Mert Kilic, Meftun Culpan, Asif Yildirim, Turhan Caskurlu

Laparoskopik parsiyel nefrektomi erken dönem deneyiminin, açık parsiyel nefrektomi ile klinik, onkolojik ve renal fonksiyonlar açısından karşılaştırılması

Amaç: Laparoskopik parsiyel nefrektomi (LPN) minimal invaziv olmasına rağmen teknik olarak zor bir prosedürdür. Günümüzde halen birçok merkezde, T1 evre böbrek tümöründe açık parsiyel nefrektomi (APN) tek seçenek olarak sunulmaktadır. Biz bu çalışmamızda LPN’deki erken dönem tücrebelerimizi klinik, onkolojik bulgular ve böbrek fonksiyonları açısından açık yöntemle karşılaştırarak sunmayı hedefledik. Gereç ve Yöntemler: 2004-2013 yılları arasında klinik T1 evre böbrek tümörü nedeniyle APN (n = 55) veya LPN (n = 26) uygulanan 81 hasta çalışmaya dahil edildi. Perioperatif ve postoperatif veriler retrospektif olarak karşılaştırıldı. APN ve LPN grupları için takip süreleri sırasıyla 72.9 ± 41.1 ve 47.6 ± 32.4 aydı (p <0,05). Bulgular: Ortalama tümör boyutu ve RENAL nefrometri skorları her iki grup için benzerdi. APN prosedürlerinin % 15'inde, LPN’lerin ise tamamında sıfır iskemi uygulandı. Tahmini kan kaybı ve perioperatif transfüzyon oranları APN grubunda daha yüksekti. Komplikasyon oranları her iki grupta benzerdi. Altıncı ayda kreatinin klirensindeki azalma APN grubunda istatistiksel olarak anlamlı iken LPN'de stabildi. Pozitif cerrahi sınır oranları APN için % 5.5 ve LPN için% 11.5 idi, p = 0,380. LPN yapılan bir hastada lokal nüks gelişti ve nefrektomi yapıldı. APN yapılan bir hastada lokal nüks ve bir başkasında ise uzak metastaz gözlendi. Her iki hastada da tirozin kinaz inhibitörü ile tedavi edildi. Sonuç: LPN teknik olarak zor bir prosedür olmasına karşın öğrenme evresinde klinik, onkolojik bulgular ve böbrek fonksiyonları açısından APN'ye benzer sonuçlar göstermiştir. Sıfır iskemi yöntemi ile kabul edilebilir perioperatif ve renal fonksiyonel sonuçlar elde edilerek LPN'nin erken dönem deneyimlerinde dahi güvenilirliği ve uygulanabilirliği gösterilmiştir.

Anahtar Kelimeler:

laparoskopi, öğrenme eğrisi, parsiyel nefrektomi, böbrek kanseri, cerrahi sınır

Comparison of early experience laparoscopic versus open partial nephrectomy in terms of clinical, oncological and renal functional outcomes

Objective: Although laparoscopic partial nephrectomy (LPN) is minimally invasive, it is also a technically challenging procedure. Currently, open partial nephrectomy (OPN) remains the only alternative in many centers for T1 kidney tumors. We reported our initial experience of LPN compared to OPN regarding clinical, oncological findings and renal functions . Material and Methods: Between 2004-2013, 81 patients who underwent OPN (n=55) or LPN (n=26) for clinically T1 renal tumors were included. Perioperative and postoperative data were compared, retrospectively. Follow-up times for OPN and LPN groups were 72.9± 41.1 and 47.6± 32.4 months, respectively (p<0,05). Results: The mean tumor size and RENAL nephrometry scores were similar for both groups. Zero-ischemia was performed in all of the LPN and 15% of the OPN procedures. Estimated blood loss and perioperative transfusion rates were higher in OPN group. Complications including grade < 3 and ≥ 3 did not differ significantly between the groups. The decrease in creatinine-clearance at 6th month was statistically significant in OPN group, while stable in LPN. Positive surgical margin rates were 5.5% for OPN and 11.5% for LPN, p=0,380. One patient in LPN developed local recurrence and underwent nephrectomy. In OPN group,one local recurrence and one distant metastasis were observed in two independent patients. Both patients recieved tyrosine kinase inhibitor.Conclusion: Although LPN is accepted as a technically challenging procedure, LPN provided comparable outcomes to OPN including clinical, oncological findings and renal functions, even in the early learning phase. Zero-ischemia technique for LPN was feasible and safe with favorable perioperative and renal functional outcomes.

