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Article(id=1322192336331846318, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1322192284670603597, articleNumber=null, orderNo=null, doi=10.16016/j.2097-0927.202504116, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1745856000000, receivedDateStr=2025-04-29, revisedDate=1750780800000, revisedDateStr=2025-06-25, acceptedDate=null, acceptedDateStr=null, onlineDate=1793164818126, onlineDateStr=2026-10-28, pubDate=1755187200000, pubDateStr=2025-08-15, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1793164818126, onlineIssueDateStr=2026-10-28, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1793164818126, creator=13701087609, updateTime=1793164818126, updator=13701087609, issue=Issue{id=1322192284670603597, tenantId=1146029695717560320, journalId=1319373162502258839, year='2025', volume='47', issue='15', pageStart='1685', pageEnd='1824', issueExtLink='null', onlineDate='null', pubDate='1755187200000', pubDateStr='2025-08-15', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1793164805810, creator='13701087609', updateTime=1793164826583, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext={EN=IssueExt(id=1322192371861799855, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1322192284670603597, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1322192371861799856, tenantId=1146029695717560320, journalId=1319373162502258839, issueId=1322192284670603597, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null, downloadFileDto=null}, startPage=1800, endPage=1805, ext={EN=ArticleExt(id=1322192336533172911, articleId=1322192336331846318, tenantId=1146029695717560320, journalId=1319373162502258839, language=EN, title=Impact of different renal artery clamping strategies on postoperative renal function in patients with pre-existing renal insufficiency in robotic partial nephrectomy, columnId=1320435174995772212, journalTitle=Journal of Army Medical University, columnName=Clinical Medicine, runingTitle=null, highlight=null, articleAbstract=
Objective‍

To compare the effects of main artery clamping (MAC) and selective artery clamping (SAC) strategies on postoperative renal function in patients with chronic renal insufficiency undergoing robot-assisted partial nephrectomy.

Methods‍

A retrospective cohort study was conducted on 231 patients with preoperative chronic renal insufficiency [eGFR <90 mL/(min·1.73 m²) with renal injury markers or eGFR <60 mL/(min·1.73 m²)] who underwent robot-assisted partial nephrectomy in the Department of Urology of the First Affiliated Hospital of Army Medical University from February 2018 to February 2024. According to intraoperative renal artery clamping strategy, they were divided into a MAC group (n=129) and a SAC group (n=102). Preoperatively, individualized renal artery clamping strategies were developed using a machine learning-based multimodal holographic 3-D reconstruction technique. Serum creatinine (Scr) level was measured at 3 d and 3 months after surgery, and estimated glomerular filtration rate (eGFR) was calculated using the chronic kidney disease epidemiology collaboration equation (CKD-EPI) formula. Renal dynamic imaging with 99mTc-DTPA or 99mTc-MAG3 was used to assess the GFR of the affected kidney.

Results‍

At 3 d after surgery, the decrease in GFR of the affected kidney was significantly lower [(8.3±7.7) vs (16.0±10.2) mL/(min·1.73 m²), 95%CI: -10.2~-5.2, P<0.001] in the SAC group than the MAC group. Scr increment analysis showed that the SAC group exhibited notably lower Scr increase [8.2 (2.5, 18.7) vs 15.5 (5.8, 28.3) μmol/L, 95%CI: -12.3~-1.8, P=0.027], and milder eGFR decline [3.0 (0.5, 7.8) vs 7.5 (2.0, 14.3) mL/(min·1.73 m²), 95%CI: -6.2~-0.8, P=0.015]. And, in 3 months after surgery, the SAC group had lower Scr level [(89.2±23.1) vs (95.3±22.1) μmol/L, 95%CI: -11.9~-0.3, P=0.042], and higher GFR of the affected kidney [(33.5±10.5) vs (26.1±10.9) mL/(min·1.73 m²), 95%CI: 4.6~10.2, P<0.001].

Conclusion‍

For patients with chronic renal insufficiency undergoing robot-assisted partial nephrectomy, SAC strategy is superior to MAC strategy in protecting postoperative renal function without increasing surgical risk.

