Background:Warm ischemic injury is one of the most important factors affecting renal function in partial nephrectomy(PN).The technique of segmental renal artery clamping emerges as an alternative to conventional renal...Background:Warm ischemic injury is one of the most important factors affecting renal function in partial nephrectomy(PN).The technique of segmental renal artery clamping emerges as an alternative to conventional renal artery clamping for renal hilar control.Objective:To evaluate the feasibility and efficiency of laparoscopic PN(LPN)with segmental renal artery clamping in comparison with the conventional technique.Design,setting,and participants:A total of 75 patients underwent LPN from June 2007 to November 2009.All patients had T1a or T1b tumor in one kidney and a normal contralateral kidney.Thirty-seven patients underwent surgeries with main renal artery clamping,and 38 underwent surgeries with segmental artery clamping.Intervention:All procedures were performed by the same laparoscopic surgeon.Measurements:Blood loss,operation time,warm ischemia(WI)time,and complications affected renal function before and after operation were recorded.Results and limitations:All LPNs were completed without conversion to open surgery or nephrectomy.The novel technique slightly increased WI time(p<0.001)and intraoperative blood loss(p=0.006),while it provided better postoperative affected renal function(p<0.001)compared with the conventional technique.The total complication rate was 12%.Among the 38 cases where segmental renal artery clamping was performed,7 had to convert to the conventional method.Tumor size and location influenced the number of clamped segmental arteries.Long-term postoperative renal function is still awaited.Conclusions:LPN with segmental artery clamping is safe and feasible in clinical practice.It minimizes the intraoperative WI injury and improves early postoperative affected renal function compared with main renal artery clamping.(C)2010 European Association of Urology.Published by Elsevier B.V.All rights reserved.展开更多
Segmental arterial mediolysis (SAM), an uncommon arteriopathy putatively caused by norepinephrine released by alpha-1 adrenergic agonists or some Beta-2 agonists capable of releasing norepinephrine from the peripheral...Segmental arterial mediolysis (SAM), an uncommon arteriopathy putatively caused by norepinephrine released by alpha-1 adrenergic agonists or some Beta-2 agonists capable of releasing norepinephrine from the peripheral sympathetic nervous system potentially can present ischemic and organ injury symptoms caused by sequelae created in its reparative phase in lieu of catastrophic hemorrhages announced in its injurious phase. The case documents this presentation—the patient presenting renal infarcts and ischemic lesions causing abdominal angina, hypertension and a nephrectomy event developing 10 years after prolonged ritodrine treatment for premature labor. This agent may have directly caused SAM or sensitized the patient to agonists causing SAM encountered at a latter date. A variety of lesions derived from injurious phase arterial injuries characterize reparative phase SAM. All were encountered in a hilar branch of the resected renal artery. These included side-by-side sequela aneurysms grossly forming a large fusiform aneurysm, granulation tissue filling adventitial medial tear spaces in which a dissecting hematomas developed, medial muscle loss centered to the outer media repaired with fibrous tissue, arterial stenosis created by reparative intimal plaques, and arterial thrombo-embolism. These lesions were mirrored in accompanying radiologic studies. The accompanying renal vein exhibited changes consistent with repair of the spastic venous angiopathy that often accompanies abdominal SAM. This angiopathy, putatively induced by Endothelin-1, suggested that this agent played a role in the genesis of the arterial lesions. Angiographic resolution of non-treated sequelae occurred in 5 months either spontaneously or due to treatment with bosentem. Conclusions: The histologic and angiographic changes demonstrate that the clinical onset of reparative SAM may be significantly delayed to produce ischemic lesions, renal infarction and in this case report, medial fibromuscular dysplasia in the hilar branch of the renal artery.展开更多
文摘Background:Warm ischemic injury is one of the most important factors affecting renal function in partial nephrectomy(PN).The technique of segmental renal artery clamping emerges as an alternative to conventional renal artery clamping for renal hilar control.Objective:To evaluate the feasibility and efficiency of laparoscopic PN(LPN)with segmental renal artery clamping in comparison with the conventional technique.Design,setting,and participants:A total of 75 patients underwent LPN from June 2007 to November 2009.All patients had T1a or T1b tumor in one kidney and a normal contralateral kidney.Thirty-seven patients underwent surgeries with main renal artery clamping,and 38 underwent surgeries with segmental artery clamping.Intervention:All procedures were performed by the same laparoscopic surgeon.Measurements:Blood loss,operation time,warm ischemia(WI)time,and complications affected renal function before and after operation were recorded.Results and limitations:All LPNs were completed without conversion to open surgery or nephrectomy.The novel technique slightly increased WI time(p<0.001)and intraoperative blood loss(p=0.006),while it provided better postoperative affected renal function(p<0.001)compared with the conventional technique.The total complication rate was 12%.Among the 38 cases where segmental renal artery clamping was performed,7 had to convert to the conventional method.Tumor size and location influenced the number of clamped segmental arteries.Long-term postoperative renal function is still awaited.Conclusions:LPN with segmental artery clamping is safe and feasible in clinical practice.It minimizes the intraoperative WI injury and improves early postoperative affected renal function compared with main renal artery clamping.(C)2010 European Association of Urology.Published by Elsevier B.V.All rights reserved.
文摘Segmental arterial mediolysis (SAM), an uncommon arteriopathy putatively caused by norepinephrine released by alpha-1 adrenergic agonists or some Beta-2 agonists capable of releasing norepinephrine from the peripheral sympathetic nervous system potentially can present ischemic and organ injury symptoms caused by sequelae created in its reparative phase in lieu of catastrophic hemorrhages announced in its injurious phase. The case documents this presentation—the patient presenting renal infarcts and ischemic lesions causing abdominal angina, hypertension and a nephrectomy event developing 10 years after prolonged ritodrine treatment for premature labor. This agent may have directly caused SAM or sensitized the patient to agonists causing SAM encountered at a latter date. A variety of lesions derived from injurious phase arterial injuries characterize reparative phase SAM. All were encountered in a hilar branch of the resected renal artery. These included side-by-side sequela aneurysms grossly forming a large fusiform aneurysm, granulation tissue filling adventitial medial tear spaces in which a dissecting hematomas developed, medial muscle loss centered to the outer media repaired with fibrous tissue, arterial stenosis created by reparative intimal plaques, and arterial thrombo-embolism. These lesions were mirrored in accompanying radiologic studies. The accompanying renal vein exhibited changes consistent with repair of the spastic venous angiopathy that often accompanies abdominal SAM. This angiopathy, putatively induced by Endothelin-1, suggested that this agent played a role in the genesis of the arterial lesions. Angiographic resolution of non-treated sequelae occurred in 5 months either spontaneously or due to treatment with bosentem. Conclusions: The histologic and angiographic changes demonstrate that the clinical onset of reparative SAM may be significantly delayed to produce ischemic lesions, renal infarction and in this case report, medial fibromuscular dysplasia in the hilar branch of the renal artery.
