Less nefrektomie

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Less nefrektomie. Marek Schmidt. Urologick klinika UK 2.LF a FN Motol, Praha. Laparoendoscopic single-site surgery (LESS). dal krok vminiinvazivit modernch operanch technologi - PowerPoint PPT Presentation

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  • LESS NEFREKTOMIEMAREK SCHMIDTUrologick klinika UK 2.LF a FN Motol, Praha

  • LAPAROENDOSCOPIC SINGLE-SITE SURGERY (LESS)

    dal krok vminiinvazivit modernch operanch technologi

    redukuje standardn poet port uvanch pi konvenn laparoskopick nefrektomii (LNE) ze 3-4 na 1, kter je vyuit kextrakci prepartu

    sniuje morbiditu spojenou sportlnmi vstupy a vylepuje kosmetick vsledek operace

    pi krtkm sledovn srovnateln peroperan a pooperan vsledky

  • LESS (LAPAROENDOSCOPIC SINGLE-SITE SURGERY)

    Potenciln vhody oproti LNE men jizva, men pooperan bolest, ni spoteba analgetik, krat rekonvalescence, mn komplikac(White et al., 2009; Tracy et al., 2008; Stolzenburg et al., 2009; Desai et al., 2009)

    Zvldnuteln technikaLESS nefrektomie pro T3a tumor s trombem renln ly 2 pacienti (Kopp et al., 2010)LESS resekce ledviny (Chan et al., 2010)

  • LESS NEFREKTOMIEkamera 5 mm s30 optikou

    kombinace obloukovch a konvennch nstroj

    standardn laparoskopick technika proveden operace

  • SOUBOR10/2010 3/2013 18 pacient sndorem cT1 cT2

    10x vlevo, 8x vpravo10 en, 8 mu

    vk 56 let (37 62)velikost ndoru 41 cm (20 70)velikost prepartu 164 cm (95 290)

    zchovn operan vkon u T1 nebyl indikovn pro centrln lokalizaci ndoru nebo byl pacientem odmtnut

    8 pacient pedchoz abdominln operace

  • OPERAN TECHNIKA

    prvnch 6 pacient mesogastrick lokalizace portu12 pacient umbilikln lokalizace

    incize 2-3 cm prodlouen na extrakn rnu

    nkdy nutnost dodatenho trokaru pi pravostrann NE

    kdykoliv konverze na konvenn laparoskopii

  • VSLEDKYu vech pacient byla operace jednoportovm pstupem dokonena bez poteby konverze

    u 2 pacient pi pravostrann NEdodaten trokar 5 mm k elevaci jater

    Histologie:16 x svtlobunn karcinom1x papilrn karcinom typ 11x onkocytomTNM10x pT1a3x pT1b2x pT2a3x pT3a

    LESSlapNEpoet18283operan as (min.)187 (170)136 (220,192)krevn ztrty (ml)130148hospitalizace (dny)5,85,3analgetika (dny)56,2opity (dny)22,1dren (dny)54,3rozmr ndoru (mm)40,6 (24-73)64 (12-129)rozmr prepartu (mm)164 (95-250)194 (92-365)

  • VSLEDKY kosmetick vsledek byl vemi pacienty hodnocen jako velmi dobr (1,7 vs. 2,8) pooperan kvalita ivota hodnocen pomoc dotaznk bezsignifikantnho rozdlu

  • OBEZITA

    Operan asOptimln vhamui BMI 20 - 24,9, eny BMI 19 - 23,92:29Mrn nadvhamui BMI 25 - 29,9, eny BMI 24 - 28,92:51Obezitamui BMI 30 - 39,9, eny BMI 29 - 38,93:50

    List1

    PACIENTRDATUMOPERATRDGOPERACESTRANAAS ZAS KASPORTYKONVERZEHOSP.JIPVKVKAVHABMINADVHADOBA SLHISTOLOGIESTAGINGGRADINGROZMER TuROZMR PrepKOMPLIKACE

    Mukov Marta38580102911/2/10SchmidtTu renisLESSsin10:3015:555:251073721.758929.12SvtlobunnT1a2251700

    Kov Miroslava48622426111/23/10SchmidtTu renisLESSsin9:1013:003:501075621.606927.01Onkocytom024900

    Je Vladimr3705017263/17/11SchmidtTu renisLESSsin8:5012:463:561073731.769430.32SvtlobunnT3a2451600

    Chrudimsk Alena5062011074/8/11SchmidtTu renisLESSdx8:5211:372:452073601.676724.01SvtlobunnT1a236950

    Blhov Zuzana4755201366/3/11SchmidtTu renisLESSsin8:4511:142:291062631.767624.51SvtlobunnT1a2201400

    Jenkov Nadda5060250418/18/11SchmidtTu renisLESSsin12:3016:334:031094611.628331.62SvtlobunnT1b265190revize

    Krlov Jana50592022010/3/11SchmidtTu renisLESSdx10:3013:453:151061611.646624.51SvtlobunnT1a2301200

    ttina Martin670625033112/1/11SchmidtTu renisLESSsin9:1014:285:181064441.7612038.72SvtlobunnT3250250