, authors=Linfei LI1, Cong WANG1, Ling WEI1, Jun ZHENG1, Juan SHEN1, Xuemei LI1, Jianli FENG2, Daodong SUN2, Yongquan WANG1, authorsList=Linfei LI, Cong WANG, Ling WEI, Jun ZHENG, Juan SHEN, Xuemei LI, Jianli FENG, Daodong SUN, Yongquan WANG, authorCompany=null, correspAuthors=Yongquan WANG, authorNote=null, correspAuthorsNote=null, copyrightStatement=© 2025 Journal of Army Medical University, copyrightOwner=Editorial Office of Journal of Army Medical University, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, fund=null), CN=ArticleExt(id=1322192337279759028, articleId=1322192336331846318, tenantId=1146029695717560320, journalId=1319373162502258839, language=CN, title=不同肾动脉阻断策略对合并慢性肾功能不全患者机器人辅助肾部分切除术后肾功能的影响, columnId=1322185541475488183, journalTitle=陆军军医大学学报, columnName=临床医学, runingTitle=null, highlight=null, articleAbstract=
目的

比较主干阻断（main artery clamping，MAC）与选择性分支阻断（selective artery clamping，SAC）两种肾动脉阻断策略对合并慢性肾功能不全患者机器人辅助肾部分切除术后肾功能的影响。

方法

采用回顾性队列研究设计，纳入2018年2月至2024年2月陆军军医大学第一附属医院泌尿外科住院收治的231例合并慢性肾功能不全［eGFR<90 mL/（min·1.73 m²）伴肾脏损伤标志，或eGFR<60 mL/（min·1.73 m²）］的肾肿瘤患者。根据术中肾动脉阻断策略，将患者分为MAC组（n=129）和SAC组（n=102）。术前采用基于机器学习的多模态全息三维重建技术制定个体化肾动脉阻断策略。采用酶法检测术前3 d、术后3 d及术后3个月的血清肌酐（serum creatinine，Scr）水平，并基于慢性肾脏病流行病学合作研究公式（chronic kidney disease epidemiology collaboration equation，CKD-EPI）公式计算估算肾小球滤过率（estimated glomerular filtration rate，eGFR）。采用核素肾动态显像（99mTc-DTPA或99mTc-MAG3）评估分肾肾小球滤过率（glomerular filtration rate，GFR）。

结果

术后3 d，SAC组患肾GFR下降幅度显著低于MAC组［（8.3±7.7） vs （16.0±10.2） mL/（min·1.73 m²），95%CI：-10.2~-5.2，P<0.001］。Scr增量分析显示，SAC组升高幅度更低［8.2（2.5，18.7） vs 15.5（5.8，28.3） μmol/L，95%CI：-12.3~-1.8，P=0.027］，eGFR下降更轻微［3.0（0.5，7.8） vs 7.5（2.0，14.3） mL/（min·1.73 m²），95%CI：-6.2~-0.8，P=0.015］。术后3个月，SAC组Scr水平更低［（89.2±23.1） vs （95.3±22.1） μmol/L，95%CI：-11.9~-0.3，P=0.042］，患肾GFR更高［（33.5±10.5） vs （26.1±10.9） mL/（min·1.73 m²），95%CI：4.6~10.2，P<0.001］。

结论

对于合并慢性肾功能不全的肾肿瘤患者，机器人辅助肾部分切除术中采用SAC策略较MAC能更好地保护术后肾功能，且不增加手术风险。

, authors=李林飞1, 王聪1, 魏灵1, 郑俊1, 沈娟1, 李雪梅1, 封建立2, 孙道东2, 王永权1, authorsList=李林飞, 王聪, 魏灵, 郑俊, 沈娟, 李雪梅, 封建立, 孙道东, 王永权, authorCompany=null, correspAuthors=王永权, authorNote=null, correspAuthorsNote=
王永权，E-mail：
WANG Yongquan，E-mail：
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Eur Urol，2011，59（5）：849-855., articleTitle=Laparoscopic partial nephrectomy with segmental renal artery clamping：technique and clinical outcomes, refAbstract=null), Reference(id=1322192346649834248, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, doi=10.1007/s00345-023-04599-2, pmid=null, pmcid=null, year=2023, volume=41, issue=11, pageStart=2975, pageEnd=2983, url=null, language=null, rfNumber=14, rfOrder=14, authorNames=WEI L, WANG C, FU J, journalName=World J Urol, refType=null, unstructuredReference=WEI L，WANG C，FU J，et al. Holographic 3D renal segments reconstruction protects renal function by promote choice of selective renal artery clamping during robot-assisted partial nephrectomy［J］. 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Int Urol Nephrol，2012，44（3）：745-751., articleTitle=Renal function and adaptive changes in patients after radical or partial nephrectomy, refAbstract=null), Reference(id=1322192346905686796, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, doi=10.1016/j.juro.2015.01.093, pmid=null, pmcid=null, year=2015, volume=193, issue=6, pageStart=1889, pageEnd=1898, url=null, language=null, rfNumber=18, rfOrder=18, authorNames=MIR M C, ERCOLE C, TAKAGI T, journalName=J Urol, refType=null, unstructuredReference=MIR M C，ERCOLE C，TAKAGI T，et al. Decline in renal function after partial nephrectomy：etiology and prevention［J］. J Urol，2015，193（6）：1889-1898., articleTitle=Decline in renal function after partial nephrectomy：etiology and prevention, refAbstract=null)], funds=null, companyList=[AuthorCompany(id=1322192337527222965, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, xref=1, ext=[AuthorCompanyExt(id=1322192337544000182, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, companyId=1322192337527222965, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1Department of Urology，First Affiliated Hospital，Army Medical University （Third Military Medical University），Chongqing), AuthorCompanyExt(id=1322192337556583095, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, companyId=1322192337527222965, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1陆军军医大学（第三军医大学）第一附属医院泌尿外科，重庆)]), AuthorCompany(id=1322192337644663480, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, xref=2, ext=[AuthorCompanyExt(id=1322192337657246393, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, companyId=1322192337644663480, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2Department of Urology，Jiangbei Branch/No.958 Hospital of PLA Army，First Affiliated Hospital，Army Medical University （Third Military Medical University），Chongqing，China), AuthorCompanyExt(id=1322192337678217914, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, companyId=1322192337644663480, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2陆军军医大学（第三军医大学）第一附属医院江北院区（陆军第九五八医院）泌尿外科，重庆)])], figs=[ArticleFig(id=1322192343013372658, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, language=EN, label=null, caption=null, figureFileSmall=wX1hCWfLuD1Ps3Aq+2LHqg==, figureFileBig=YTc3v4Kc/wEe8Dm81EUt7g==, tableContent=null), ArticleFig(id=1322192343109841651, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, language=CN, label=图1, caption=术前三维重建模型中慢性肾功能不全患者肿瘤供血血管定位过程

