摘要
目的：本课题通过对行肾癌根治术的患者资料进行回顾性研究,利用Kaplan-Meier生存分析,二分类Logistic回归模型,COX回归模型等统计分析方法,探讨行肾癌根治术患者预后的可能影响因素。对比研究行后腹腔镜下肾癌根治术和行开放肾癌根治术的Ⅰ-Ⅱ期肾癌患者资料,分析其临床疗效,探讨后腹腔镜下肾癌根治术的优势。
方法：对2006年1月1日-2011年12月31日湘雅医院泌尿外科收治的290例行肾癌根治术的患者进行术后随访,并对随访得到的208例患者资料进行统计分析,对可能影响预后的因素,如患者的年龄、性别、血尿、腰痛、体检发现肿瘤、病程、吸烟、肥胖、术前合并症、肾肿瘤大小及位置、淋巴结转移、组织学分型、临床病理分期、术后治疗、体重改变等作为分析因子进行统计分析。
通过比较后腹腔镜手术组与开放手术组在患者年龄、性别、肿瘤位置、肿瘤大小、临床病理分期、组织学分型、手术时间、术中输血例数、肠道恢复通气时间、镇痛时间、术后并发症、术后住院时间、总费用、复发例数、死亡例数的差异,研究后腹腔镜肾癌根治术与开放肾癌根治术的临床疗效。
结果：
1.肾癌根治术后肿瘤复发研究,x2检验(P<0.05)结果显示年龄、性别、血尿、体检发现肿瘤、吸烟、临床病理分期、淋巴结转移是其影响因素。二分类Logistic回归模型分析显示年龄、血尿、吸烟、临床病理分期、淋巴结转移与肿瘤复发显著相关。
2.肾癌根治术后患者生存率计算,Kaplan-Meier生存分析结果示3个月、6个月、12个月、24个月、36个月、60个月及以上生存率分别为99.2%、98.5%、97.4%、94.1%、90.8%、86.8%。
3.肾癌根治术后患者生存率研究,单因素Log-rang检验筛选出年龄、血尿、体检发现肿瘤、吸烟、肿瘤大小、临床病理分期、淋巴结转移是影响因素。进一步COX模型分析,影响肾癌患者术后生存率的主要因素包括：年龄、血尿、吸烟、临床病理分期、淋巴结转移。
4.后腹腔镜与开放肾癌根治手术疗效比较：后腹腔镜与开放肾癌根治术在患者年龄、性别、肿瘤位置、肿瘤大小、组织学类型等方面差异无统计学意义。后腹腔镜组在及早恢复肠道通气并进食,减少术后镇痛时间,缩短术后住院时间等方面优于开放手术,并且具有统计学意义。而在手术时间、术中输血例数、术后并发症发生率、总费用、肿瘤复发率、死亡率等方面虽然与开放性手术组有差异但无统计学意义。
结论：1、年龄,血尿,吸烟,临床病理分期,淋巴结转移是肾癌根治术后患者肿瘤复发和生存率的主要影响因素。
2、后腹腔镜肾癌根治术是一种安全、有效治疗肾癌的先进方法,是治疗Ⅰ-Ⅱ期肾癌的首选方法。相较开放肾癌根治术,后腹腔镜下肾癌根治术能达到同样的治疗效果,但在缩短术后患者肠道通气时间,尽早进食,减少术后镇痛时间,缩短术后住院时间等方面优于开放手术,对患者恢复有利。
Objective:To explore the influencing factors of the prognosis of the renal cell carcinoma after radical nephrectomy with retrospective study.And to evaluate the clinical efficacy and safety of Laparoscopic Radical Nephrectomy (LRN) compared with Open Radical Nephrectomy(ORN).
Methods:The clinical data were obtained from290patients diagnosed with renal cell carcinoma and received radical nephrectomy from January1st2006to December30th2011. With the addition of telephone follow-up, we collected all the information of208patients about gender, age, hematuresis, lumbago, check up discoveries, course of disease, smoking, weight, basic disease, operation time, the size and position of the carcinoma,lymph node and distance metastasis,pathological gradation, tumor staging,immuno-therapy. Then all the data were processed respectively using the SPSS17.0analysis software. Survival rates were calculated by Kaplan-Meier, and COX regression many factors survival analysis model was used to analyze the relationship of the influencing factors and the prognosis.
We evaluated the role of the LRN in contrast to the ORN by analyzing the data of the age, gender, the size and the position of the carcinoma, pathological gradation staging, operation time,transfusion, time to recovery intestinal ventilation, the time of postoperative analgesia, postoperative complications, time of postoperative hospital stay, total cost, recurrence and death number.
Results:1. Chi-square test (P<0.05) showed gender, age, hematuresis, check up discoveries, smoking, tumor staging, lymph node metastasis were related with the prognosis of the tumor recurring;Logistic regression model shows age, hematuresis,smoking,tumor staging and lymph node metastasis are remarkably correlative with recurring;
2.The survival rates of patients who lived for3months,6months,1year,2years,3years,5years and more than5years after operation were99.2%,98.5%,97.4%,94.1%,90.8%,86.8%,respectively;
3. Log-rang test showed gender, age, hematuresis, check up discoveries, smoking, the size of the tumor,AJCC pathological staging, lymph node metastasis were related with the survival of the patients; Statistical analysis using COX regression model presented that the main dangerous influencing factors of survival were age, hematuresis, smoking, tumor staging and lymph node metastasis.
4.There are no significant difference between LRN and ORN in the gender,the age,the size and the position of the tumor, the total cost, the rates of the recurrence and the death, There are statistically significant difference in the time of recovering intestinal ventilation,postoperative analgesia and postoperative hospital stay.In conclusion, the laparoscopic approach was more minimally invasive than the open approach in management the renal lesions.
Conclusions:
1.Age, hematuresis, smoking, pathological staging, lymph node metastasis are the most remarkable factors with the prognosis of the renal carcinoma after radical nephrectomy;
2.LRN is a safe and effective new "gold standard" for the surgical treatment of I-II stage renal cell carcinoma. It's more minimally invasive than the open approach in management the renal lesions.
引文
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