单中心肾门部肿瘤行肾部分切除术经验总结
|
摘要
目的:总结肾门部肿瘤行肾部分切除术的手术经验,探讨肾部分切除术治疗肾门部肿瘤的可行性及相关技术难点。方法:回顾性分析2014年6月～2016年6月我院行肾部分切除术的66例肾门部肿瘤患者临床资料,其中男38例,女28例,平均年龄(52.6±11.0)岁,平均肿瘤最大径为(4.0±1.8)cm,平均R.E.N.A.L.评分为(9.1±1.3),美国麻醉医师协会(ASA)评分为(1.8±0.4)分。分析手术时间、肾动脉阻断时间、术中估计出血量、手术并发症发生率、手术切缘阳性率、术后病理结果及肾功能变化等指标。结果:所有手术均成功完成,其中行开放手术12例,行腹腔镜手术18例,行机器人手术36例,无一例中转根治,无切缘阳性。患者平均手术时间为(208.8±62.0)min、平均阻断时间为(24.0±8.4)min、平均术中出血量为(147.8±97.7)ml,术后1周肾小球滤过率(eGFR)下降率11.1%。其中1例术中出血1 000ml,输血后治愈,另有3例因尿漏延长放置负压引流管放置时间。术后病理示:透明细胞癌47例、血管平滑肌脂肪瘤7例、嫌色细胞癌6例、乳头状肾细胞癌2例,嗜酸细胞腺瘤、TFE-3基因融合相关肾癌、梭形细胞癌、单纯性囊肿各1例。66例患者均获得随访,随访时间24～48个月,期间均无瘤生存。结论:对于有经验术者,行肾门部肿瘤肾部分切除术出血等并发症发生率低,围术期肾功能变化小,未见肿瘤复发转移,提示手术安全可行,但其远期疗效仍需进一步研究。
Objective:To summarize the experience of partial nephrectomy for hilar tumors and to discuss the feasibility and technical difficulties of partial nephrectomy for hilar tumors.Method:The clinical data of 66 patients with hilar tumors who underwent partial nephrectomy in our center from June 2014 to June 2016 were retrospectively analyzed,including 38 males and 28 females,with an average age of(52.6±11.0)years old,maximum diameter of(4.0±1.8)cm,R.E.N.A.L.score of(9.1±1.3),and ASA score of(1.8±0.4).The operation time,warm ischemia time,estimated blood loss,incidence of complications,positive rate of surgical margin,pathological results and change rate of renal function were carefully collected and analyzed.Result:All operations were successfully completed,including 12 open operations,18 laparoscopic operations and 36 robotic operations.None of them was converted to radical nephrectomy and no margin of incision was positive.The mean operation time,warm ischemia time and estimated blood loss were(208.8±62.0)min,(24.0±8.4)min and(147.8±97.7)ml respectively.The glomerular filtration rate(eGFR)decreased by 11.1% one week after operation.One case bled 1 000 ml during operation and was treated with blood transfusion.Another 3 cases had prolonged negative pressure drainage tube placement due to urinary leakage.Postoperative pathology showed:among all the cases,there were 47 cases of clear cell carcinoma,7 cases of angiomyolipoma,6 cases of chromophobe cell carcinoma,2 cases of papillary cell carcinoma,1 case of eosinophilic adenoma,1 case of TFE-3 gene fusion associated renal cell carcinoma,1 case of spindle cell carcinoma and 1 case of simple cyst.All of 66 patients were followed up for 24 to 48 months,and they all survived without tumor recurrence during the follow-up period.Conclusion:For experienced surgeons,the incidence of complications such as hemorrhage after partial nephrectomy for hilar tumors and change rate of perioperative renal function were low,and no recurrence or metastasis was found,suggesting that such operations are safe and feasible,but its long-term efficacy still needs further study.
Objective:To summarize the experience of partial nephrectomy for hilar tumors and to discuss the feasibility and technical difficulties of partial nephrectomy for hilar tumors.Method:The clinical data of 66 patients with hilar tumors who underwent partial nephrectomy in our center from June 2014 to June 2016 were retrospectively analyzed,including 38 males and 28 females,with an average age of(52.6±11.0)years old,maximum diameter of(4.0±1.8)cm,R.E.N.A.L.score of(9.1±1.3),and ASA score of(1.8±0.4).The operation time,warm ischemia time,estimated blood loss,incidence of complications,positive rate of surgical margin,pathological results and change rate of renal function were carefully collected and analyzed.Result:All operations were successfully completed,including 12 open operations,18 laparoscopic operations and 36 robotic operations.None of them was converted to radical nephrectomy and no margin of incision was positive.The mean operation time,warm ischemia time and estimated blood loss were(208.8±62.0)min,(24.0±8.4)min and(147.8±97.7)ml respectively.The glomerular filtration rate(eGFR)decreased by 11.1% one week after operation.One case bled 1 000 ml during operation and was treated with blood transfusion.Another 3 cases had prolonged negative pressure drainage tube placement due to urinary leakage.Postoperative pathology showed:among all the cases,there were 47 cases of clear cell carcinoma,7 cases of angiomyolipoma,6 cases of chromophobe cell carcinoma,2 cases of papillary cell carcinoma,1 case of eosinophilic adenoma,1 case of TFE-3 gene fusion associated renal cell carcinoma,1 case of spindle cell carcinoma and 1 case of simple cyst.All of 66 patients were followed up for 24 to 48 months,and they all survived without tumor recurrence during the follow-up period.Conclusion:For experienced surgeons,the incidence of complications such as hemorrhage after partial nephrectomy for hilar tumors and change rate of perioperative renal function were low,and no recurrence or metastasis was found,suggesting that such operations are safe and feasible,but its long-term efficacy still needs further study.
