后腹腔镜下根治性肾切除术治疗肾癌的疗效观察

Clinical results of retroperitoneoscopic radical nephrectomy

目的评价后腹腔镜下根治性肾切除术的临床疗效。方法回顾性分析后腹腔镜下根治性肾切除术（A组）及开放性根治性肾切除术（B组）患者的临床资料。A组76例,男49例,女27例。年龄26～75岁,平均53岁。肾肿瘤位于左侧42例,右侧34例;肾上极36例,中极23例,下极17例。肿瘤平均直径5．4（2．0～10．2）cm,肿瘤分期T1 65例,T2 11例。病程5 d～17个月。B组73例,男45例,女28例。年龄18～79岁,平均56岁。肾肿瘤位于左侧35例,右侧38例;肾上极28例,中极21例,下极24例。肿瘤平均直径5．9（2．4～11．7）cm,肿瘤分期T1 54例,T2 19例。病程2 d～24个月。患者均行B超、IVU、逆行造影以及CT和（或）MRI检查确定肿瘤大小、位置、分期、是否有瘤栓和淋巴结转移等。2组患者的年龄、性别、美国麻醉师协会评分（ASA评分）、体重指数（body mass index,BMI）、肿瘤大小、患侧、Fuhrman分级比较,差异均无统计学意义（P值均〉0．05）。比较2组手术时间、术中出血量、术后肠功能恢复时间（以患者术后排气时间计算）、止痛药物（双氯芬酸钠）用量、并发症、住院总天数、随访时间、局部复发、切口种植转移等指标。结果A组平均手术时间69（50～175）min,平均术中出血量77（15～500）ml。平均术后肠功能恢复时间1（1～2）d,术后切口感染者5例,出现切口侧下腹部皮肤感觉过敏者6例,无严重并发症出现。平均术后止痛药物用量50（50～100）mg。平均术后住院6（5～10）d。B组平均手术时间121（80～220）min。平均术中出血量273（120～800）ml。平均术后肠功能恢复时间2（1～3）d,术后出现切口感染者9例,出现切口侧下腹部皮肤感觉过敏者45例,无严重并发症出现。平均术后止痛药物用量125（100～150）mg。平均术后住院11（7～15）d。A组手术时间、术中出血量、术后肠功能恢复时间、术后止痛药物用量、术后并发症、术后住院总天数方面明显优于开放手术组（P值均〈0．01）。A组平均随访36．3（12～70）个月,未见局部复发和远处转移者;B组平均随访39．8（12～75）个月,术后15个月失访1例,余均无局部复发,2例T2患者因肾癌肝转移分别于术后18个月和22个月死亡。2组5年无瘤生存率分别为98．1％和96．9％（P〉0．05）。结论后腹腔镜下根治性肾切除术具有微创、安全、可靠等特点。对于T1～T2 N0M0肾癌患者,后腹腔镜下根治性肾切除术的疗效与开放手术相当。

Objective To assess the oncological efficacy of retroperitoneoscopic radical nephrectomy compared with open radical nepbrectomy. Methods The clinical data were reviewed between 76 patients who underwent retroperitoneoscopic radical nephrectomy （group A） and 73 patients who underwent open radical nephrectomy （group B）. There were 49 males and 27 females in group A. The average age was 53 years. Forty-two tumors were on the left kidney and 34 on the right side. Thirty- six tumors were at the upper pole of kidney, 23 at the middle, and 17 at the lower pole. The mean tumor size was 5.4 cm in diameter （range 2.0 to 10.2 cm）, 65 cases had Tm stage tumor and 11 had T2 stage by AJCC staging. The duration of the disease ranged from 5 days to 17 months. There were 45 males and 28 females in group B. The average age was 56 years. Thirty-five tumors were on the left and 38 on the right side. Twenty-eight tumors were at the upper pole of kidney, 21 at the middle, and 24 at the lower pole. The mean tumor size was 5.9 cm in diameter （range 2.4 to 11. 7 cm）, 54 cases had T1 stage tumor and 19 had T2 stage. The duration of the disease ranged from 2 days to 24 months. All patients were evaluated preoperatively with uhrasonography, IVU, retrograde urography, CT and MRI. Variables including patient demographics （age, gender, ASA scores, BMI, tumor size, affected side, Fuhrman grade）, operative and postoperative data （operating time, estimated blood loss, recovery of intestinal function, postoperative complications, analgesic requirements, postoperative length of hospital stay, follow-up period, local recurrence, port site metastases） were compared between the groups. Results Patients were well matched for age, gender, ASA scores, BMI, tumor size, affected side, Fuhrman grade in both groups （P〉0.05）. In group A, mean operating time was 69 rain （range 50 to 175）, mean blood loss was 77 ml （range 15 to 500）, mean recovery of intestinal function was 1 day （range 1 to 2）, mean analgesic use was 50 mg （range 50 to 100）, and mean postoperative length of hospital stay was 6 days （range 5 to 10）. There were no major complications, and minor complications included wound infection （5 cases） and abdominal pain （6 cases）. In group B, mean operating time was 121 min （range 80 to 220）, mean blood loss was 273 ml （range 120 to 800）, mean recovery of intestinal function was 2 day （range 1 to 3）, mean analgesic use was 125 mg （range 100 to 150）, and mean postoperative length of hospital stay was 11 days （range 7 to 15）. There were no major complications, and minor complications included wound infection （9 cases） and abdominal pain （45 cases）. In group A, operating time, estimated blood loss, recovery of intestinal function, postoperative complications, analgesic requirements, and postoperative length of hospital stay were better than those in group B （P〈0.01）. Median follow up was 36.3 months （range 12 to 70） for group A and 39.8 months （range 12 to 75） for group B. One patients died of cardiovascular disease, and other patients survived without any recurrence and metastasis of disease in the A group. In contrast, 2 died of liver metastasis in the B group. A comparison of the 5-year disease-free survival rates of the A （98.1 % ） and B groups （96.9 % ） revealed no significant difference （P〉0.05）. Conclusions Retroperitoneoscopic radical nephrectomy is characterized by microtrauma, safety, and reliability. Retroperitoneoscopic radical nephrectomy is oncologically equivalent to open radical nephrectomy for renal cell carcinoma of T1/2 N0 M0.