腹腔镜肾部分切除术的可行性分析及手术经验总结
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摘要
目的:分析比较腹腔镜和开放肾部分切除术的临床适应征及临床效果,讨论腹腔镜肾部分切除手术的规范化标准问题和相关技术要点,并介绍术者关于腹腔镜肾部分切除手术的临床体会。
方法:选择河北医科大学第二医院泌尿外科自2005年1月～2011年1月行肾部分切除术的患者病例,其中行腹腔镜手术患者11例,行开放手术者25例。两组患者术前均行双肾CT及增强CT扫描,临床诊断为肾脏良性肿瘤或按2002年AJCC的TNM分期标准T1a期的恶性肿瘤患者,按肾部分切除术适应症纳入手术范围。术后病理报告:肾透明细胞癌17例,乳头状肾细胞癌2例,肾嫌色细胞癌1例,肾血管平滑肌脂肪瘤14例,多房囊性肾细胞癌1例,重复肾畸形1例。收集两组患者的年龄、体重、肿瘤直径、手术时间、热缺血时间、手术失血量、术后住院时间、腹腔镜手术是否中转开放、术后并发症及随访有无复发、转移等资料,进行统计学分析比较。
结果:两组患者的年龄、体重分布及肿瘤大小没有统计学差异。OPN与LPN两组比较,平均手术时间为(130.6±43.9)min比(174.1±55.7)min;平均出血量为(355.5±337.0)ml比(303.3±165.3)ml;平均术后住院时间为(9.5±3.3)d比(9.4±3.2)d;平均热缺血时间为(22.8±7.5)min比(33.1±12.1)min。结果显示:OPN组手术时间短于LPN组,P<0.05,两组之间差异有统计学差异;两组间其它指标比较没有统计学差异。11例LPN均顺利完成,无中转开放手术及术后出血病例,25例OPN中有一例因术后出血行二次手术止血;腹腔镜组1例术中切漏肾盂,开放组2例切漏肾盂,均用3-0可吸收线缝合,术后均无漏尿;腹腔镜组2例患者术后持续感染高热,予以血培养及抗生素升级治疗后感染均得到控制;术后病理报告所有恶性肿瘤患者切缘病理均为阴性,所有患者术后复查肾功能在正常范围内,随访5～68个月肿瘤无复发,LPN和OPN二组术中及术后并发症比较也没有统计学差异。
结论:腹腔镜肾部分切除术与开放手术相比,腰部切口小,瘢痕不明显,手术损伤小,术后恢复时间缩短,并能减少出血量;但对于同种难度的手术患者,LPN会延长手术时间和术中肾脏热缺血时间。对于满足适应症的肾脏肿瘤,无论是良性疾病,还是恶性疾病,腹腔镜肾部分切除术是一种可行的手术方式,安全、有效,而且对于操作技术娴熟者而言,肿瘤大小和位置已经不完全是阻碍行腹腔镜肾部分切除术的主要因素,随着手术技术的熟练,手术的效果也在不断提高。LPN现阶段仍存在着较多的难点与争论,因为手术操作的复杂性及关于技术细节的不同观点,所以LPN依然没有完全取代OPN成为治疗早期肾脏肿瘤的标准方法,它仍处在不断发展的阶段,但是LPN已经成为了治疗早期肾脏肿瘤的重要选择之一。相信随着腹腔镜设备的改进、新材料的应用和手术经验的积累,腹腔镜下止血、缝合技术及肾脏低温保护技术的不断成熟,LPN会进一步缩短手术时间及肾脏热缺血时间,发挥微创手术的优势,在不久的将来可能会成为泌尿外科医生和患者治疗早期肾脏肿瘤的首选。
Objective: To analyze and compare the clinical indication and effect of laparoscopic partial nephrectomy and open partial nephrectomy,discuss the normalized standard and technique of laparoscopic partial nephrectomy,and introduce the doctor’s comprehension about laparoscopic partial nephrectomy.
Methods: Select 36 patients from the department of urinary surgery of the Second Hospital of Hebei Medical University,who have accepted the partial nephrectomy ,range from January,2005 to January,2011,including 11 cases of laparoscopic partial nephrectomy and 25 cases of open partial nephrectomy.All the cases were diagnosed through CT of kidney,and were confirmed through the pathological report.And then collect the age ,size of tumor,operative time, warm ischemia time,blood loss,recovery time,postoperative complications,hospital stay and follow-up inves- tigation.Then analyze the data.
