后腹腔镜下节段性肾动脉阻断保留肾单位手术的初步结果和体会

Clinical experience and initial outcome of segmental renal artery clamping during retroperitoneoscopic nephron-sparing surgery

目的：探讨后腹腔镜下节段性肾动脉阻断保留肾单位肾部分切除术治疗局限性小肾肿瘤的临床应用价值和初步结果。方法：回顾性总结贵阳医学院附属医院2011年9月-2013年6月采取后腹腔镜下节段性肾动脉阻断保留肾单位肾部分切除术治疗局限性小肾肿瘤患者44例。男26例,女18例,平均年龄50.2岁;平均肿瘤直径（2.8±0.9）cm;肿瘤位于下极25例,中极10例,上极9例;T1a期36例,良性肿瘤8例;肾透明细胞癌23例,乳头状癌7例,嫌色细胞癌6例,肾错构瘤8例。统计患者手术时间（min）、术中出血量（ml）、术后胃肠功能恢复时间（h）、手术并发症发生率（%）、切缘阳性率（%）、总住院时间（d）以及术后6个月术侧肾的肾小球滤过率（eGFR）下降（%）等参数,所有患者随访6-12个月,监测肿瘤复发情况。结果：44例患者手术时间110-192min,平均132min;术中出血40-120ml,平均74ml,无一例输血,无中转;术后胃肠功能恢复时间16.2-23.5h,平均19.3h;手术并发症发生率9.1%（4/44）;住院时间4-9d,平均4.6d;切缘阳性率2.3%（1/44）。患者随访期内无肿瘤复发,术后6个月44例患肾eGFR较术前无明显变化。术后6-12个月7例（7/44,15.9%）患肾eGFR较术前下降13.4-18.5ml/min,平均下降15.2ml/min（P〈0.05）。结论：后腹腔镜下节段性肾动脉阻断保留肾单位肾部分切除术具有创伤小、术中失血量少、胃肠功能恢复快、手术并发症少、住院时间短等优点。少部分患者术后远期患肾肾功能有一定影响,需要进一步观察。该术式是治疗局限性小肾肿瘤的一种安全有效的手术方法。

Objective：To study the initial experience and outcomes of segmental renal artery clamping during retroperitoneoscopic nephron-sparing partial nephrectomy for localized renal neoplasms.Method：Totally,44patients（mean ages,50.2years）with renal localized small mass in our hospital from September 2011 to June 2013 underwent retroperitoneoscopic segmental renal artery clamping nephron-sparing partial nephrectomy,including 26 males and 18 females.Twenty-five tumors located in renal lower pole,ten cases in renal middle pole and nine cases in upper pole.According to 2009 TNM stage,36 cases were in T1 a,and eight patients were found benign tumor.Renal clear cell carcinoma（RCC）were diagnosed in 23 cases,papillocarcinoma in seven cases,chromophobe carcinoma in six cases and angiomyolipoma in eight cases.The data of operative time（OT）,estimated blood loss（EBL）,gastrointestinal function recovery time（GRT）,the rate of complications,hospitalization day and operated kidney estimated glomerular filtration rate（eGFR）changes,and rate of positive surgical margin（RPM）were collected.All patients were followed up for 6-12 months.Result：None had conversion to open surgery.The operative time was 110-192（mean,132）min.Estimated blood loss was 40-120（mean,74）ml.Gastrointestinal function recovery time was 16.2-23.5（mean,19.3）h.The rate of complication was 9.1%（4/44）.The hospitalization day was 4-9（mean 4.6）d.The rate of positive surgical margin was 2.3%（1/44）.All cases were no statistical significant change in operated kidney eGFR over six months,while there were statistical significant changes after 6-12 months in seven cases（P〈 0.05）.No evidence of recurrence was found during follow-up period.Conclusion：Retroperitoneoscopic segmental renal artery clamping partial nephrectomy is a safe and effective surgical treatment for renal localized small mass for it has some advantages of less invasion,less intraoperative blood loss,faster recovery of gastrointestinal function,fewer complications,shorter hospital stay.However,we should pay attention to long-term outcomes for there was a significant decline operated renal eGFR over long-term follow-up period（more than six months）.