175例局限性肾癌保留肾单位手术治疗结果分析
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摘要
目的评价保留肾单位手术治疗局限性肾细胞癌的临床效果。
材料和方法回顾性分析自1999年6月至2008年11月因肾细胞癌于中国医学科学院肿瘤医院泌尿外科施行保留肾单位手术治疗的171例患者的临床资料,其中4例患者为双侧肾癌,分别施行了两次肾部分切除术。
结果23例患者为保留肾单位手术绝对适应证,50例为相对适应证,102例为选择性适应证。手术方式均为肾部分切除术,159例行术中阻断肾蒂,平均阻断时间15分钟,最短5分钟,最长30分钟。术后病理结果:肾透明细胞癌163例,乳头状肾细胞癌4例,嫌色细胞癌6例,多房囊性肾细胞癌2例。肿瘤平均直径为2.8cm(0.5-7cm),其中T1aNOMO 153例,T1bNOMO 22例。手术切缘距肿瘤0.1-2cm,平均为0.7cm。所有病例手术切缘均为阴性。术后出现并发症8例,围手术期无患者出现急性肾功能衰竭。中位随访时间为33月(3-119月),1例局部复发,1例出现远处转移,5年肿瘤特异性生存率及5年总生存率分别为98.5%和95.9%。
结论对于局限性肾细胞癌,保留肾单位手术对肿瘤控制的疗效满意,手术合并症发生率较低,且部分保留了患肾功能,是一种安全可靠的术式。
Objective: To evaluate the results of Nephron-sparing surgery for localized renal cell carcinomas.
Material & Methods: A retrospective analysis was peroformed for 171 patients who were affected by renal cell carcinoma and treated with nephron-sparing sugery between June 1999 and November 2005.There was 4 patients had bilateral tumors and nephron-sparing surgery was performed twice among those patients.
Results: Nephron-sparing sugery was done for absolute indication in 23 patients,for relative indication in 50 patients,and for elective indication in 102 patients. All was treated with partial nephrectomy .The renal vessel was clamped in 159 cases intraoperative, the mean intraoperative renal interrupted time was 15 mins(range 5 to 30).The histological subtype was clear cell carcinoma in 163 cases,papillary renal cell carcinoma in 4 cases,chromophobe in 6 cases,multilocular cystic renal cell carinoma in 2 cases. The mean tumor size was 2.8 cm (range 0.5 to 7cm).The mean size of surgical margin was 7 mm and surgical margin were negative in all cases.Eight patients had postoperative complications and no perioperative acute renal failure occurred. After a median follow-up of 33 months (range 3 to 119), one patient had developed local recurrence, one patient had developed distant progression.5 year cancer specific survival rates and overall survival rates were 98.5% and 95.9%.
Conclusions: For patients with localized renal cell carcinomas, nephron-sparing surgery can achieve an effective oncologic outcome and a low local recurrence rate, it is an affective and safe operation and can providing functional advantage by the maximal preservation of unaffected renal parenchyma.
材料和方法回顾性分析自1999年6月至2008年11月因肾细胞癌于中国医学科学院肿瘤医院泌尿外科施行保留肾单位手术治疗的171例患者的临床资料,其中4例患者为双侧肾癌,分别施行了两次肾部分切除术。
结果23例患者为保留肾单位手术绝对适应证,50例为相对适应证,102例为选择性适应证。手术方式均为肾部分切除术,159例行术中阻断肾蒂,平均阻断时间15分钟,最短5分钟,最长30分钟。术后病理结果:肾透明细胞癌163例,乳头状肾细胞癌4例,嫌色细胞癌6例,多房囊性肾细胞癌2例。肿瘤平均直径为2.8cm(0.5-7cm),其中T1aNOMO 153例,T1bNOMO 22例。手术切缘距肿瘤0.1-2cm,平均为0.7cm。所有病例手术切缘均为阴性。术后出现并发症8例,围手术期无患者出现急性肾功能衰竭。中位随访时间为33月(3-119月),1例局部复发,1例出现远处转移,5年肿瘤特异性生存率及5年总生存率分别为98.5%和95.9%。
结论对于局限性肾细胞癌,保留肾单位手术对肿瘤控制的疗效满意,手术合并症发生率较低,且部分保留了患肾功能,是一种安全可靠的术式。
Objective: To evaluate the results of Nephron-sparing surgery for localized renal cell carcinomas.