引文
1 Lattouf J B,Beri A,DAmbros O F,et al.Laparoscopic partial nephrectomy for hilar tumors:technique and results[J].Eur Urol,2008,54(2):409-416.
2 Lee H,Oh J J,Byun S S,et al.Can partial nephrectomy provide equal oncological efficiency and safety compared with radical nephrectomy in patients with renal cell carcinoma(≥4cm)?A propensity score-matched study[J].Urol Oncol,2017,35(6):379-385.
3吴震杰,王坚超,刘承宗,等.区域血流荧光可视化成像在机器人肾部分切除术中的初步应用体会[J].中华泌尿外科杂志,2017,38(7):489-492.
4时佳子,刘冰,吴震杰,等.腹腔镜肾部分切除手术技巧探讨[J].临床泌尿外科杂志,2017,32(8):642-644.
5 Garisto J,Bertolo R,Dagenais J,et al.Robotic versus open partial nephrectomy for highly complex renal masses:Comparison of perioperative,functional,and oncological outcomes[J].Urol Oncol,2018,36(10):471.e1-471.e9.
6时佳子,吴震杰,鲍一,等.单术者机器人辅助腹腔镜肾部分切除术学习曲线分析[J].临床泌尿外科杂志,2017,32(8):589-591.
7 Dulabon L M,Kaouk J H,Haber G P,et al.Multi-institutional analysis of robotic partial nephrectomy for hilar versus nonhilar lesions in 446consecutive cases[J].Eur Urol,2011,59(3):325-330.
8 Di Pierro G B,Tartaglia N,Aresu L,et al.Laparoscopic partial nephrectomy for endophytic hilar tumors:feasibility and outcomes[J].Eur J Surg Oncol,2014,40(6):769-774.
9 Gill I S,Colombo J R Jr,Frank I,et al.Laparoscopic partial nephrectomy for hilar tumors[J]J Urol,2005,174(3):850-853;discussion 853-854.
10许晖阳,莫承强,王宗任,等.机器人辅助腹腔镜下肾部分切除术的短期疗效分析(附22例报告)[J].临床泌尿外科杂志,2017,32(5):335-338.
11过菲,杨波,杨庆,等.“蛙跳式”选择性肾动脉阻断法在腹腔镜保留肾单位手术中的应用[J].第二军医大学学报,2016,37(2):133-137.
12 Erdem S,Tefik T,Mammadov A,et al.The use of selfretaining barbed suture for inner layer renorrhaphy significantly reduces warm ischemia time in laparoscopic partial nephrectomy:outcomes of a matched-pair analysis[J].J Endourol,2013,27(4):452-458.
13张崔建,曹剑哲,李学松,等.切缘环形缝合技术在肾部分切除术中的应用效果[J].中华外科杂志,2015,53(11):852-855.
14 Eyraud R,Long J A,Snow-Lisy D,et al.Robot-assisted partial nephrectomy for hilar tumors:perioperative outcomes[J].Urology,2013,81(6):1246-1251.
2 Lee H,Oh J J,Byun S S,et al.Can partial nephrectomy provide equal oncological efficiency and safety compared with radical nephrectomy in patients with renal cell carcinoma(≥4cm)?A propensity score-matched study[J].Urol Oncol,2017,35(6):379-385.
3吴震杰,王坚超,刘承宗,等.区域血流荧光可视化成像在机器人肾部分切除术中的初步应用体会[J].中华泌尿外科杂志,2017,38(7):489-492.
4时佳子,刘冰,吴震杰,等.腹腔镜肾部分切除手术技巧探讨[J].临床泌尿外科杂志,2017,32(8):642-644.
5 Garisto J,Bertolo R,Dagenais J,et al.Robotic versus open partial nephrectomy for highly complex renal masses:Comparison of perioperative,functional,and oncological outcomes[J].Urol Oncol,2018,36(10):471.e1-471.e9.
6时佳子,吴震杰,鲍一,等.单术者机器人辅助腹腔镜肾部分切除术学习曲线分析[J].临床泌尿外科杂志,2017,32(8):589-591.
7 Dulabon L M,Kaouk J H,Haber G P,et al.Multi-institutional analysis of robotic partial nephrectomy for hilar versus nonhilar lesions in 446consecutive cases[J].Eur Urol,2011,59(3):325-330.
8 Di Pierro G B,Tartaglia N,Aresu L,et al.Laparoscopic partial nephrectomy for endophytic hilar tumors:feasibility and outcomes[J].Eur J Surg Oncol,2014,40(6):769-774.
9 Gill I S,Colombo J R Jr,Frank I,et al.Laparoscopic partial nephrectomy for hilar tumors[J]J Urol,2005,174(3):850-853;discussion 853-854.
10许晖阳,莫承强,王宗任,等.机器人辅助腹腔镜下肾部分切除术的短期疗效分析(附22例报告)[J].临床泌尿外科杂志,2017,32(5):335-338.
11过菲,杨波,杨庆,等.“蛙跳式”选择性肾动脉阻断法在腹腔镜保留肾单位手术中的应用[J].第二军医大学学报,2016,37(2):133-137.
12 Erdem S,Tefik T,Mammadov A,et al.The use of selfretaining barbed suture for inner layer renorrhaphy significantly reduces warm ischemia time in laparoscopic partial nephrectomy:outcomes of a matched-pair analysis[J].J Endourol,2013,27(4):452-458.
13张崔建,曹剑哲,李学松,等.切缘环形缝合技术在肾部分切除术中的应用效果[J].中华外科杂志,2015,53(11):852-855.
14 Eyraud R,Long J A,Snow-Lisy D,et al.Robot-assisted partial nephrectomy for hilar tumors:perioperative outcomes[J].Urology,2013,81(6):1246-1251.