适合腹腔镜保留肾单位手术治疗Tla期肾癌的CT评估
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摘要
探讨MSCT在肾癌LNSS术前评估中的应用价值,为临床在术前合理的选择手术适应证及制定手术方案提供更多、更有价值的信息。本文收集经术后病理证实为T1a期肾癌患者共40例,术前病人均行64层螺旋CT三期增强扫描,检查后图像传到工作站,将各时相数据分别进行多平面图像重组(MPR)、最大密度投影(MIP)、容积再现法(VR)处理。通过观察原始轴位图像、VR、MIP及MPR重建图像评估患侧肾脏的血管解剖结构、肾肿瘤相关情况(大小、位置、侵入肾实质深度、与周围血管及集合系统的毗邻关系)及对侧肾脏的相关情况(大体解剖、功能状态及合并疾病情况),并与术中所见及(或)大体病理结果进行对照性研究。结果表明,重建后均获得了质量满意的图像,MSCT能够准确显示患肾血管的解剖结构,对于副肾动脉、肾动脉提前分支解剖变异能准确显示其数量、位置、走行、分布及其与周围结构的毗邻关系等;MSCT能够准确显示肾肿瘤的大小、位置、侵入肾实质的深度、与周围血管及集合系统的毗邻关系;MSCT能够准确评估对侧肾脏肾缺如等先天变异及解剖性孤立肾,能够准确诊断对侧肾脏同时合并的肾癌、肾结石、肾动脉狭窄、肾囊肿等疾病,对于对侧肾脏的功能状态评估能够起到补充、筛查的作用。研究认为,MSCT能够对肾癌LNSS术前进行全面综合评估,对指导临床医生合理的选择手术适应证,准确的评估手术难度,制定详实的手术方案具有很高的临床应用价值。
Kidney cancer, also known as renal cell carcinoma (RCC), is the most common malignant tumor of adult kidneys. Surgery operation is the one of the primary means of treating renal cell carcinoma,and it is also the only way to cure kidney cancer. As a kind of mini-invasive surgery, with the advantage of less trauma and fewer complications, laparoscopic nephron sparing surgery (LNSS) can miximize to protect the kidney. Thus, it has been recognized by the urology field and widely applied in the clinical operations. Because LNSS for renal cell carcinoma is complex and difficult to handle, it is required to have accurate preoperative evaluation. However, traditional imaging methods in the application of LNSS preoperative evaluation have some limitations. MSCT can continuously collect data within a certain volume at a fast speed, and then conduct a variety of 3D post-processing based on the volume data. Therefore, the evaluation can be done by MSCT about anatomical structure of kidney vessels, kidney tumor and contralateral kidney. However, most domestic literatures are concentrated on the assessment of renal vascular anatomy, only a few are involved in the research of comprehensive Preoperative evaluation.
Objective: studying the practical application of MSCT to the preoperative evaluation in laparoscopic nephron sparing surgery for renal cell carcinoma, and providing much more valuable information for choosing the appropriate clinical plans and taking the responding surgical measures.
Subjects and Methods: Triphasic spiral CT scan was performed on 40 patients(including: 25 males and 15 females;range of age: 7~82 years old; average age: 57.2 years old)who have pathologically turned out to suffer from renal cell carcinoma at T1a stage during the period from June, 2009 to January, 2011. The subjects included 37 patients suffering from clear cell carcinoma RCC, 2 from papillary RCC, 1 from multilocular cystic RCC, 19 from Left kidney cancer, and 21 from right kidney cancer.
All subjects had experienced the enhanced preoperative MSCT examination before the radical nephrectomy by the Siemens 64-slice spiral CT. And all of them had fasted for 6-8 hours before the examination and been scanned by taking the supine posture. The scan was done at one time during the period from the inhale to breath-hold, ranging from the top of the diaphragm to the iliac crest level. The venous channel was established through the antecubital vein by means of non-ionic contrast media ultavist or omnipaque, whose iodine content is 300mg/l and total dose is 80-100ml, and then was injected by automatic high pressure injector at a speed of 4.0ml/s. The data recorded after injection for cortical phase, parenchymal phase, renal pelvis secretory phase were respectively 29s、64s and 180s. The slice thickness was 5mm, and slice distance was also 5mm. The original scanning data was reconstructed with 1mm thickness and transmitted to the workstation (ADW4.2), and then conducted the post-processing of multiplanar reconstruction (MPR), maximum intensity projection (MIP), volume rendering (VR) . Through the axial images and a variety of post-processing images,the assessment indicators of Kidney cancer patients were observed: vascular anatomy of the kidney, kidney tumor-related conditions (size, location, depth of invasion of renal parenchyma, the syntagmatic relations between renal collecting system and the surrounding blood vessels.etc) and the contralateral kidney-related conditions (gross anatomy, functional state and comorbidities situations. etc). MSCT evaluation index data were compared with the data seen from general surgery and pathology in the operation, and were analyzed statistically by SPSS11.5 statistical analysis software. The paper aims at evaluating the consistency between the MSCT evaluation and the results from the corresponding gross pathology after operation and (or) from the surgery operation.