Material & Methods: A retrospective analysis was peroformed for 171 patients who were affected by renal cell carcinoma and treated with nephron-sparing sugery between June 1999 and November 2005.There was 4 patients had bilateral tumors and nephron-sparing surgery was performed twice among those patients.
Results: Nephron-sparing sugery was done for absolute indication in 23 patients,for relative indication in 50 patients,and for elective indication in 102 patients. All was treated with partial nephrectomy .The renal vessel was clamped in 159 cases intraoperative, the mean intraoperative renal interrupted time was 15 mins(range 5 to 30).The histological subtype was clear cell carcinoma in 163 cases,papillary renal cell carcinoma in 4 cases,chromophobe in 6 cases,multilocular cystic renal cell carinoma in 2 cases. The mean tumor size was 2.8 cm (range 0.5 to 7cm).The mean size of surgical margin was 7 mm and surgical margin were negative in all cases.Eight patients had postoperative complications and no perioperative acute renal failure occurred. After a median follow-up of 33 months (range 3 to 119), one patient had developed local recurrence, one patient had developed distant progression.5 year cancer specific survival rates and overall survival rates were 98.5% and 95.9%.
Conclusions: For patients with localized renal cell carcinomas, nephron-sparing surgery can achieve an effective oncologic outcome and a low local recurrence rate, it is an affective and safe operation and can providing functional advantage by the maximal preservation of unaffected renal parenchyma.
引文
[1] Ljungberg B,Hanbury DC, Kuczyk MA,et al. Renal cell carcinoma guideline[J]. Eur Urol 2007,51:1502-1510.
[2] Parkin DM,Bray F,Ferlay J,et al. Global cancer statistics, 2002[J]. CA Cancer J Clin 2005,55:74-108.
[3] Vogelzang NJ,Stadler WM. Kidney cancer[J]. Lancet 1998,352:1691-6.
[4] Robson CJ. Radical nephrectomy for renal cell carcinoma[J]. J Urol, 1963, 89(1): 37- 42.
[5]Uzzo RG, Novick AC. Nephron sparing surgery for renal tumors:indications techniques and outcomes [J]. J Urol,2001,166:6-18.
[6] Fergany AF, Hafez KS, Novick AC. Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year followup[J].J Urol. 2000,163:442-445.
[7] Lee CT, Katz J, ShiW, et al. Surgical management of renal tumors 4 cm or less in a contemporary cohort[J]. J Urol. 2000,163:730-736.
[8] Belldegrun A, Tsui KH, deKernion JB, et al. Efficacy of nephron-sparing surgery for renal cell carcinoma: analysis based on the new 1997 tumor-node-metastasis staging system[J]. J Clin Oncol.1999,17:2868-2875.
[9] Novick AC.Renal-sparing sugery for renal cell carcinoma[J].Urol Clin North Am. 1993,20:277-282.
[10] Lerner SE., Hawkins CA, et al: Disease outcome in patients with low stage renal cell carcinoma treated with nephron sparing or radical surgery[J]. J Urol, 1996,155(6): 1868-73.
[11] Hafez KS, Fergany AF, Novick AC. Nephron sparing surgery for localized renal cell carcinoma: impact of tumor size on patient survival, tumor recurrence and TNM staging[J].J Urol, 1999,162:1930-3.
[12] Patard JJ,Shvarts O,Lam JS,et al. Safety and efficacy of partial nephrectomy for all T1 tumors based on an international multicenter experience[J]. J Urol 2004,171:2181-5.
[13]Leibovich BC, Blute ML, Cheville JC, et al. Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy[J]. J Urol,2004,171:1066-1070.