    Jank Miroslav54080510002/7/12SchmidtTu renisLESSsin11:1013:592:491054581.757524.50SvtlobunnT3a2501600

    Steda Marek75113006656/15/12SchmidtTu renisLESSdx9:0012:003:001054371.828926.91SvtlobunnT1a2291120

    Stank Alois4506141026/19/12SchmidtTu renisLESSsin9:1012:253:151061671.7510434.02SvtlobunnT1a1352100

    Roumbersk Adolf5311270458/15/12SchmidtTu renisLESSdx13:0016:143:141061591.8310130.22SvtlobunnT1a1402900

    Piskaov Markta656024079710/5/12SchmidtTu renisLESSdx10:1013:062:561054471.646423.80Papilrn 1T2a901500

    Bene Petr4611190919/7/12SchmidtTu renisLESS/NEdx8:5011:452:5540/183661.698730.52SvtlobunnT1b2481900

    Broov Jarmila3752020819/6/12ChocholatTu renisLESSsin9:1012:553:451091751.727124.01Papilrn 2T1a1301400

    Manek Ji4701161556/12/12BabjukTu renisLESSdx12:0014:352:3510108651.637026.31SvtlobunnT1a230145revize

    List2

    Mui BMIeny BMIoper.as

    -1PodvhaMen ne 20Men ne 19

    0Normln vha20 - 24,919 - 23,92:52

    1Mrn nadvha25 - 29,924 - 28,93:03

    2Obezita30 - 39,929 - 38,94:11

    3Tk obezitaVy ne 40Vy ne 39

    Graf2

    24.5351239669

    24.0238086701

    24.4897959184

    23.7953599048

    26.8687356599

    30.159156738

    24.5389649018

    33.9591836735

    26.953125

    30.3460743802

    31.6262764822

    38.7396694215

    29.0612244898

    operan as

    BMI

    BMI vs operan as

    List3

    PACIENTRDATUMOPERATRDGOPERACESTRANAAS ZAS KROZMER TuASROZMR PrepPORTYKONVERZEHOSP.JIPVKVKAVHABMINADVHADOBA SLHISTOLOGIESTAGINGGRADINGKOMPLIKACE

    Blhov Zuzana4755201366/3/11SchmidtTu renisLESSsin8:4511:14202:2924.51401062631.767624.51SvtlobunnT1a20

    Chrudimsk Alena5062011074/8/11SchmidtTu renisLESSdx8:5211:37362:4524.0952073601.676724.01SvtlobunnT1a20

    Jank Miroslav54080510002/7/12SchmidtTu renisLESSsin11:1013:59502:4924.51601054581.757524.50SvtlobunnT3a20

    Piskaov Markta656024079710/5/12SchmidtTu renisLESSdx10:1013:06902:5623.81501054471.646423.80Papilrn 1T2a0

    Steda Marek75113006656/15/12SchmidtTu renisLESSdx9:0012:00293:0026.91121054371.828926.91SvtlobunnT1a20

    Roumbersk Adolf5311270458/15/12SchmidtTu renisLESSdx13:0016:14403:1430.22901061591.8310130.22SvtlobunnT1a10

    Krlov Jana50592022010/3/11SchmidtTu renisLESSdx10:3013:45303:1524.51201061611.646624.51SvtlobunnT1a20

    Stank Alois4506141026/19/12SchmidtTu renisLESSsin9:1012:25353:1534.02101061671.7510434.02SvtlobunnT1a10

    Kov Miroslava48622426111/23/10SchmidtTu renisLESSsin9:1013:00243:5027.0901075621.606927.01Onkocytom00

    Je Vladimr3705017263/17/11SchmidtTu renisLESSsin8:5012:46453:5630.31601073731.769430.32SvtlobunnT3a20

    Jenkov Nadda5060250418/18/11SchmidtTu renisLESSsin12:3016:33654:0331.61901094611.628331.62SvtlobunnT1b2revize

    ttina Martin670625033112/1/11SchmidtTu renisLESSsin9:1014:28505:1838.72501064441.7612038.72SvtlobunnT32

    Mukov Marta38580102911/2/10SchmidtTu renisLESSsin10:3015:55255:2529.11701073721.758929.12SvtlobunnT1a20

    Graf1

    0.1034722222

    0.1145833333

    0.1173611111

    0.1222222222

    0.125

    0.1347222222

    0.1354166667

    0.1354166667

    0.1597222222

    0.1638888889

    0.16875

    0.2208333333

    0.2256944444

  • VVOJ OPERANCH VKON PRO KARCINOM LEDVINY

  • ZVRLESS NE je alternativn variantou konvenn lapNE pro pacienty sndory ledvin T1 T2, kter nejsou indikovny kzchovnmu vkonu.

    Jej zvldnut je mon u operatra se zkuenostmi sklasickou LNE bhem prvnch 5 vkonOperan as obou metod je po krtk learning curve srovnatelnKosmetick efekt operace je pacienty hodnocen kladn

    Peroperan morbiditu, morbiditu spojenou se zavdnm port a pooperan kvalitu ivota je nutn posoudit na vt skupin operovanch pacientOptimln pacient thl, mal rozmr ndoru, mal tukov pouzdro ledviny.

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