绿色区域：示术前全息三维重建显示的右肾肿瘤；蓝色箭头：示供血分支动脉

, figureFileSmall=wX1hCWfLuD1Ps3Aq+2LHqg==, figureFileBig=YTc3v4Kc/wEe8Dm81EUt7g==, tableContent=null), ArticleFig(id=1322192343319556852, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, language=EN, label=null, caption=null, figureFileSmall=DO9y6Cc/UWhYrBK1swiG/w==, figureFileBig=nHX/UMU8azO81cn/lLoB8A==, tableContent=null), ArticleFig(id=1322192343403442933, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, language=CN, label=图2, caption=机器人辅助肾部分切除术中慢性肾功能不全患者肿瘤供血血管的定位与阻断过程

蓝色箭头：示供血分支动脉

, figureFileSmall=DO9y6Cc/UWhYrBK1swiG/w==, figureFileBig=nHX/UMU8azO81cn/lLoB8A==, tableContent=null), ArticleFig(id=1322192343491523318, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, language=EN, label=null, caption=null, figureFileSmall=null, figureFileBig=null, tableContent=
指标MAC组（n=129）SAC组（n=102）P
年龄/岁59（49，67）56（49，69）0.089
女性53（41.1）39（38.2）0.686
BMI/（kg/m²）24.1（22.3，26.7）24.5（22.0，26.1）0.275
肿瘤T分期0.158
T1a88（68.2）76（74.5）
T1b37（28.7）26（25.5）
T2a4（3.1）0
肿瘤最大直径/cm3.55±1.633.35±1.540.349
RENAL评分/分6（5，7）6（5，7）0.641
术前3 d患肾GFR/［mL/（min·1.73 m²）］40.1±9.141.8±10.90.216
术前3 d Scr/（μmol/L）75.1±17.077.9±22.80.300
术前3 d eGFR/［mL/（min·1.73 m²）］76.3±11.575.6±14.80.698
), ArticleFig(id=1322192343592186615, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, language=CN, label=表1, caption=