[14] Becker F, Siemer S, Hack M, et al. Excellent long-term cancer control with elective nephron-sparing surgery for selected renal cell carcinomasmeasuring more than 4 cm[J]. Eur Urol.2006:49:1058-1063.
[15] Novick AC.Renal hypothemria:in vivo and ex vivo[J].Urol Clin North Am.l983,10(4):637-644.
[16] Campbell SC,Novick AC,Streem SB,et al.Complications of nephron sparing surgery for renal tumors[J]. J Urol. 1994; 151 (5): 1177-1180.
[17] Stephenson AJ, Hakimi AA,Snyder ME, et al.Complications of radical and partial nephrectomy in a large contemporary cohort[J]. J Urol,2004,171(1): 130-134.
[18] Cozar JM,Tallada M.Open partial nephrectomy in renal cancera feasible gold standard technique in all hospitals[J]. Adv Urol.2008:916463.
[19]Sorbellini M,Kattan MW,Snyder ME, et al.Prognostic nomogram for renal insufficiency after radical or partial nephrectomy[J]. J Urol,2006,176(2):472-476.
[20] Lau WK, Blute ML,Weaver AL, et al.Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney[J].Mayo Clin Proc,2000,75(12): 1236-1242.
[21] Russo P.Open partial nephrectomy:an essential operation with an expanding role[J].Curr Opin Urol,2007,17:309-315.
[22] Lesage K,Joniau S,Poppel HV.Coparison between open partial and radical nephrectomy for renal tumors:perioperative outcome and health-related quality of life[J]. Eur Urol,2007,51: 614-620.
[23] McKiernan J.Simmons R,Katz J, et al.Natural history of chronic renal insufficiency after partial and radical nephrectomy[J],Urology,2002,59(6): 816-820.
[24] Adkins KL,Chang SS,Cookson MS,et al.Partial nephrectomy safely preserves renal function in patients with a solitary kindey[J].J Urol,2003,169(1):79-81.
[25] Saranchuk JW,Touijer AK,Hakaimian P,et al.Partial nephrectomy for patients with a solitary kindey:the Memorial Sloan-Kettering experience[J].Bju Int,2004,94(9):1323-8.
[26] Moinzadeh A, Gill IS, Finelli A, et al.Laparoscopic partial nephrectomy: 3-year followup[J].J Urol,2016,175(2):459-462.
[27] Lane BR, Gill IS.5-year outcomes of laparoscopic partial nephrectomy[J].J Urol,2007,177(1):70-4.
[28] Gill IS, Kavoussi LR,Lane BR,et al.Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors[J]. J Urol,2007,178(1):41-46.
[29] Lane BR,Babineau DC,Poggio ED,et al. Factors predicting renal functional outcome after partial nephrectomy[J].J Urol,2008,180(6):2368-9.
[30] Black P, Filipas D, Fichtner J, et al. Nephron sparing surgery for central renal tumors: experience with 33 cases[J]. J Urol,2000; 163:737-743.
[31] Miller DC, Hollingsworth JM, Hafez KS, et al. Partial nephrectomy for small renal masses: an emerging quality of care concern[J]? J Urol,2006;175:853-57.
[32] Nuttall M, Cathcart P, van der Meulen J, et al. A description of radical nephrectomy practice and outcomes in England: 1995-2002[J]. BJU Int,2005;96:58-61.
[33] Schlichter A, Schubert R,Werner W,et al.How accurate is diagnostic imaging in determination of size andmultifocality of renal cell carcinoma as a prerequisite for nephron-sparing surgery?[J].Uro Int,2000,64(4) 192-197.
[34]李泉林,关宏伟,张秋萍,等.肾细胞癌保肾手术安全切除范围的探讨[J].中华泌尿外科杂志,2002,23:709-711.
[35]Piper NY,Bishoff JT,Magee C,et al.Is a 1-cm margin necessary during nephron-sparing surgery for renal cell carcinoma[J].Urology,2001;58:849-852.
