腹腔镜下保留肾单位手术治疗T1肾癌

Clinical study of laparoscopic nephron sparing surgery for T1 renal cell carcinoma

目的 探讨腹腔镜下保留肾单位手术治疗T1肾癌的方法和疗效。方法 肾癌患者32例。男24例，女8例。年龄31～72岁，平均49岁。均经B超、CT或MRI检查确诊为T1N0M0肾癌。肿瘤位于左肾21例，右肾11例；肾上极10例，下极13例，肾脏中部5例，近肾盂部位4例；偏背侧18例，腹侧14例。肿瘤平均直径（2．8±0．8）cm。25例行后腹腔途经，肿瘤位于偏腹侧者7例行经腹途径腹腔镜下保留肾单位术，均沿瘤体边缘外0．5cm处分离切除肿瘤。手术前后行肾核素扫描（ECT）检测分肾功能。结果 31例完成腹腔镜下保留肾单位手术，1例因缝合后肾脏渗血明显，中转开放手术。32例阻断肾蒂时间平均（24±4）min。3例开放血流后有明显渗血，均有2次阻断肾蒂史，阻断血管时间〉30min。31例平均手术时间（105±15）min，平均出血量（120±22）ml，6例术中输血400ml。5例肿瘤位于肾脏中部者术前放置双J管。3例切除肿瘤后暴露肾盏，于术后当日通过膀胱镜放置双J管引流，其中2例于术后2～3d发生漏尿，引流量200～300ml，分别于术后15、21d引流液＜20ml后拔出负压引流管后愈合。术后复查SCr、BUN均正常。术后住院时间平均（9±2）d。术后病理报告切缘均未见肿瘤残留。平均随访（23±5）个月，肿瘤无复发。术后1个月B超和CT复查发现患侧肾手术部位局部血肿3例，术后3个月血肿吸收。术后15d复查双肾ECT，9例患侧肾血流较术前下降10％～15％，3例下降20％；术后1个月复查，7例患侧肾血流较术前下降10％～15％；术后（23±5）个月复查，仍有3例患侧肾血流较术前下降10％～15％。结论 腹腔镜下保留肾单位手术安全可行。

Objective To evaluate the clinical efficacy and safety of laparoscopic nephron sparing surgery in the treatment of T1 renal cell carcinoma. Methods Thirty-two patients （24 males and 8 females） were diagnosed with T1 N0 M0 renal cell carcinoma by ultrasound, CT or MRI and un- derwent laparoscopic nephron sparing surgery. The mean age was （49 ± 2）years old （from 31 to 72 years old）. The mean tumor diameter was （2.8±0.8）era. There were 21 tumors in left kidney, 11 in right kidney. Of them, 10 tumors were in upper pole, 13 in lower pole, 5 in kidney center, 4 close to renal hilum, 18 in dorsal side and 14 in ventral side of the kidney. Tumor masses were resected with the surgical margin of 0.5 era. Twenty-five cases were done through retroperitoneal approach and 7 cases was done through transperitoneal approach. The pathological results showed that there were clear cell renal carcinoma in 28 cases, granule cell renal carcinoma in 3 eases and oncocytoma in 1 ease. Renal function was examined by ECT before and after the surgery. Results Thirty-one eases underwent laparoscopic nephron sparing surgery successfully and only one ease converted to open surgery due to excessive intra-operative bleeding. The mean renal pedicle blocking time was （24±4）min （from 19 to 52 min）. There were 3 cases having blocking time longer than 30 rain （38 min, 45 min and 52 min） and accepted secondary blockage during the procedure. The mean operative time was （105±15） rain. The mean estimated blood loss was （120±22）ml. Only 6 cases accepted 400 ml blood transfu sion. D-J stents were placed in 5 cases with the tumor in kidney center before operation. In 3 cases with intra-operative exposure of renal calyx, D-J stents were placed after operation. Urine leakage in 2 cases were noted at 2 and 3 days and recovered at 15 and 21 days after operation. The mean hospital stay was （9±2）days. There was no recurrence in a mean follow-up time of （23±5）months. There were 3 cases with local hematoma （1 case of 4 cm×3 cm, 2 cases of 2 cm×3 cm） in the surgical site confirmed by ultrasound or CT scan 1 month after surgery and they disappeared 3 months after the operation. Serum creatinine and urea nitrogen were all in normal range after operation. Compared with renal blood flow of the operated kidney before operation, there were 9 cases decreased by 10%-15 and 3 cases decreased by 20% at 15 days, 7 cases decreased by 10%-15% at 1 month and 3 cases de creased by 10%-15%at （23±5）months after operation. Conchmion Laparoscopic nephron sparing surgery is one of feasible and safe options for the treatment of T1 renal cell carcinoma.