2组患者术前基本资料的比较［x¯±s，M（P25，P75），例（%）］

, figureFileSmall=null, figureFileBig=null, tableContent=
指标MAC组（n=129）SAC组（n=102）P
年龄/岁59（49，67）56（49，69）0.089
女性53（41.1）39（38.2）0.686
BMI/（kg/m²）24.1（22.3，26.7）24.5（22.0，26.1）0.275
肿瘤T分期0.158
T1a88（68.2）76（74.5）
T1b37（28.7）26（25.5）
T2a4（3.1）0
肿瘤最大直径/cm3.55±1.633.35±1.540.349
RENAL评分/分6（5，7）6（5，7）0.641
术前3 d患肾GFR/［mL/（min·1.73 m²）］40.1±9.141.8±10.90.216
术前3 d Scr/（μmol/L）75.1±17.077.9±22.80.300
术前3 d eGFR/［mL/（min·1.73 m²）］76.3±11.575.6±14.80.698
), ArticleFig(id=1322192343676072696, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, language=EN, label=null, caption=null, figureFileSmall=null, figureFileBig=null, tableContent=
项目MAC组（n=129）SAC组（n=102）P
术后3 d患肾GFR/［mL/（min·1.73 m²）］24.1±10.133.4±11.5<0.001
术后3个月患肾GFR/［mL/（min·1.73 m²）］26.1±10.933.5±10.5<0.001
术后3 d Scr/（μmol/L）97.0±23.791.9±30.40.148
术后3个月Scr/（μmol/L）95.3±22.189.2±23.10.042
术后3 d eGFR/［mL/（min·1.73 m²）］67.3±15.771.6±16.90.047
术后3个月eGFR/［mL/（min·1.73 m²）］67.8±15.173.3±17.60.011
患肾GFRa/［mL/（min·1.73 m²）］16.0±10.28.3±7.7<0.001
Scra/（μmol/L）15.5（5.8，28.3）8.2（2.5，18.7）0.027
eGFRa/［mL/（min·1.73 m²）］7.5（2.0，14.3）3.0（0.5，7.8）0.015
热缺血时间/min20.0±3.320.1±7.20.915
手术时间/min111±19115±410.381
失血量/mL89±4681±880.352
), ArticleFig(id=1322192343759958777, tenantId=1146029695717560320, journalId=1319373162502258839, articleId=1322192336331846318, language=CN, label=表2, caption=

患者术中及术后指标的比较［x¯±s，M（P25，P75），例（%）］

, figureFileSmall=null, figureFileBig=null, tableContent=
项目MAC组（n=129）SAC组（n=102）P
术后3 d患肾GFR/［mL/（min·1.73 m²）］24.1±10.133.4±11.5<0.001
术后3个月患肾GFR/［mL/（min·1.73 m²）］26.1±10.933.5±10.5<0.001
术后3 d Scr/（μmol/L）97.0±23.791.9±30.40.148
术后3个月Scr/（μmol/L）95.3±22.189.2±23.10.042
术后3 d eGFR/［mL/（min·1.73 m²）］67.3±15.771.6±16.90.047
术后3个月eGFR/［mL/（min·1.73 m²）］67.8±15.173.3±17.60.011
患肾GFRa/［mL/（min·1.73 m²）］16.0±10.28.3±7.7<0.001
Scra/（μmol/L）15.5（5.8，28.3）8.2（2.5，18.7）0.027
eGFRa/［mL/（min·1.73 m²）］7.5（2.0，14.3）3.0（0.5，7.8）0.015
热缺血时间/min20.0±3.320.1±7.20.915
手术时间/min111±19115±410.381
失血量/mL89±4681±880.352
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不同肾动脉阻断策略对合并慢性肾功能不全患者机器人辅助肾部分切除术后肾功能的影响
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李林飞 1 , 王聪 1 , 魏灵 1 , 郑俊 1 , 沈娟 1 , 李雪梅 1 , 封建立 2 , 孙道东 2 , 王永权 1
陆军军医大学学报 | 临床医学 2025,47(15): 1800-1805
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陆军军医大学学报 |临床医学 2025 , 47 (15) : 1800 -1805
不同肾动脉阻断策略对合并慢性肾功能不全患者机器人辅助肾部分切除术后肾功能的影响
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李林飞1, 王聪1, 魏灵1, 郑俊1, 沈娟1, 李雪梅1, 封建立2, 孙道东2, 王永权1
作者信息
  • 1陆军军医大学（第三军医大学）第一附属医院泌尿外科，重庆
  • 2陆军军医大学（第三军医大学）第一附属医院江北院区（陆军第九五八医院）泌尿外科，重庆
通讯作者:
王永权，E-mail：
WANG Yongquan，E-mail：
Impact of different renal artery clamping strategies on postoperative renal function in patients with pre-existing renal insufficiency in robotic partial nephrectomy
Linfei LI1, Cong WANG1, Ling WEI1, Jun ZHENG1, Juan SHEN1, Xuemei LI1, Jianli FENG2, Daodong SUN2, Yongquan WANG1
Affiliations
  • 1Department of Urology，First Affiliated Hospital，Army Medical University （Third Military Medical University），Chongqing
  • 2Department of Urology，Jiangbei Branch/No.958 Hospital of PLA Army，First Affiliated Hospital，Army Medical University （Third Military Medical University），Chongqing，China
出版时间: 2025-08-15 doi: 10.16016/j.2097-0927.202504116
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摘要
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目的

比较主干阻断（main artery clamping，MAC）与选择性分支阻断（selective artery clamping，SAC）两种肾动脉阻断策略对合并慢性肾功能不全患者机器人辅助肾部分切除术后肾功能的影响。