[36]Castilla EA,Liou LS,Abrahams NA,et al.Prognostic importance of resection margin width after nephron-sparing surgery for renal cell carcinoma[J].Urology,2002,60:993-997.
[37]Poppel HV.The optimal margins in nephron-spadng surgery[J].Curr Opin Urol,2004,14:227-228.
[38]Novick AC.Nephron-sparing surgery for renal cell eareinoma[J].Annu Rev Med,2002,53:393-407.
[39]Poppel HV,Dilen K,Baert L.Incidental renal cell carcinoma and nephron sparing surgery[J].Curr Opin Urol,2001,11:281-286.
[40]Duvdevani M,Laufer M,Kastin A,et al.Is frozen section analysis in nephron sparing surgery necessary? A clinicopathological study of 301 cases[J].J Urol,2005,173:2385-2387.
[41]Ghavamian R,Cheville JC,Lohse CM,et al.Renal cell carcinoma in the solitary kindey:an analysis of complications and outcome after nephron sparing sugery[J].J Urol.2002,168(2):454-459.
[42]Belldegum A,Tsui KH,Kenrion JB,et al.Effieacy of nephron-sparing sugery for renal cell carcinoma:analysis based on the new 1997 utmor-node-metastasis staging system[J].J Clin Oncol.1999,17(9):2868-2875.
[43]Duque JLF,Loughlin KR,Leary MPO,et al.Partial nephrectomy:alternative treatment for selected patients with renal cell carcinoma[J].Urology,1998,52(4):584-590.
[44]Herr HW.Partial nephrectomy for unilateral renal carcinoma and a normal contralateral kidney:10-year followup[J].J Urol,1999,161(I):33-35.
[45]Licht MR,Novick AC.Nephron sparing surgery for renal cell carcinoma[J].J Urol.1993,149(1):1-7.
[46]Butler BP,Novick AC,Miller DP,et al.Management of small unilateral renal cell carcinomas:radical versus nephron-sparing sugery[J].Urology,1995,45(1):34-40.
[47]Moll V,Becht E,Ziegler M.Kindey preserving surgery in renal cell tumors:indications,techniques and results in 152 patients[J].J Urol.1993,150:319-323.
[48]Barbalias GA,Liatsikos EN,Tsintavis A,et al.Adenocarcinoma of the kidney:nephron sparing surgical approach vs radical nephrectomy[J].J Surg Oncol.1999,72(3):156-161.
[49]Armiento MD,Damiano R,Feleppa B,et al.Elective conservative surgery for renal carcinoma versus radical nephrectomy:a prospective study[J].BJU Int,1997,79(1):15-19.
[50]Krejci KG,Blute ML,Cheville JC,et al.Nephron-sparing surgery for renal cell carcinoma:clinicopathologic features predictive of patient outcome[J].Urology,2003,62(4):641-646.
[2] Parkin DM,Bray F,Ferlay J,et al. Global cancer statistics, 2002[J]. CA Cancer J Clin 2005,55:74-108.
[3] Vogelzang NJ,Stadler WM. Kidney cancer[J]. Lancet 1998,352:1691-6.
[4] Robson CJ. Radical nephrectomy for renal cell carcinoma[J]. J Urol, 1963, 89(1): 37- 42.
[5]Uzzo RG, Novick AC. Nephron sparing surgery for renal tumors:indications techniques and outcomes [J]. J Urol,2001,166:6-18.
[6] Fergany AF, Hafez KS, Novick AC. Long-term results of nephron sparing surgery for localized renal cell carcinoma: 10-year followup[J].J Urol. 2000,163:442-445.
[7] Lee CT, Katz J, ShiW, et al. Surgical management of renal tumors 4 cm or less in a contemporary cohort[J]. J Urol. 2000,163:730-736.
[8] Belldegrun A, Tsui KH, deKernion JB, et al. Efficacy of nephron-sparing surgery for renal cell carcinoma: analysis based on the new 1997 tumor-node-metastasis staging system[J]. J Clin Oncol.1999,17:2868-2875.