Results: Firstly, after MSCT assessment on vascular anatomy to all the kidneys was compared with the intraoperative findings one by one in detail, MSCT evaluation was completely consistent with the intraoperative findings, and the accuracy was 100%. Total variance rate of renal artery anatomy was 62.5%. Secondly, MSCT measurements of tumor size were respectivley compared with the measured data from gross pathology, and conducted the statistical analysis by paired“t”test. The result was P > 0.05, indicating that the MSCT measurements and pathologic measurements were no statistical difference. MSCT assessments on tumor location were compared with gross pathology specimens and intraoperative findings, MSCT findings and the gross pathology specimens and intraoperative findings were exactly consistent, and the accuracy was 100%. MSCT assessments teams on the depth of tumor invasion of renal parenchyma, and on the syntagmatic relations betweeen the surrounding blood vessels and renal collecting system, were compared with group findings from gross pathology specimens and (or) from surgery operation. The statistics showed that the corresponding results were quite consistent (Kappa =0.949,0.872, 0.936) . Thirdly, the general anatomy of the contralateral kidney: One case in the research was found suffering from RCC in lower pole of right kidney and absent left kidney by MSCT enhanced examination. The other cases had no clear abnormalities and congenital variations in the CT gross anatomy examination on contralateral kidney, and the results were conformed to other relevant examination. The functional state of the contralateral kidney: Three cases were found abnormal in size, shape and degree of enhancement. In them, the first one was found that the contralateral kidney was obviously atrophic and small and its degree of enhancement was reduced. The second was found that the shape of kidney was irregular with multiple patchy low-density enhancement area, and its degree of enhancement was significantly uneven. The third was found that degree of enhancement was apparently reduced with the renal accumulation of water. The rest cases had no abnormalities in size, shape and degree of enhancement by CT examination. However, three of them were found suffering from mild renal impairment by other comprehensive examination. Therefore, the accuracy of CT examination in examining renal function abnormal was only 50% in this research. Contralateral kidney combined with diseases: In the 39 contralateral kidneys (one of them was conducted radical nephrectomy due to renal cell carcinoma), 17 were not found other diseases. 22 were comined with one or several diseases: mainly with the renal cyst (16 cases), kidney calculi (5 cases), renal artery calcification (6 cases), renal artery stenosis (2 cases), and hydronephrosis (1 case), etc.
Conclusion: As a non-invasive,comprehensive, efficient and accurate imaging method, MSCT can combine the fast volume scanning with intravenous injection of contrast agent and the computer-aided image post-processing. With the“one-stop”examination, MSCT can conduct a comprehensive evaluation for preoperative laparoscopic nephron sparing surgery. It has high clinical value to guide doctors in making the appropriate choice for clinical surgical indications, assessing accurately the difficult of operation, and laying the detailed and feasible operational plan.
Kidney cancer, also known as renal cell carcinoma (RCC), is the most common malignant tumor of adult kidneys. Surgery operation is the one of the primary means of treating renal cell carcinoma,and it is also the only way to cure kidney cancer. As a kind of mini-invasive surgery, with the advantage of less trauma and fewer complications, laparoscopic nephron sparing surgery (LNSS) can miximize to protect the kidney. Thus, it has been recognized by the urology field and widely applied in the clinical operations. Because LNSS for renal cell carcinoma is complex and difficult to handle, it is required to have accurate preoperative evaluation. However, traditional imaging methods in the application of LNSS preoperative evaluation have some limitations. MSCT can continuously collect data within a certain volume at a fast speed, and then conduct a variety of 3D post-processing based on the volume data. Therefore, the evaluation can be done by MSCT about anatomical structure of kidney vessels, kidney tumor and contralateral kidney. However, most domestic literatures are concentrated on the assessment of renal vascular anatomy, only a few are involved in the research of comprehensive Preoperative evaluation.