Results: There were no significance in the age,weight and tumor size of the two groups.Comparing the operative time,blood loss, hospital stay and warm ischemia time,the result is (OPN vs LPN:130.6±43.9min vs 174.1±55.7min;355.5±337.0ml vs 303.3±165.3ml;9.5±3.3d vs 9.4±3.2d;22.8±7.5min vs 33.1±12.1min).Only the difference in the operative time is significant(P<0.05).The 11 cases of LPN were done successfully,with no transference to OPN for postoperative bleeding;During the 25 cases of OPN, there was one cases which needed the second operation to hemostasis. One cases of LPN and two cases of OPN cut the pelvis to open,after saturation,there were no leakage of urine afteroperation; And two cases of LPN had a continuous infection and fever,which were cured after the use of better antibiotics; The cutting edge of all malignant tumor cases was negative in the postoperative pathological reports,with no relatpse after 5～68 months’follow up, and the kidney function of the two teams after operation is in the normal range.
Conclusion: Laparoscopic partial nephrectomy is not only less traumatic , less scar ,but also less blood loss,postoperative discomforts and hospital stay. But to do an operation with the same difficulty,LPN will have a long operation time and warm ischemia time. For the patients with kidney neoplasms, laparoscopic partial nephrectomy is feasible,safe and effective.For the surgeon with proficient surgical technique,the size and site of the neoplasms is no longer the scruple,and the operative effect is elevating.Because of the operative complicacy and different viewpoint about the technical details,there is also much argument about LPN,LPN is still in a developing stage and become a important choice to treat kidney neoplasms.We believe in that,with more and more new laparoscopic equipments and materials be used,and the mature of the laparoscopic hemostasis skills ,suture and hypothymia protection technique ,the operation time and warm ischemia time of LPN will be mostly shortened,LPN will be the preference of the surgeons and patients in the future before long.
方法:选择河北医科大学第二医院泌尿外科自2005年1月～2011年1月行肾部分切除术的患者病例,其中行腹腔镜手术患者11例,行开放手术者25例。两组患者术前均行双肾CT及增强CT扫描,临床诊断为肾脏良性肿瘤或按2002年AJCC的TNM分期标准T1a期的恶性肿瘤患者,按肾部分切除术适应症纳入手术范围。术后病理报告:肾透明细胞癌17例,乳头状肾细胞癌2例,肾嫌色细胞癌1例,肾血管平滑肌脂肪瘤14例,多房囊性肾细胞癌1例,重复肾畸形1例。收集两组患者的年龄、体重、肿瘤直径、手术时间、热缺血时间、手术失血量、术后住院时间、腹腔镜手术是否中转开放、术后并发症及随访有无复发、转移等资料,进行统计学分析比较。
结果:两组患者的年龄、体重分布及肿瘤大小没有统计学差异。OPN与LPN两组比较,平均手术时间为(130.6±43.9)min比(174.1±55.7)min;平均出血量为(355.5±337.0)ml比(303.3±165.3)ml;平均术后住院时间为(9.5±3.3)d比(9.4±3.2)d;平均热缺血时间为(22.8±7.5)min比(33.1±12.1)min。结果显示:OPN组手术时间短于LPN组,P<0.05,两组之间差异有统计学差异;两组间其它指标比较没有统计学差异。11例LPN均顺利完成,无中转开放手术及术后出血病例,25例OPN中有一例因术后出血行二次手术止血;腹腔镜组1例术中切漏肾盂,开放组2例切漏肾盂,均用3-0可吸收线缝合,术后均无漏尿;腹腔镜组2例患者术后持续感染高热,予以血培养及抗生素升级治疗后感染均得到控制;术后病理报告所有恶性肿瘤患者切缘病理均为阴性,所有患者术后复查肾功能在正常范围内,随访5～68个月肿瘤无复发,LPN和OPN二组术中及术后并发症比较也没有统计学差异。
结论:腹腔镜肾部分切除术与开放手术相比,腰部切口小,瘢痕不明显,手术损伤小,术后恢复时间缩短,并能减少出血量;但对于同种难度的手术患者,LPN会延长手术时间和术中肾脏热缺血时间。对于满足适应症的肾脏肿瘤,无论是良性疾病,还是恶性疾病,腹腔镜肾部分切除术是一种可行的手术方式,安全、有效,而且对于操作技术娴熟者而言,肿瘤大小和位置已经不完全是阻碍行腹腔镜肾部分切除术的主要因素,随着手术技术的熟练,手术的效果也在不断提高。LPN现阶段仍存在着较多的难点与争论,因为手术操作的复杂性及关于技术细节的不同观点,所以LPN依然没有完全取代OPN成为治疗早期肾脏肿瘤的标准方法,它仍处在不断发展的阶段,但是LPN已经成为了治疗早期肾脏肿瘤的重要选择之一。相信随着腹腔镜设备的改进、新材料的应用和手术经验的积累,腹腔镜下止血、缝合技术及肾脏低温保护技术的不断成熟,LPN会进一步缩短手术时间及肾脏热缺血时间,发挥微创手术的优势,在不久的将来可能会成为泌尿外科医生和患者治疗早期肾脏肿瘤的首选。
Objective: To analyze and compare the clinical indication and effect of laparoscopic partial nephrectomy and open partial nephrectomy,discuss the normalized standard and technique of laparoscopic partial nephrectomy,and introduce the doctor’s comprehension about laparoscopic partial nephrectomy.
