腹腔镜肾部分切除术治疗T1a期肾细胞癌
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摘要
目的探讨腹腔镜肾部分切除术(laparoscopic partial nephrectomy,LPN)在T1a期肾细胞癌治疗中的临床价值。方法 2009年1月～2017年9月我科对119例T1a期肾癌在腹腔镜下经腹膜后肾动脉阻断下行肾部分切除术。结果手术均顺利完成,3例因术中出血、2例因肿瘤位置暴露困难中转开放手术。手术时间59～236 min,(112. 6±16. 2) min;肾缺血时间19～43 min,(28. 6±9. 2) min。术中出血20～137 ml,(74. 7±41. 5) ml。术后引流管留置时间2～11 d,(4. 2±1. 2) d。术后继发性出血11例,经止血、卧床后好转;尿漏2例,半卧位、延长引流管留置时间好转;切口感染2例,通畅引流加强换药后愈合。术后病理:肾透明细胞癌87例,乳头状肾细胞癌24例,囊性肾细胞癌2例,肾嫌色细胞癌2例,未分类肾细胞癌4例;3例手术切缘阳性。83例随访6～31个月,中位随访时间12个月,复发2例,2例切缘阳性者1例术后17个月因车祸死亡,1例术后12个月肾上腺转移,经沟通后采取靶向药物治疗。结论 LPN治疗T1a期肾脏恶性肿瘤具有创伤小、恢复快等优势,能提高手术的安全性。
Objective To evaluate the clinical value of laparoscopic partial nephrectomy(LPN) in the treatment of T1 a stage renal cell carcinoma. Methods From January 2009 to September 2017,119 cases of T1 a stage renal carcinoma received LPN under retroperitoneal renal artery occlusion. Results The operations were successfully performed in all the cases. Conversion to open surgery was required in 3 cases of intraoperative bleeding and 2 cases of difficulty of exposure to tumor location. The operation time was59-236 min( mean,112.6 ± 16.2 min). The renal ischemic time was 19-43 min(mean,28. 6 ± 9. 2 min). The intraoperative blood loss was 20-137 ml(mean,74. 7 ± 41. 5 ml). The postoperative indwelling time of drainage was 2-11 d( mean,4.2 ±1.2 d). There were 11 cases of secondary bleeding,which were improved after hemostasis and bed rest,2 cases of urinary leakage,which were improved after half-lying position and prolonged drainage tube retention,and 2 cases of incision infection,which healed after unimpeded drainage and dressing change. Postoperative pathological results showed 87 cases of renal clear cell carcinoma,24 cases of papillary renal cell carcinoma,2 cases of cystic renal cell carcinoma,2 cases of chromophobe renal cell carcinoma,and 4 cases of unclassified renal cell carcinoma. Positive surgical margin was seen in 3 cases. Follow-ups for 6-31 months(median,12 months) in 83 cases found 2 cases of recurrence. Of 2 patients with positive surgical margin,one died of traffic accident at 17 months after operation and the other developed adrenal metastasis at 12 months after operation and was given targeted therapy after informed consent. Conclusion With the advantages of less trauma and faster recovery,LPN can improve the safety of treatment for T1 a stage renal malignant tumor.
Objective To evaluate the clinical value of laparoscopic partial nephrectomy(LPN) in the treatment of T1 a stage renal cell carcinoma. Methods From January 2009 to September 2017,119 cases of T1 a stage renal carcinoma received LPN under retroperitoneal renal artery occlusion. Results The operations were successfully performed in all the cases. Conversion to open surgery was required in 3 cases of intraoperative bleeding and 2 cases of difficulty of exposure to tumor location. The operation time was59-236 min( mean,112.6 ± 16.2 min). The renal ischemic time was 19-43 min(mean,28. 6 ± 9. 2 min). The intraoperative blood loss was 20-137 ml(mean,74. 7 ± 41. 5 ml). The postoperative indwelling time of drainage was 2-11 d( mean,4.2 ±1.2 d). There were 11 cases of secondary bleeding,which were improved after hemostasis and bed rest,2 cases of urinary leakage,which were improved after half-lying position and prolonged drainage tube retention,and 2 cases of incision infection,which healed after unimpeded drainage and dressing change. Postoperative pathological results showed 87 cases of renal clear cell carcinoma,24 cases of papillary renal cell carcinoma,2 cases of cystic renal cell carcinoma,2 cases of chromophobe renal cell carcinoma,and 4 cases of unclassified renal cell carcinoma. Positive surgical margin was seen in 3 cases. Follow-ups for 6-31 months(median,12 months) in 83 cases found 2 cases of recurrence. Of 2 patients with positive surgical margin,one died of traffic accident at 17 months after operation and the other developed adrenal metastasis at 12 months after operation and was given targeted therapy after informed consent. Conclusion With the advantages of less trauma and faster recovery,LPN can improve the safety of treatment for T1 a stage renal malignant tumor.
引文
1李鸣,何志嵩,高江平,等.多中心肾癌临床特征分析.中华泌尿外科杂志,2010,31(2):77-80.
2 邢念增,王明帅.高选择性肾动脉分支阻断术在腹腔镜肾部分切除术中的应用.中华医学杂志,2012,92(18):1275-1277.
3 Jewett MA,Mattar K,Basiuk J,et al. Active surveillance of small renal masses:progression patterns of early stage kidney cancer. Eur Urol,2011,60(1):39-44.
4 Klatte T, Shariat SF, Remzi M. Systematic review and metaanalysis of perioperative and oncologic outcomes of laparoscopic cryoablation versus laparoscopic partial nephrectomy for the treatment of small renal tumors. J Urol,2014,191(5):1209-1217.