Objective: studying the practical application of MSCT to the preoperative evaluation in laparoscopic nephron sparing surgery for renal cell carcinoma, and providing much more valuable information for choosing the appropriate clinical plans and taking the responding surgical measures.
Subjects and Methods: Triphasic spiral CT scan was performed on 40 patients(including: 25 males and 15 females;range of age: 7~82 years old; average age: 57.2 years old)who have pathologically turned out to suffer from renal cell carcinoma at T1a stage during the period from June, 2009 to January, 2011. The subjects included 37 patients suffering from clear cell carcinoma RCC, 2 from papillary RCC, 1 from multilocular cystic RCC, 19 from Left kidney cancer, and 21 from right kidney cancer.
All subjects had experienced the enhanced preoperative MSCT examination before the radical nephrectomy by the Siemens 64-slice spiral CT. And all of them had fasted for 6-8 hours before the examination and been scanned by taking the supine posture. The scan was done at one time during the period from the inhale to breath-hold, ranging from the top of the diaphragm to the iliac crest level. The venous channel was established through the antecubital vein by means of non-ionic contrast media ultavist or omnipaque, whose iodine content is 300mg/l and total dose is 80-100ml, and then was injected by automatic high pressure injector at a speed of 4.0ml/s. The data recorded after injection for cortical phase, parenchymal phase, renal pelvis secretory phase were respectively 29s、64s and 180s. The slice thickness was 5mm, and slice distance was also 5mm. The original scanning data was reconstructed with 1mm thickness and transmitted to the workstation (ADW4.2), and then conducted the post-processing of multiplanar reconstruction (MPR), maximum intensity projection (MIP), volume rendering (VR) . Through the axial images and a variety of post-processing images,the assessment indicators of Kidney cancer patients were observed: vascular anatomy of the kidney, kidney tumor-related conditions (size, location, depth of invasion of renal parenchyma, the syntagmatic relations between renal collecting system and the surrounding blood vessels.etc) and the contralateral kidney-related conditions (gross anatomy, functional state and comorbidities situations. etc). MSCT evaluation index data were compared with the data seen from general surgery and pathology in the operation, and were analyzed statistically by SPSS11.5 statistical analysis software. The paper aims at evaluating the consistency between the MSCT evaluation and the results from the corresponding gross pathology after operation and (or) from the surgery operation.
Results: Firstly, after MSCT assessment on vascular anatomy to all the kidneys was compared with the intraoperative findings one by one in detail, MSCT evaluation was completely consistent with the intraoperative findings, and the accuracy was 100%. Total variance rate of renal artery anatomy was 62.5%. Secondly, MSCT measurements of tumor size were respectivley compared with the measured data from gross pathology, and conducted the statistical analysis by paired“t”test. The result was P > 0.05, indicating that the MSCT measurements and pathologic measurements were no statistical difference. MSCT assessments on tumor location were compared with gross pathology specimens and intraoperative findings, MSCT findings and the gross pathology specimens and intraoperative findings were exactly consistent, and the accuracy was 100%. MSCT assessments teams on the depth of tumor invasion of renal parenchyma, and on the syntagmatic relations betweeen the surrounding blood vessels and renal collecting system, were compared with group findings from gross pathology specimens and (or) from surgery operation. The statistics showed that the corresponding results were quite consistent (Kappa =0.949,0.872, 0.936) . Thirdly, the general anatomy of the contralateral kidney: One case in the research was found suffering from RCC in lower pole of right kidney and absent left kidney by MSCT enhanced examination. The other cases had no clear abnormalities and congenital variations in the CT gross anatomy examination on contralateral kidney, and the results were conformed to other relevant examination. The functional state of the contralateral kidney: Three cases were found abnormal in size, shape and degree of enhancement. In them, the first one was found that the contralateral kidney was obviously atrophic and small and its degree of enhancement was reduced. The second was found that the shape of kidney was irregular with multiple patchy low-density enhancement area, and its degree of enhancement was significantly uneven. The third was found that degree of enhancement was apparently reduced with the renal accumulation of water. The rest cases had no abnormalities in size, shape and degree of enhancement by CT examination. However, three of them were found suffering from mild renal impairment by other comprehensive examination. Therefore, the accuracy of CT examination in examining renal function abnormal was only 50% in this research. Contralateral kidney combined with diseases: In the 39 contralateral kidneys (one of them was conducted radical nephrectomy due to renal cell carcinoma), 17 were not found other diseases. 22 were comined with one or several diseases: mainly with the renal cyst (16 cases), kidney calculi (5 cases), renal artery calcification (6 cases), renal artery stenosis (2 cases), and hydronephrosis (1 case), etc.