方法

采用回顾性队列研究设计，纳入2018年2月至2024年2月陆军军医大学第一附属医院泌尿外科住院收治的231例合并慢性肾功能不全［eGFR<90 mL/（min·1.73 m²）伴肾脏损伤标志，或eGFR<60 mL/（min·1.73 m²）］的肾肿瘤患者。根据术中肾动脉阻断策略，将患者分为MAC组（n=129）和SAC组（n=102）。术前采用基于机器学习的多模态全息三维重建技术制定个体化肾动脉阻断策略。采用酶法检测术前3 d、术后3 d及术后3个月的血清肌酐（serum creatinine，Scr）水平，并基于慢性肾脏病流行病学合作研究公式（chronic kidney disease epidemiology collaboration equation，CKD-EPI）公式计算估算肾小球滤过率（estimated glomerular filtration rate，eGFR）。采用核素肾动态显像（99mTc-DTPA或99mTc-MAG3）评估分肾肾小球滤过率（glomerular filtration rate，GFR）。

结果

术后3 d，SAC组患肾GFR下降幅度显著低于MAC组［（8.3±7.7） vs （16.0±10.2） mL/（min·1.73 m²），95%CI：-10.2~-5.2，P<0.001］。Scr增量分析显示，SAC组升高幅度更低［8.2（2.5，18.7） vs 15.5（5.8，28.3） μmol/L，95%CI：-12.3~-1.8，P=0.027］，eGFR下降更轻微［3.0（0.5，7.8） vs 7.5（2.0，14.3） mL/（min·1.73 m²），95%CI：-6.2~-0.8，P=0.015］。术后3个月，SAC组Scr水平更低［（89.2±23.1） vs （95.3±22.1） μmol/L，95%CI：-11.9~-0.3，P=0.042］，患肾GFR更高［（33.5±10.5） vs （26.1±10.9） mL/（min·1.73 m²），95%CI：4.6~10.2，P<0.001］。

结论

对于合并慢性肾功能不全的肾肿瘤患者，机器人辅助肾部分切除术中采用SAC策略较MAC能更好地保护术后肾功能，且不增加手术风险。

肾肿瘤  /  肾功能不全  /  肾部分切除术  /  机器人辅助手术  /  血管阻断
Objective‍

To compare the effects of main artery clamping (MAC) and selective artery clamping (SAC) strategies on postoperative renal function in patients with chronic renal insufficiency undergoing robot-assisted partial nephrectomy.

Methods‍

A retrospective cohort study was conducted on 231 patients with preoperative chronic renal insufficiency [eGFR <90 mL/(min·1.73 m²) with renal injury markers or eGFR <60 mL/(min·1.73 m²)] who underwent robot-assisted partial nephrectomy in the Department of Urology of the First Affiliated Hospital of Army Medical University from February 2018 to February 2024. According to intraoperative renal artery clamping strategy, they were divided into a MAC group (n=129) and a SAC group (n=102). Preoperatively, individualized renal artery clamping strategies were developed using a machine learning-based multimodal holographic 3-D reconstruction technique. Serum creatinine (Scr) level was measured at 3 d and 3 months after surgery, and estimated glomerular filtration rate (eGFR) was calculated using the chronic kidney disease epidemiology collaboration equation (CKD-EPI) formula. Renal dynamic imaging with 99mTc-DTPA or 99mTc-MAG3 was used to assess the GFR of the affected kidney.

Results‍

At 3 d after surgery, the decrease in GFR of the affected kidney was significantly lower [(8.3±7.7) vs (16.0±10.2) mL/(min·1.73 m²), 95%CI: -10.2~-5.2, P<0.001] in the SAC group than the MAC group. Scr increment analysis showed that the SAC group exhibited notably lower Scr increase [8.2 (2.5, 18.7) vs 15.5 (5.8, 28.3) μmol/L, 95%CI: -12.3~-1.8, P=0.027], and milder eGFR decline [3.0 (0.5, 7.8) vs 7.5 (2.0, 14.3) mL/(min·1.73 m²), 95%CI: -6.2~-0.8, P=0.015]. And, in 3 months after surgery, the SAC group had lower Scr level [(89.2±23.1) vs (95.3±22.1) μmol/L, 95%CI: -11.9~-0.3, P=0.042], and higher GFR of the affected kidney [(33.5±10.5) vs (26.1±10.9) mL/(min·1.73 m²), 95%CI: 4.6~10.2, P<0.001].

