Compared The Prone Position With The Lateral Position In The Application Of Retroperitoneal Laparoscopic Nephrectomy And The Value Of Multislice Spiral CT Renal Angiography

Background: In1991, Clayman first reported nephrectomy by thelaparoscopic way. In our country, the first laparoscopic nephrectomy wasreported by Yanqun in1993. In the same year Gaur used balloon dilationmethod for peritoneal laparoscopic surgery,which creating a history oflaparoscopic nephrectomy retroperitoneal approach.Recent years, due to laparoscopic instruments, equipment and operatingtechniques was being improved and perfected, the laparoscopic nephrectomynot only been widely used in our country,but also has been gradually appliedto various nephrectomy for treating some kidney diseases, includinghydronephrosis, renal atrophy, renal dysplasia, kidney cancer, renal pelvis andureter cancer, renal tuberculosis and so on. Regardless of the degree ofoperative trauma, blood loss,recovery time after operate and hospital stay,laparoscopic surgery have an unparalleled advantage compared withconventional open surgery.Moreover,it has trend for replacing opennephrectomy and become standard surgical approach in nephrectomy.There are two surgical approach in laparoscopic nephrectomy,intraperitoneal route and retroperitoneal route. By the intraperitonealroute,laparoscopic nephrectomy has a advantage of larger space ofpneumoperitoneum and better surgical vision,which increases surgicaloperating space and is convenient to operate.But it also some disadvantage, forexample the interference of the internal organs in peritoneal, instrumentspulling and pushing around the organs in the abdominal cavity, the need toincrease the puncture channels and the operation can easily easy to damage theabdominal organs, caused by intra-abdominal infections, intestinal adhesions,bowel obstruction, and other relational complications. Subsequent laparoscopic nephrectomy by retroperitoneal approach was setup. Duringsurgery, abdominal cavity is expansed by homemade water balloon or balloonwhich filled with CO₂gas and establish pneumoperitoneum manual space tocomplete the surgery. Because the kidney is in the retroperitoneal, separationkidney is more direct and accurate,surgical operations is more concise byretroperitoneal approach.Moreover, steps after intraperitoneal due to doesnot enter the abdominal cavity thereby avoiding abdominal organs injury,postoperative adhesions, the less the chance of intestinal obstruction,postoperative recovery of gastrointestinal function faster, but it also has itslimitations: the relatively small operating space. Traditional retroperitonealroute nephrectomy surgery contralateral supine lumbar approach, we use theway to the implementation of the prone position by retroperitoneallaparoscopic nephrectomy with the gravity and the abdominal organs naturallydrooping under the posture of this surgery, which reduce the interference ofthe peritoneal cavity organs of surgery establish puncture channel filled withCO₂gas, the pressure is maintained at11^<sup>15mmHg, to enable them to meetthe operative space is revealed, the successful completion of the surgicalprocedure.As we all know, controling precisely renal vascular is one of the keys oflaparoscopic nephrectomy, including effective searching renal vascular,fully exposeing it,choosing effective ligation site and mode ofartery.Therefore,in order to shorten the operation time,reduce the risk ofsurgery and improve the probability of successive surgery,it is very importantto estimate whether anatomical variations or not in patients before surgery.Multi-slice spiral CT renal angiography can clearly display thethree-dimensional the renal artery and the distribution of its branches; Inaddition,there is the ability to diagnosis the anatomic abnormality anddeformity of vascular,vessel lumen without stenosis, the presence or absenceof plaque or calcification of the wall; there no abnormal increase tumorcollateral circulation vascular tumor and surrounding blood vessels, thethree-dimensional relationships of the surrounding tissues and organs; renal vein and inferior vena cava with or without cancer plug, also better displayvein anatomy the abnormal abnormal venous return and tumor. Therefore,giving multislice spiral CT renal angiography before surgery, it is effectiveway to guide operator to accurate control kidney vessels,reduce bleeding andinjuries, shorten the operation time,reduce the risk of surgery and improve theprobability of successive surgery. For the reason that,so as to obtainthree-dimensional anatomical images of the kidneys and blood vessels withinthe scan range, we must select the patient of nephrectomy, imitate the positionin surgery and render multi-slice spiral CT renal angiography with prone andlateral position respectively.Objective: The goal of this experiment is to confirmed the advantage ofoperative route in prone position, by means of collecting relevant clinical datathat radical nephrectomy through the retroperitoneal approach and objectivedata that is measured by multislice spiral CT renal angiography and statisticalanalysis.And then to promote and apply it for clinical.Method:1Select the patients that is treated in the Second Hospital of HebeiMedical University, Department of Urology during the September2011toDecember2012,then randomly assign to two groups.Two groups of patients isexamined by Abdominal B ultrasound or renal CT enhanced scan and weconfirmed that all patients had renal mass.Clinical tumor stage:T₁N₀M₀,30cases,T₂N₀M₀,8cases. So they should be received operative treatment ofradical nephrectomy surgery.The subject of side-lying position is18cases,8males and10females,age from30to76（average:52.67±13.55）;Body massindex（IBM）:19.95²8.41Kg/m²（average:23.33～1.86Kg/m²）;Tumor size:3.5⁸.0cm（average:6.25±0.97cm）; The