Conclusion: As a non-invasive,comprehensive, efficient and accurate imaging method, MSCT can combine the fast volume scanning with intravenous injection of contrast agent and the computer-aided image post-processing. With the“one-stop”examination, MSCT can conduct a comprehensive evaluation for preoperative laparoscopic nephron sparing surgery. It has high clinical value to guide doctors in making the appropriate choice for clinical surgical indications, assessing accurately the difficult of operation, and laying the detailed and feasible operational plan.
引文
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[2]那彦群,孙光.中国泌尿外科疾病诊断治疗指南[M].2009版.北京:人民卫生出版社,2009,5-8.
[3]Eble JN,Sauter G,Epstein JI,et al.World health organization classification of tumours.Pathology & genetics.Tumours of the urinary system and male genital organs [M].Lyon:IARC Press,2004.9-43.
[4]Robson CJ.Radical nephrectomy for renal cell carcinoma[J].Jurol,1963,89(1):37-42.
[5]Berger A,Crouzet S,Canes D, et al.Minimally invasive nephron-sparing surgery.Curr Opin Urol,2008,18(5):462-466.
[6]Winfield HN,Donovan JF,Godet AS,et al.Laparoscopic partial nephrectomy:initial case report for benign isease. J Endourol, 1993,7:521-6.
[7]Zorn KC,Gong EM,Orvieto MA,et al.Comparison of laparoscopic radical and partial nephrectomy:effects on long-term serum creatinine. Urology,2007,69(6):1035-1040.
[8]Gill IS,Kavoussi LR,Lane BR,et al.Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumours[J].J Urol 2007,178(1):41-46.
[9]Gill IS.Minimally invasive nephron-sparing surgery.Curr Opin Urol, 2003,13(3):179.
[10]Frank I,Colombo J R Jr,Rubinstein M,et al.Laparoscopic Partial Nephrectomy for Centrally Located Renal Tumors[J].Journal of Urology, 2006,175(3):849-852.
[11]张旭.保留肾单位的腹腔镜肾肿瘤切除术[J].中华腔镜泌尿外科杂志,2008,2(3):198.
[12]Ng CS,Gill IS, Ramani AP,et al.Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: patient selection and perioperative outcomes[J]. J Urol,2005,174(3): 846-849.
[13]张旭,李宏召.腹腔镜下保留肾单位手术治疗肾肿瘤现状[J].中华泌尿外科杂志,2007,28(7):437-438.
[14]Lane BR,Babineau DC,Poggio ED,et al.Factors predicting renal functional outcome after partial nephrectomy[J].J Urol,2008,180(6):2363-8, discussion 2363-9.
[15]张旭.泌尿外科腹腔镜手术学[M].北京:人民卫生出版社,2008, 74-84.
[16]Gill IS,Matin SF,Desai MM,et al.comparative analysis oflaparoscopic versus open partial nephrectomy for renal tumors in 200 patients[J]. J Urol , 2003,170(1):64-68.
[17]Lang EK, Macchia RJ ,Thomas R,et al.Improved detection of renal pathologic features on multiphasic helical CT compared with IVU in patients presenting with microscopic hematuria. Urology,2003,61:528- 532.
[18]Janoff DM,Davol P, Hazzard J,et al.Computerized tomography with 3-dimensional reconstruction for the evaluation of renal size and arterial anatomy in the living kidney donor[J].J U rol,2004,171(1):27-30.
[19]Urban BA, Ratner LE, Fishman EK. Three dimensional volume rendered CT angiogsaphy of the renal arteries and veins:norm alanatomy, variants,and clinical applications[J].Radiographics,2001,21:373-386.
[20]徐文坚,Sebastian Lange.泌尿系统影像诊断学[M].北京:人民卫生出版社,2003,19.
[21]Smith PA, Ratner LE, Lynch FC,Corl FM, Fishman EK.Role of CT angiography in the preoperative evaluation for laparoscopic nephrectomy[J]. Radiographics ,1998,18:589-601.
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