[9] Novick AC.Renal-sparing sugery for renal cell carcinoma[J].Urol Clin North Am. 1993,20:277-282.
[10] Lerner SE., Hawkins CA, et al: Disease outcome in patients with low stage renal cell carcinoma treated with nephron sparing or radical surgery[J]. J Urol, 1996,155(6): 1868-73.
[11] Hafez KS, Fergany AF, Novick AC. Nephron sparing surgery for localized renal cell carcinoma: impact of tumor size on patient survival, tumor recurrence and TNM staging[J].J Urol, 1999,162:1930-3.
[12] Patard JJ,Shvarts O,Lam JS,et al. Safety and efficacy of partial nephrectomy for all T1 tumors based on an international multicenter experience[J]. J Urol 2004,171:2181-5.
[13]Leibovich BC, Blute ML, Cheville JC, et al. Nephron sparing surgery for appropriately selected renal cell carcinoma between 4 and 7 cm results in outcome similar to radical nephrectomy[J]. J Urol,2004,171:1066-1070.
[14] Becker F, Siemer S, Hack M, et al. Excellent long-term cancer control with elective nephron-sparing surgery for selected renal cell carcinomasmeasuring more than 4 cm[J]. Eur Urol.2006:49:1058-1063.
[15] Novick AC.Renal hypothemria:in vivo and ex vivo[J].Urol Clin North Am.l983,10(4):637-644.
[16] Campbell SC,Novick AC,Streem SB,et al.Complications of nephron sparing surgery for renal tumors[J]. J Urol. 1994; 151 (5): 1177-1180.
[17] Stephenson AJ, Hakimi AA,Snyder ME, et al.Complications of radical and partial nephrectomy in a large contemporary cohort[J]. J Urol,2004,171(1): 130-134.
[18] Cozar JM,Tallada M.Open partial nephrectomy in renal cancera feasible gold standard technique in all hospitals[J]. Adv Urol.2008:916463.
[19]Sorbellini M,Kattan MW,Snyder ME, et al.Prognostic nomogram for renal insufficiency after radical or partial nephrectomy[J]. J Urol,2006,176(2):472-476.
[20] Lau WK, Blute ML,Weaver AL, et al.Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney[J].Mayo Clin Proc,2000,75(12): 1236-1242.
[21] Russo P.Open partial nephrectomy:an essential operation with an expanding role[J].Curr Opin Urol,2007,17:309-315.
[22] Lesage K,Joniau S,Poppel HV.Coparison between open partial and radical nephrectomy for renal tumors:perioperative outcome and health-related quality of life[J]. Eur Urol,2007,51: 614-620.
[23] McKiernan J.Simmons R,Katz J, et al.Natural history of chronic renal insufficiency after partial and radical nephrectomy[J],Urology,2002,59(6): 816-820.
[24] Adkins KL,Chang SS,Cookson MS,et al.Partial nephrectomy safely preserves renal function in patients with a solitary kindey[J].J Urol,2003,169(1):79-81.
[25] Saranchuk JW,Touijer AK,Hakaimian P,et al.Partial nephrectomy for patients with a solitary kindey:the Memorial Sloan-Kettering experience[J].Bju Int,2004,94(9):1323-8.
[26] Moinzadeh A, Gill IS, Finelli A, et al.Laparoscopic partial nephrectomy: 3-year followup[J].J Urol,2016,175(2):459-462.
[27] Lane BR, Gill IS.5-year outcomes of laparoscopic partial nephrectomy[J].J Urol,2007,177(1):70-4.
[28] Gill IS, Kavoussi LR,Lane BR,et al.Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors[J]. J Urol,2007,178(1):41-46.
[29] Lane BR,Babineau DC,Poggio ED,et al. Factors predicting renal functional outcome after partial nephrectomy[J].J Urol,2008,180(6):2368-9.