Conclusion‍

For patients with chronic renal insufficiency undergoing robot-assisted partial nephrectomy, SAC strategy is superior to MAC strategy in protecting postoperative renal function without increasing surgical risk.

kidney neoplasms  /  renal insufficiency  /  partial nephrectomy  /  robotic surgical procedures  /  vascular occlusion
李林飞, 王聪, 魏灵, 郑俊, 沈娟, 李雪梅, 封建立, 孙道东, 王永权. 不同肾动脉阻断策略对合并慢性肾功能不全患者机器人辅助肾部分切除术后肾功能的影响. 陆军军医大学学报, 2025 , 47 (15) : 1800 -1805 . DOI: 10.16016/j.2097-0927.202504116
Linfei LI, Cong WANG, Ling WEI, Jun ZHENG, Juan SHEN, Xuemei LI, Jianli FENG, Daodong SUN, Yongquan WANG. Impact of different renal artery clamping strategies on postoperative renal function in patients with pre-existing renal insufficiency in robotic partial nephrectomy[J]. Journal of Army Medical University, 2025 , 47 (15) : 1800 -1805 . DOI: 10.16016/j.2097-0927.202504116
正文
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肾部分切除术（partial nephrectomy，PN）作为治疗早期肾脏肿瘤的标准术式，在肿瘤根治与肾功能保护之间实现了重要平衡。然而，手术过程中不可避免的肾动脉阻断、缺血再灌注损伤、功能性肾组织丢失等医源性因素，导致约20%的患者术后出现肾功能进行性下降。这一现象在术前已存在慢性肾脏疾病（chronic kidney disease，CKD）的患者中尤为突出——流行病学研究显示，全球约9.1%的成人患有CKD［1］，而肾癌患者中CKD发生率高达22%［2］。随着全球肾脏病预后组织（Kidney Disease：Improving Global Outcomes，KDIGO） 制定的2024版指南将CKD诊断标准明确为持续3个月以上的估算肾小球滤过率（estimated glomerular filtration rate，eGFR）<90 mL/（min·1.73 m²）伴肾脏损伤标志或eGFR<60 mL/（min·1.73 m²）［3］，这一人群的临床识别率显著提升，使得围手术期肾功能保护策略的优化成为泌尿外科领域亟待解决的关键问题［4-5］。当前，肾动脉阻断策略的选择存在显著学术分歧。虽然选择性分支阻断（selective artery clamping，SAC）理论上可通过保留非肿瘤区域血供减少缺血损伤，但现有研究多聚焦于肾功能正常人群。CACCIAMANI等［6］的Meta分析显示，在全人群中SAC对肾功能的保护优势仅体现在术后短期随访中；而ZHANG等［7］的研究则提示SAC可能延长手术时间并增加出血风险。这种争议可能源于研究人群的异质性——健康肾脏的代偿能力可能掩盖了SAC的潜在获益，使得针对CKD这一高危亚组的专项研究显得尤为必要。本研究系统评估机器人辅助下SAC对合并CKD患者的肾功能保护效果，在研究人群上严格依据KDIGO 2024标准筛选CKD患者，填补了该高危人群手术策略的循证空白，通过技术上创新性地结合机器学习多模态三维重建技术，实现了个体化分支动脉的精确定位，突破了传统SAC技术的解剖识别瓶颈，同时，在评估体系上采用核素肾动态显像定量分肾功能，弥补了单纯依靠eGFR评估肾功能的局限性。通过系统阐明SAC在CKD患者中的临床价值，本研究不仅为制定个体化精准手术方案提供了高级别循证医学证据，更对改善这类特殊人群的长期预后具有重要的临床实践意义。
1　资料与方法
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1.1　研究对象