Keywords:

laparoscopy, learning curve, partial nephrectomy, renal cancer, surgical margins,

PDF

___

Referans 1. Ljungberg B, Albiges L, Abu-Ghanem Y, et al. European Association of Urology Guidelines on Renal Cell Carcinoma: The 2019 Update. European urology. 2019;75(5):799-810. Epub 2019/02/26. doi: 10.1016/j.eururo.2019.02.011. PubMed PMID: 30803729.
Referans 2. Gill IS, Kavoussi LR, Lane BR, et al. Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors. The Journal of urology. 2007;178(1):41-6. Epub 2007/06/19. doi: 10.1016/j.juro.2007.03.038. PubMed PMID: 17574056.
Referans 3. Subramonian K, DeSylva S, Bishai P, Thompson P, Muir G. Acquiring surgical skills: a comparative study of open versus laparoscopic surgery. European urology. 2004;45(3):346-51; author reply 51. Epub 2004/03/24. doi: 10.1016/j.eururo.2003.09.021. PubMed PMID: 15036681.
Referans 4. Hanzly M, Frederick A, Creighton T, et al. Learning curves for robot-assisted and laparoscopic partial nephrectomy. Journal of endourology. 2015;29(3):297-303. Epub 2014/08/12. doi: 10.1089/end.2014.0303. PubMed PMID: 25111313.
Referans 5. Marszalek M, Meixl H, Polajnar M, et al. Laparoscopic and open partial nephrectomy: a matched-pair comparison of 200 patients. European urology. 2009;55(5):1171-8. Epub 2009/02/24. doi: 10.1016/j.eururo.2009.01.042. PubMed PMID: 19232819.
Referans 6. Gill IS, Ramani AP, Spaliviero M, et al. Improved hemostasis during laparoscopic partial nephrectomy using gelatin matrix thrombin sealant. Urology. 2005;65(3):463-6. Epub 2005/03/23. doi: 10.1016/j.urology.2004.10.030. PubMed PMID: 15780356.
Referans 7. Ramani AP, Desai MM, Steinberg AP,et al. Complications of laparoscopic partial nephrectomy in 200 cases. The Journal of urology. 2005;173(1):42-7. Epub 2004/12/14. doi: 10.1097/01.ju.0000147177.20458.73. PubMed PMID: 15592022.
Referans 8. Orvieto MA, Chien GW, Tolhurst SR, et al. Simplifying laparoscopic partial nephrectomy: technical considerations for reproducible outcomes. Urology. 2005;66(5):976-80. Epub 2005/11/16. doi: 10.1016/j.urology.2005.05.013. PubMed PMID: 16286106.
Referans 9. Link RE, Bhayani SB, Allaf ME, et al. Exploring the learning curve, pathological outcomes and perioperative morbidity of laparoscopic partial nephrectomy performed for renal mass. The Journal of urology. 2005;173(5):1690-4. Epub 2005/04/12. doi: 10.1097/01.ju.0000154777.24753.1b. PubMed PMID: 15821559.
Referans 10. Wright JL, Porter JR. Laparoscopic partial nephrectomy: comparison of transperitoneal and retroperitoneal approaches. The Journal of urology. 2005;174(3):841-5. Epub 2005/08/12. doi: 10.1097/01.ju.0000169423.94253.46. PubMed PMID: 16093966.
Referans 11. Webb CM, Kamel M, Eltahawy E, et al. A comparative study of open, laparoscopic and robotic partial nephrectomy in obese patients. Urology annals. 2015;7(2):231-4. Epub 2015/04/04. doi: 10.4103/0974-7796.152023. PubMed PMID: 25835601; PubMed Central PMCID: PMCPMC4374264.
Referans 12. Lee S, Oh J, Hong SK, Lee SE, Byun SS. Open versus robot-assisted partial nephrectomy: effect on clinical outcome. Journal of endourology. 2011;25(7):1181-5. Epub 2011/06/11. doi: 10.1089/end.2010.0670. PubMed PMID: 21657825.
Referans 13. Porpiglia F, Mari A, Bertolo R, et al. Partial Nephrectomy in Clinical T1b Renal Tumors: Multicenter Comparative Study of Open, Laparoscopic and Robot-assisted Approach (the RECORd Project). Urology. 2016;89:45-51. Epub 2016/01/09. doi: 10.1016/j.urology.2015.08.049. PubMed PMID: 26743388.