[30] Black P, Filipas D, Fichtner J, et al. Nephron sparing surgery for central renal tumors: experience with 33 cases[J]. J Urol,2000; 163:737-743.
[31] Miller DC, Hollingsworth JM, Hafez KS, et al. Partial nephrectomy for small renal masses: an emerging quality of care concern[J]? J Urol,2006;175:853-57.
[32] Nuttall M, Cathcart P, van der Meulen J, et al. A description of radical nephrectomy practice and outcomes in England: 1995-2002[J]. BJU Int,2005;96:58-61.
[33] Schlichter A, Schubert R,Werner W,et al.How accurate is diagnostic imaging in determination of size andmultifocality of renal cell carcinoma as a prerequisite for nephron-sparing surgery?[J].Uro Int,2000,64(4) 192-197.
[34]李泉林,关宏伟,张秋萍,等.肾细胞癌保肾手术安全切除范围的探讨[J].中华泌尿外科杂志,2002,23:709-711.
[35]Piper NY,Bishoff JT,Magee C,et al.Is a 1-cm margin necessary during nephron-sparing surgery for renal cell carcinoma[J].Urology,2001;58:849-852.
[36]Castilla EA,Liou LS,Abrahams NA,et al.Prognostic importance of resection margin width after nephron-sparing surgery for renal cell carcinoma[J].Urology,2002,60:993-997.
[37]Poppel HV.The optimal margins in nephron-spadng surgery[J].Curr Opin Urol,2004,14:227-228.
[38]Novick AC.Nephron-sparing surgery for renal cell eareinoma[J].Annu Rev Med,2002,53:393-407.
[39]Poppel HV,Dilen K,Baert L.Incidental renal cell carcinoma and nephron sparing surgery[J].Curr Opin Urol,2001,11:281-286.
[40]Duvdevani M,Laufer M,Kastin A,et al.Is frozen section analysis in nephron sparing surgery necessary? A clinicopathological study of 301 cases[J].J Urol,2005,173:2385-2387.
[41]Ghavamian R,Cheville JC,Lohse CM,et al.Renal cell carcinoma in the solitary kindey:an analysis of complications and outcome after nephron sparing sugery[J].J Urol.2002,168(2):454-459.
[42]Belldegum A,Tsui KH,Kenrion JB,et al.Effieacy of nephron-sparing sugery for renal cell carcinoma:analysis based on the new 1997 utmor-node-metastasis staging system[J].J Clin Oncol.1999,17(9):2868-2875.
[43]Duque JLF,Loughlin KR,Leary MPO,et al.Partial nephrectomy:alternative treatment for selected patients with renal cell carcinoma[J].Urology,1998,52(4):584-590.
[44]Herr HW.Partial nephrectomy for unilateral renal carcinoma and a normal contralateral kidney:10-year followup[J].J Urol,1999,161(I):33-35.
[45]Licht MR,Novick AC.Nephron sparing surgery for renal cell carcinoma[J].J Urol.1993,149(1):1-7.
[46]Butler BP,Novick AC,Miller DP,et al.Management of small unilateral renal cell carcinomas:radical versus nephron-sparing sugery[J].Urology,1995,45(1):34-40.
[47]Moll V,Becht E,Ziegler M.Kindey preserving surgery in renal cell tumors:indications,techniques and results in 152 patients[J].J Urol.1993,150:319-323.
[48]Barbalias GA,Liatsikos EN,Tsintavis A,et al.Adenocarcinoma of the kidney:nephron sparing surgical approach vs radical nephrectomy[J].J Surg Oncol.1999,72(3):156-161.
[49]Armiento MD,Damiano R,Feleppa B,et al.Elective conservative surgery for renal carcinoma versus radical nephrectomy:a prospective study[J].BJU Int,1997,79(1):15-19.
[50]Krejci KG,Blute ML,Cheville JC,et al.Nephron-sparing surgery for renal cell carcinoma:clinicopathologic features predictive of patient outcome[J].Urology,2003,62(4):641-646.