本研究为回顾性队列研究，选取了2018年2月至2024年2月于陆军军医大学第一附属医院泌尿外科住院治疗的肾肿瘤患者。纳入标准：①年龄18~75岁；②术后病理检查证实肾肿瘤（良性或恶性）；③eGFR<90 mL/（min·1.73 m²）且伴有至少一项肾脏损伤标志（包括蛋白尿、尿沉渣异常或肾小管疾病引起的电解质紊乱等），或eGFR<60 mL/（min·1.73 m²），上述所有异常指标需持续存在不少于3个月；④接受机器人辅助下肾部分切除术治疗。排除标准：①临床资料不完整；②随访时间不足6个月；③术中中转开放性手术或根治性肾切除术者。根据术中血管夹闭策略不同，分为主干阻断（main artery clamping，MAC）组（MAC组，n=129）和选择性分支阻断组（SAC组，n=102）。术前采用基于机器学习的多模态全息三维重建技术制定个体化肾动脉阻断策略。采用酶法检测术前3 d、术后3 d及术后3个月的血清肌酐（serum creatinine，Scr）水平，并基于慢性肾脏病流行病学合作研究公式（chronic kidney disease epidemiology collaboration equation，CKD-EPI）公式计算eGFR。采用核素肾动态显像（99mTc-DTPA或99mTc-MAG3）评估分肾肾小球滤过率（glomerular filtration rate，GFR）。由于核素显像技术涉及放射学检查，将其使用限制在术前3 d、术后3 d和术后3个月，以确保最大限度地保护患者。本研究已通过陆军军医大学第一附属医院伦理委员会审批［（B）KY2025027］，并免除患者知情同意。
1.2　手术方法
1.2.1　术前规划
所有患者行上腹部螺旋CT增强扫描（层厚0.6~1.0 mm），生成的图像以DICOM格式存储。将患者的DICOM数据导入全息三维重建系统（重庆沁影科技有限公司全息三维医学成像系统），利用人工智能卷积神经网络算法，将5段肾动脉分布的血供区域及其与肿瘤的关系进行模拟重建后，逐步去除冗余解剖结构，精确定位肿瘤供应血管（图1），SAC组的选择标准是术者能够在一个或多个动脉供血段内准确识别肿瘤的位置，并能够细致地解剖这些动脉分支。手术团队结合肿瘤T分期、肾肿瘤解剖学评分系统 （renal nephrometry score，RENAL）、肿瘤位置、大小、深度及与肾血管的关系等因素进行讨论，最终确定腹膜内或腹膜后入路的选择及对相关患者选择实施分支阻断策略。
1.2.2　手术流程
常规消毒铺巾，经腹膜内或腹膜后入路建立手术通道，解剖分离暴露肾动脉主干和主要分支后，MAC组患者行肾动脉主干阻断，SAC组患者行选择性阻断肿瘤区域供血的动脉分支（图2），切开Gerota’s筋膜，完整切除肿瘤，使用3-0 V-Loc倒刺线精细缝合内层血管和集合系统，2-0 V-Loc倒刺线全层缝合肾实质。术区留置引流管，逐层关闭切口，切除标本常规送病理检查。
1.3　观察指标
记录并比较2组患者的基线临床资料以及手术相关指标，包括性别、年龄、BMI、肿瘤T分期、肿瘤最大直径、RENAL评分、术前3 d Scr/eGFR、热缺血时间、手术时间、失血量、并发症发生率。通过术前3 d、术后3 d及术后3个月这3个时间点动态监测Scr和eGFR以评估总肾功能变化，同时采用放射性核素ECT测定分肾功能，并对2组患者测量结果进行差异性分析。
1.4　统计学分析
本研究采用SPSS 27.0进行统计分析。计量资料中符合正态分布的数据以x¯±s表示，组间比较采用独立样本t检验；非正态分布的数据以M（P25，P75）表示，组间比较采用Mann-Whitney U检验。计数资料以例（%）表示，组间比较采用χ²检验或Fisher确切概率法（理论频数<5时）。等级资料如肿瘤T分期采用Mann-Whitney U检验进行分析。所有统计检验为双侧检验，P<0.05认为差异具有统计学意义。连续变量的正态性通过Shapiro-Wilk检验验证，组间差异的效应量以均数差值（MD）或中位数差值及95%CI报告。
2　结果
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2.1　基线特征均衡可比
结果显示，MAC组与SAC组在人口学特征（年龄、性别、BMI）、肿瘤特征（T分期、最大直径、RENAL评分）及术前3 d肾功能指标（患肾GFR、Scr、eGFR）方面均差异无统计学意义（表1），提示2组基线特征均衡可比。
2.2　手术安全性相当
2组热缺血时间、手术时间和失血量无显著差异（表2），常见并发症发生率亦无统计学差异。结果表明SAC技术未增加手术风险，具备临床可行性。
2.3　SAC显著改善术后肾功能
2.3.1　急性肾损伤显著减轻
与MAC组相比，SAC组术后3 d患肾GFR下降幅度显著更低（95%CI：-10.2~-5.2，P<0.001），eGFR下降更轻微（95%CI：-6.2~-0.8，P=0.015）；Scr增量分析显示，SAC组升高幅度更低（95%CI：-12.3~-1.8，P=0.027；表2）。结果表明SAC策略可有效缓解缺血再灌注损伤。
2.3.2　远期肾功能恢复优势
术后3个月随访显示，SAC组Scr水平显著低于MAC组（95%CI：-11.9~-0.3，P=0.042），患肾GFR更高（95%CI：4.6~10.2，P<0.001），eGFR亦更优（95%CI：1.2~9.8，P=0.011）。结果表明SAC技术对肾功能保护具有持续临床效益。
3　讨论