5 吴肖冰,张古田,张帆,等.肾部分切除术治疗孤立肾肾癌的安全性和疗效分析.中华外科杂志,2016,54(10):746-750.
6 吴旭红,郭宏骞.解剖性零缺血肾部分切除术及术后肾功能.东南大学学报(医学版),2014,33(4):527-530.
7 Rezaeetalab GH,Karami H,Dadkhah F,et al. Laparoscopic versus open partial nephrectomy for stage T1a of renal tumors. Urol J,2016,13(6):2903-2907.
8 Lane BR,Campbell SC,Gill IS. 10-year oncologic outcomes after laparoscopic and open partial nephrectomy. J Urol,2013,190(1):44-49.
9 曹靖,陈文军,甲明,等.热缺血时间对腹腔镜下肾部分切除术后早期肾功能的影响分析.中华泌尿外科杂志,2015,36(6):414-418.
10 Ramirez D,Caputo PA,Krishnan J,et al. Robot-assisted partial nephrectomy with intracorporeal renal hypothermia using ice slush:step-by-step technique and matched comparison with warm ischaemia. BJU Int,2016,117(3):531-536.
11 马超光,闫成智. 3D腹腔镜肾部分切除术治疗肾肿瘤(附11例报告).中国微创外科杂志,2017,17(8):704-713.
12 董洪超,王勤章,丁国富,等. T1b期肾癌患者经后腹腔镜肾部分切除术后的分肾功能分析.现代泌尿外科杂志,2017,22(3):181-184.
13 吴斌,张峰.单极电凝免缝合技术在腹腔镜肾部分切除术中初步应用.中华医学杂志,2016,96(48):3885-3887.
14 Hua X,Ying-Ying C,Zu-Jun F,et al. Obesity,hypertension and diabetes mellitus affect complication rate of different nephrectomy techniques. Actas Urol Esp,2014,38(10):640-646.
15 庄永江,蔡超,张辉见,等. Ro SCo评分系统在腹腔镜肾部分切除术中的运用.实用医学杂志,2017,33(7):1109-1112.
16 Isac WE,Autorino R,Hillyer SP,et al. The impact of body mass index on surgical outcomes of robotic partial nephrectomy. BJU Int,2012,110(11 Pt C):E997-E1002.
17 Davidiuk AJ, Parker AS, Thomas CS, et al. Mayo adhesive probability score:an accurate image-based scoring system to predict adherent perinephric fat in partial nephrectomy. Eur Urol,2014,66(6):1165-1171.
2 邢念增,王明帅.高选择性肾动脉分支阻断术在腹腔镜肾部分切除术中的应用.中华医学杂志,2012,92(18):1275-1277.
3 Jewett MA,Mattar K,Basiuk J,et al. Active surveillance of small renal masses:progression patterns of early stage kidney cancer. Eur Urol,2011,60(1):39-44.
4 Klatte T, Shariat SF, Remzi M. Systematic review and metaanalysis of perioperative and oncologic outcomes of laparoscopic cryoablation versus laparoscopic partial nephrectomy for the treatment of small renal tumors. J Urol,2014,191(5):1209-1217.
5 吴肖冰,张古田,张帆,等.肾部分切除术治疗孤立肾肾癌的安全性和疗效分析.中华外科杂志,2016,54(10):746-750.
6 吴旭红,郭宏骞.解剖性零缺血肾部分切除术及术后肾功能.东南大学学报(医学版),2014,33(4):527-530.
7 Rezaeetalab GH,Karami H,Dadkhah F,et al. Laparoscopic versus open partial nephrectomy for stage T1a of renal tumors. Urol J,2016,13(6):2903-2907.
8 Lane BR,Campbell SC,Gill IS. 10-year oncologic outcomes after laparoscopic and open partial nephrectomy. J Urol,2013,190(1):44-49.
9 曹靖,陈文军,甲明,等.热缺血时间对腹腔镜下肾部分切除术后早期肾功能的影响分析.中华泌尿外科杂志,2015,36(6):414-418.
10 Ramirez D,Caputo PA,Krishnan J,et al. Robot-assisted partial nephrectomy with intracorporeal renal hypothermia using ice slush:step-by-step technique and matched comparison with warm ischaemia. BJU Int,2016,117(3):531-536.
11 马超光,闫成智. 3D腹腔镜肾部分切除术治疗肾肿瘤(附11例报告).中国微创外科杂志,2017,17(8):704-713.
12 董洪超,王勤章,丁国富,等. T1b期肾癌患者经后腹腔镜肾部分切除术后的分肾功能分析.现代泌尿外科杂志,2017,22(3):181-184.
13 吴斌,张峰.单极电凝免缝合技术在腹腔镜肾部分切除术中初步应用.中华医学杂志,2016,96(48):3885-3887.
14 Hua X,Ying-Ying C,Zu-Jun F,et al. Obesity,hypertension and diabetes mellitus affect complication rate of different nephrectomy techniques. Actas Urol Esp,2014,38(10):640-646.
15 庄永江,蔡超,张辉见,等. Ro SCo评分系统在腹腔镜肾部分切除术中的运用.实用医学杂志,2017,33(7):1109-1112.
16 Isac WE,Autorino R,Hillyer SP,et al. The impact of body mass index on surgical outcomes of robotic partial nephrectomy. BJU Int,2012,110(11 Pt C):E997-E1002.
17 Davidiuk AJ, Parker AS, Thomas CS, et al. Mayo adhesive probability score:an accurate image-based scoring system to predict adherent perinephric fat in partial nephrectomy. Eur Urol,2014,66(6):1165-1171.