin M., Stifelman M.D. Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes. The Journal of urology, 2009; 182(3), 866-873.
27. Kim S.P., Abouassaly R. Treatment of Patients with Positive Margins after Partial Nephrectomy. The Journal of urology, 2016; 196(2), 301.
28. Shikanov S., Wille M., Large M., Lifshitz D.A., Zorn K.C., Shalhav A.L., Eggener S.E. Knotless closure of the collecting system and renal parenchyma with a novel barbed suture during laparoscopic porcine partial nephrectomy. Journal of endourology, 2009; 23(7), 1157-1160.
29. Zondervan P.J., Gozen A.S., Opondo D., Rassweiler J.J., Jean J., Laguna M.P. Partial nephrectomy: Is there an advantage of the self-retaining barbed suture in the perioperative period? A matched case–control comparison. World journal of urology, 2012; 30(5), 659-664.
30. Benway B.M., Wang A.J., Cabello J.M., Bhayani S.B. Robotic partial nephrectomy with sliding-clip renorrhaphy: technique and outcomes. European Urology, 2009; 55(3), 592-599.
31. Ho H., Schwentner C., Neururer R., Steiner H., Bartsch G., Peschel R. Robotic-assisted laparoscopic partial nephrectomy: surgical technique and clinical outcomes at 1 year. BJU international, 2009; 103(5), 663-668.