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3.1　PN在肾功能保护中的临床价值与局限性
随着肾脏肿瘤早期诊断率的提高，保留肾单位的PN已成为治疗局限性肾肿瘤的首选方法。相较于根治性肾切除术，PN在保护术后肾功能方面具有显著优势。欧洲泌尿外科学会、美国泌尿外科学会及中国泌尿外科指南均推荐，只要技术可行，应优先选择PN，尤其对于合并CKD或心血管疾病的患者［7-8］。然而，PN术后肾功能下降仍不容忽视。研究显示，PN术后患者的中位eGFR可下降约20 mL/（min·1.73 m²）［9］，且合并CKD、高血压、糖尿病及肥胖的患者肾功能下降更为显著［10-11］。此外，术后肾功能减退可能增加心血管事件风险［12］，提示当前PN技术仍需优化以进一步保护肾功能。
3.2　SAC技术的发展与争议
肾动脉通常分为5个节段动脉（尖段、上段、中段、下段和后段），SAC通过精准阻断肿瘤供血动脉，减少正常肾组织缺血损伤。多项研究表明，SAC可延长缺血耐受时间，降低术后eGFR下降幅度［13-15］。一项纳入987例患者的荟萃分析进一步证实，SAC或超选择性阻断较MAC能更好地保护肾功能［6］。然而，SAC的临床适用性仍存争议。部分研究指出，SAC可能延长手术时间并增加出血风险，尤其是对于较大肿瘤（最大直径>4 cm）或内生型肿瘤［7］。此外，小样本研究显示SAC对术后eGFR的影响有限［16］，可能与病例选择偏倚或健侧肾功能代偿有关。因此，SAC的获益人群仍需更严格的前瞻性研究界定。
3.3　慢性肾功能不全患者的特殊考量
迄今为止，针对术前存在肾功能不全患者的研究和文献仍然较为稀缺，亟待进一步深入探讨。本研究填补了这一空白，为临床实践提供了重要参考依据。本研究严格依据2024年KDIGO标准［3］筛选患者，重点关注术前已存在肾功能损害的群体。需要说明的是既往研究表明，无论是接受根治性肾切除术还是肾部分切除术的患者，其术后3个月与12个月的Scr水平和eGFR均无显著差异［17］。本研究结果与上述研究结果一致。考虑到术后3个月时患者的随访依从性较好，临床资料完整性较高，因此选择术后3个月的肾功能指标（Scr、eGFR和患肾GFR）作为评估患者远期肾功能状态的可靠依据。
本研究发现，在手术时间、失血量及热缺血时间无显著差异的前提下，SAC组术后eGFR下降幅度低于MAC组，提示SAC对CKD患者的肾功能保护更具优势。这一结果可能归因于SAC减少了正常肾组织的缺血损伤，尤其适用于外周型或单一动脉供血的肿瘤。SAC的适用性受肿瘤位置和大小影响。本研究中，SAC组肿瘤直径均≤4 cm，且术前三维重建明确了供血动脉，这可能是术中出血可控的关键。对于体积较大或内生型肿瘤，若累及多支动脉，SAC可能无法完全阻断血供，此时MAC仍是更稳妥的选择。
本研究在术前使用了基于机器学习的多模态全息三维重建技术，将患者的DICOM数据导入全息三维重建系统，重建出骨骼、腹部器官、血管、肿瘤病灶及邻近组织的全息图像。初步模型通过软件计算建立了血管供应与肾脏表面的一致性，影像专业人员手工审核并修正得到最终的3D模型，有效辅助了临床抉择，显著提高了行分支阻断的策略选择［14］。
本研究尚有一些局限性：①作为回顾性研究设计，未能系统评估术中血管损伤等重要因素对患者术后生活质量的影响；②由于纳入病例的时间跨度较大，期间手术技术的进步可能对研究结果产生潜在影响；③随访方案的不一致性可能导致对总体肾功能和分肾功能评估存在偏倚，因此研究结论仍需通过长期随访和前瞻性研究加以验证；④本研究未对术后保留肾实质体积进行定量评估，而这一指标已被证实是影响肾功能预后的关键因素［18］；⑤所有手术操作由同一位经验丰富的外科医师完成，这一单中心、单术者的研究模式可能限制研究结果的普遍适用性。尽管如此，对于合并慢性肾功能不全的肾肿瘤患者，本研究结果支持在技术条件允许的情况下，采用SAC技术可能有助于更好地保护术后肾功能，从而改善患者长期生活质量。

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2025年第47卷第15期
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doi: 10.16016/j.2097-0927.202504116
  • 接收时间：2025-04-29
  • 首发时间：2026-10-28
  • 出版时间：2025-08-15
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  • 收稿日期：2025-04-29
  • 修回日期：2025-06-25
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    1陆军军医大学（第三军医大学）第一附属医院泌尿外科，重庆
    2陆军军医大学（第三军医大学）第一附属医院江北院区（陆军第九五八医院）泌尿外科，重庆

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