subject of prone position is20cases,（9males and11females）,age from26⁷4y（average:52.55±13.31y）;BMI:19.10²5.95Kg/m²（average:23.33¹.86Kg/m²）;tumor size:4.7⁸.5cm（average:6.40±0.98cm）.The preoperative patients that have notobvious symptoms are11cases,that have the naked eye hematuria are6cases,that have the waist pain are11cases,that have the naked eye hematuria combining with the waist pain are10cases.The preoperative patients wereexamined by renal CT enhanced scan and MRI and did not find tumor bolt inrenal vein and vena cava, lymph node metastasis in renal hilar and distantorgans,the contralateral renal function is normal.Lateral position：left tumor:9cases,right tumor：9cases; prone position:left tumor:11cases,right tumor：9cases;Preoperative patients with no obvioussymptoms in11cases,6cases of gross hematuria the Or pain11grosshematuria merger or else the pain in10cases. The kidneys of patients withpreoperative enhanced CT scan or MRI found no renal vein tumor thrombusand vena cava tumor thrombus in renal hilar lymph node metastasis anddistant metastasis, contralateral normal renal function. Collection of twogroups of patients, age, body mass index, tumor size, operative time,intra-operative blood loss, postoperative catheter disconnect time,postoperative abdominal drainage tube pulled out, the number of days ofpostoperative ambulation, postoperative hospitalization time, intra-operativecomplications and follow-up without recurrence, metastasis, and for statisticalanalysis and comparison.2Patients for inpatient Urology, the Second Hospital of Hebei MedicalUniversity, into the group of patients with preoperative abdominal Bultrasound or renal CT enhanced scan confirmed renal mass, the neednephrectomy. Into the group of10patients,5males and5females,5cases left,the right side of five cases. Age40⁶6y, average51.80±7.56y BMI:22.86²8.41Kg/m²and an average of24.85±1.96Kg/m²underwent CTangiography were used two different posture in the prone position and lateralposition, get scanned kidneys and blood vessels in the range ofthree-dimensional anatomical images, after the measurement of the linearlength of the renal artery and renal film distance, the shortest distance of theabdominal wall, statistically analyzed and compared.Results:1Compareing the two subjects of surgical effect: the above data,statistical analysis applied SPSS13.0software. P <0.05meaned differences and had statistical significance.The easurement data of normally distributionwas expressed by mean±SD, comparison of between groups used a grouptest,the measurement data of skewed distribution showedmedian（minimum^maximum）, comparison of between groups used Twoindependent samples of Mann-Whity U test,P <0.05meaned differencesand had statistical significance.We used χ²test to compare the incidence ofIntraoperative and postoperative complications.Between the two subjects,theage, body mass index, tumor size, blood loss in operating, postoperativecatheter disconnect time, postoperative abdominal drainage tube to pull out oftime, the number of days of postoperative ambulation, postoperative hospitaltime was not statistically significant （P>0.05）. Compared with the subjects ofthe lateral position （142.22±10.46min）,operative time is more longer in thesubjects of prone position （118.75±15.46min）, P<0.05.38cases weresuccessfully completed by laparoscope,there are no relay open surgery andsecond operation cases because of postoperative bleeding. Pathology afteroperation showed:28cases of renal cell carcinoma, six cases of papillary renalcell carcinoma, chromophobe renal cell carcinoma cases, three cases of renalangiomyolipoma.There is no recurrence and metastasis duringPostoperativefollow-up of4¹8months. The intraoperative and postoperativecomplication rate was not statistically significant in two subjects.2The data is obtained by measuring, statistical analysis is completed bySPSS13.0software. Mean±SD express the normal distribution ofmeasurement data and use a paired t-test. Left renal tumor:compared withthe subjects of the lateral position （4.25±0.09cm）,the length of the renalartery is more larger in the subjects of prone position （23.34±0.93cm）, P<0.05.Compared with the subjects of the lateral position （4.25±0.09cm）,theshortest distance between renal capsule and the posterior abdominal wall ismore longer in subjects of prone position（4.39±0.12cm）,P <0.05.Right renaltumor: compared with the subjects of the lateral position（32.04±0.32cm）,the length of the renal artery is more larger in the subjectsof prone position（32.48±0.34cm）, P <0.05.Compared with the subjects of the lateral position （4.19±0.21cm）,the shortest distance between renal capsuleand the posterior abdominal wall is more longer in subjects of prone position（4.33±0.23cm）.Conclusions:1There is two ways of nephrectomy by bretroperitoneal route,waistapproach in lateral position and dorsal approach in prone positionrespectively.The effect of two ways is identical and the complications ofIntraoperate and post operate is not significant different.In the subjects ofprone position,due to the effect of gravity,intra-abdominal organ can naturallydroop,which can give the surgeon a widely view,operative space and shortenthe operative time.This way of nephrectomy is safe and feasible,clinicalapplicative value.2The three-dimensional reconstruction of multi-slice spiral CT renalangiography confirmed that: if the patients are applied complete proneposition to imitate operative position,intra-abdominal organ can naturallydroop by the effect of gravity,renal artery is pulled and lengthen,the distancebetween renal capsule and napes is plused,which offera widelyview,operative space to surgeon.The way in prone position provides a newoperative route with laparoscopic nephrectomy in clinical and possessesclinical applicative value.