单孔多通道后腹腔镜肾脏肿瘤冷冻消融术2例报告

Retroperitoneal laparoendoscopic single-site(LESS) renal cryoablation: the first clinical series in China

目的完善相关术前评估并取得患者知情同意后,在国内首次尝试进行单孔多通道后腹腔镜下肾脏肿瘤冷冻消融术,探讨该手术的可行性和安全性,总结操作经验。方法 2012年3月14日和19日我科先后完成单孔多通道(TriPort TM)后腹腔镜下肾肿瘤冷冻消融术2例。例1为79岁男性,Charlson合并症指数(Age-weighted)为4,肿瘤最大径2.7cm,R.E.N.A.L.评分为2+2+3+p+3=10p,术前eGFR为61.5ml/(min.1.73m2);例2为43岁女性,Charlson合并症指数(Age-weighted)为3,肿瘤最大径2.6cm,R.E.N.A.L.评分为1+1+1+a+2=5a,术前eGFR为187.8ml/(min.1.73m2)。手术方法:于腋中线水平,髂嵴最高点与第12肋下缘连线中点处取一2cm纵行皮肤切口,充分游离暴露肿瘤表面,腹腔镜监视下将两把2mm直角冷刀经皮穿刺后置入瘤体内,按照EndoCare冷刀手术操作系统完成两个循环后退出冷冻刀头。结果 2例手术均顺利完成,手术时间、冷冻时间、术中出血分别为:185/170min,30/30min,50/30ml;术后第1、2、3天患者视觉疼痛模拟评分分别为:2/1,1/1,0/0;术后住院时间分别为:6/5d;无任何术中、术后并发症。术后病理组织学评估2例均为透明细胞癌,Furhman分级分别为Ⅱ和Ⅰ。术后1个月复查肾功能分别为:60.2和144.3ml/(min.1.73m2);术后1周、1个月复查肾脏增强CT提示肿瘤已完全消退,无局部复发。结论初步经验表明单孔多通道后腹腔镜下肾脏肿瘤冷冻消融术切口小、肾功能损害小,术后患者疼痛轻、恢复快,肿瘤治疗近期疗效确切,但需严格把握临床适应证。远期疗效有待前瞻性大样本的长期随访对照研究。

Objective To summarize our experience on the first clinical series of retroperitoneal laparoendoscopic single-site(LESS) renal cryoablation in China's Mainland and to assess its safety and feasibility after obtaining the informed consents.Methods Two patients with small renal masses underwent retroperitoneal laparoendoscopic single-site renal cryoablation by the same urologic surgical team at March 14,2012 and March 19,2012 in our department.The male patient was 79 years old,with the Charlson comorbidity index(CCI,Age-weighted) being 4,maximal tumor diameter being 2.7 cm,R.E.N.A.L.score being 2+2+3+p+3=10p,and preoperation eGFR being 61.5 ml/(min·1.73 m2).The female patient was 43 years old with CCI(Age-weighted) being 3,maximal tumor diameter being 2.6 cm,R.E.N.A.L.score being 1+1+1+a+2=5a,and preoperation eGFR being 187.8 ml/(min·1.73 m2).At the level of midaxillary line,we made a 2-cm longitudinal skin incision at the mid-point between the iliac crest and the inferior margin of 12th rib.The renal masses were fully isolated and exposed,and then two 2-mm cryoprobes were percutaneously introduced and placed into the tumor under laparoscopic visualization.Two freeze-thaw cryoablation cycles were performed according to the instruction of EndoCare Cryo-Care Surgery System.Results The two procedures were smoothly completed without any extra skin incision.The operative duration,cyroablation time,estimated blood loss,and postoperative hospital stay of the male and female patients were 185/170 min,30/30 min,50 /30 ml,6/5 d,respectively;and the postoperative pain scores measured by the visual analogscale(VAS) were 2/1,1/1,and 0/0 at day 1,day 2,and day 3,respectively.Pathologic examination revealed clear cell renal cell carcinoma in both patients(Fuhrman gradeⅡandⅠ).The eGFR at 1-month after operation was 60.2/144.3 ml/(min·1.73 m2) in both patients.CT scan found no evidence of recurrence at the cyroablative region 1 week and 1 month after operation.Conclusion Our initial experience shows that laparoendoscopic single-site renal cryoablation is a safe,feasible and effective procedure,with small incision,less pain,less damage of renal function,rapid recovery,and satisfactory short-term effect,but the patients should be carefully chosen.And the long-term effect should be confirmed by large sample study.