Methods: Select 36 patients from the department of urinary surgery of the Second Hospital of Hebei Medical University,who have accepted the partial nephrectomy ,range from January,2005 to January,2011,including 11 cases of laparoscopic partial nephrectomy and 25 cases of open partial nephrectomy.All the cases were diagnosed through CT of kidney,and were confirmed through the pathological report.And then collect the age ,size of tumor,operative time, warm ischemia time,blood loss,recovery time,postoperative complications,hospital stay and follow-up inves- tigation.Then analyze the data.
Results: There were no significance in the age,weight and tumor size of the two groups.Comparing the operative time,blood loss, hospital stay and warm ischemia time,the result is (OPN vs LPN:130.6±43.9min vs 174.1±55.7min;355.5±337.0ml vs 303.3±165.3ml;9.5±3.3d vs 9.4±3.2d;22.8±7.5min vs 33.1±12.1min).Only the difference in the operative time is significant(P<0.05).The 11 cases of LPN were done successfully,with no transference to OPN for postoperative bleeding;During the 25 cases of OPN, there was one cases which needed the second operation to hemostasis. One cases of LPN and two cases of OPN cut the pelvis to open,after saturation,there were no leakage of urine afteroperation; And two cases of LPN had a continuous infection and fever,which were cured after the use of better antibiotics; The cutting edge of all malignant tumor cases was negative in the postoperative pathological reports,with no relatpse after 5～68 months’follow up, and the kidney function of the two teams after operation is in the normal range.
Conclusion: Laparoscopic partial nephrectomy is not only less traumatic , less scar ,but also less blood loss,postoperative discomforts and hospital stay. But to do an operation with the same difficulty,LPN will have a long operation time and warm ischemia time. For the patients with kidney neoplasms, laparoscopic partial nephrectomy is feasible,safe and effective.For the surgeon with proficient surgical technique,the size and site of the neoplasms is no longer the scruple,and the operative effect is elevating.Because of the operative complicacy and different viewpoint about the technical details,there is also much argument about LPN,LPN is still in a developing stage and become a important choice to treat kidney neoplasms.We believe in that,with more and more new laparoscopic equipments and materials be used,and the mature of the laparoscopic hemostasis skills ,suture and hypothymia protection technique ,the operation time and warm ischemia time of LPN will be mostly shortened,LPN will be the preference of the surgeons and patients in the future before long.
引文
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2吕文成,王文营,杜林栋,等.腹腔镜肾部分切除术(附160例报告) [J]临床泌尿外科杂志, 2010, 25(7), 498-500
3 Uzzo R G, Novick AC. Nephron sparing surgery for renal tumors indications. Techniques, and outeomes[J]. J Urol, 2001, 166: 8
4 Aron M, Tuma B. Laparoscopie partial nephrectomy: newer trends[J]. Indian J Urol, 2009, 25: 516-522
5 Aron M, Tuma B. Laparoscopie partial nephrectomy: newer trends[J]. Indian J Urol, 2009, 25: 516-522
6 Uzzo R G, Novick A C. Nephron sparing surgery for renal tumors: indications. Techniques, and outeomes[J]. J Urol, 2001, 166: 8
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