Referans 14. Han KS, Song GH, You D, Song C, et al. Comparison of Hand-Assisted Laparoscopic vs Robot-Assisted Laparoscopic vs Open Partial Nephrectomy in Patients with T1 Renal Masses. Journal of endourology. 2017;31(4):374-9. Epub 2014/10/30. doi: 10.1089/end.2014.0517. PubMed PMID: 25353326.
Referans 15. Bravi CA, Larcher A, Capitanio U, et al. Perioperative Outcomes of Open, Laparoscopic, and Robotic Partial Nephrectomy: A Prospective Multicenter Observational Study (The RECORd 2 Project). European urology focus. 2019. Epub 2019/11/16. doi: 10.1016/j.euf.2019.10.013. PubMed PMID: 31727523.
Referans 16. Reifsnyder JE, Ramasamy R, Ng CK, et al. Laparoscopic and open partial nephrectomy: complication comparison using the Clavien system. JSLS : Journal of the Society of Laparoendoscopic Surgeons. 2012;16(1):38-44. Epub 2012/08/22. doi: 10.4293/108680812x13291597716942. PubMed PMID: 22906328; PubMed Central PMCID: PMCPMC3407455.
Referans 17. Lane BR, Babineau DC, Poggio ED, et al. Factors predicting renal functional outcome after partial nephrectomy. The Journal of urology. 2008;180(6):2363-8; discussion 8-9. Epub 2008/10/22. doi: 10.1016/j.juro.2008.08.036. PubMed PMID: 18930264.
Referans 18. Shen Z, Xie L, Xie W, et al. The comparison of perioperative outcomes of robot-assisted and open partial nephrectomy: a systematic review and meta-analysis. World journal of surgical oncology. 2016;14(1):220. Epub 2016/08/24. doi: 10.1186/s12957-016-0971-9. PubMed PMID: 27549155; PubMed Central PMCID: PMCPMC4994255.
Referans 19. Thompson RH, Lane BR, Lohse CM, et al. Renal function after partial nephrectomy: effect of warm ischemia relative to quantity and quality of preserved kidney. Urology. 2012;79(2):356-60. Epub 2012/02/09. doi: 10.1016/j.urology.2011.10.031. PubMed PMID: 22310752.
Referans 20. Tabayoyong W, Abouassaly R, Kiechle JE, et al. Variation in Surgical Margin Status by Surgical Approach among Patients Undergoing Partial Nephrectomy for Small Renal Masses. The Journal of urology. 2015;194(6):1548-53. Epub 2015/06/23. doi: 10.1016/j.juro.2015.06.076. PubMed PMID: 26094808.
Referans 21. Choi JE, You JH, Kim DK, Rha KH, Lee SH. Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic review and meta-analysis. European urology. 2015;67(5):891-901. Epub 2015/01/13. doi: 10.1016/j.eururo.2014.12.028. PubMed PMID: 25572825.
Referans 22. Tellini R, Antonelli A, Tardanico R, et al. Positive Surgical Margins Predict Progression-free Survival After Nephron-sparing Surgery for Renal Cell Carcinoma: Results From a Single Center Cohort of 459 Cases With a Minimum Follow-up of 5 Years. Clinical genitourinary cancer. 2019;17(1):e26-e31. Epub 2018/09/30. doi: 10.1016/j.clgc.2018.08.004. PubMed PMID: 30266249.
Referans 23. Yossepowitch O, Thompson RH, Leibovich BC, et al. Positive surgical margins at partial nephrectomy: predictors and oncological outcomes. The Journal of urology. 2008;179(6):2158-63. Epub 2008/04/22. doi: 10.1016/j.juro.2008.01.100. PubMed PMID: 18423758; PubMed Central PMCID: PMCPMC2704565.
Referans 24. Bensalah K, Pantuck AJ, Rioux-Leclercq N, et al. Positive surgical margin appears to have negligible impact on survival of renal cell carcinomas treated by nephron-sparing surgery. European urology. 2010;57(3):466-71. Epub 2009/04/11. doi: 10.1016/j.eururo.2009.03.048. PubMed PMID: 19359089.
Referans 25. López-Costea M, Bonet X, Pérez-Reggeti J, Etcheverry B, Vigués F. Oncological outcomes and prognostic factors after nephron-sparing surgery in renal cell carcinoma. International urology and nephrology. 2016;48(5):681-6. Epub 2016/02/11. doi: 10.1007/s11255-016-1217-z. PubMed PMID: 26861062.