经腰腹联合途径腹腔镜手术治疗肾肿瘤的临床研究

Efficacy of trans-lumbar-and-peritoneally joint approach for renal neoplasms by laparoscopic surgery： a clinically prospective study

目的 探讨经腰腹联合途径腹腔镜手术治疗肾肿瘤的安全性和有效性. 方法 回顾性分析2007年1月至2013年12月收治的100例肾肿瘤患者的临床资料,根据肿瘤大小及手术方式分为4组.4 cm≤肿瘤直径＜7 cm患者60例,行经腰腹联合途径腹腔镜下肾部分切除术30例（A组）,男17例,女13例.平均年龄（49.7±14.5）岁.体质量（65.2± 14.1） kg.肿瘤位于左侧16例,右侧14例.肿瘤大小（4.2±0.9）cm.经腹腔途径腹腔镜下肾部分切除术30例（B组）,男16例,女14例.平均年龄（48.5±13.9）岁.体质量（63.9±15.0） kg.肿瘤位于左侧17例,右侧13例.肿瘤大小（4.3±1.0）cm.肿瘤直径≥7 cm患者40例,行经腰腹联合途径腹腔镜下根治性肾切除术20例（C组）,男11例,女9例.平均年龄（52.3±13.1）岁.体质量（64.4±13.5） kg.肿瘤位于左侧12例,右侧8例.肿瘤大小（8.5±0.9）cm.经腹腔途径腹腔镜下根治性肾切除术20例（D组）,男12例,女8例.平均年龄（53.5±12.8）岁.体质量（65.0±13.6） kg.肿瘤位于左侧10例,右侧10例.肿瘤大小（8.7±0.9）cm.4组手术均采用全麻,A、C组手术体位和操作步骤与经腹膜后途径腹腔镜手术基本相同,仅术中完全打开侧腹膜,连通腹腔和腹膜后腔,扩大手术操作空间. 结果 本研究100例手术均顺利完成,无中转开放.A、B组手术时间分别为（109.5±22.5）、（110.7±23.6） min,热缺血时间分别为（24.0±2.5）、（24.8±2.4） min,估计出血量分别为（61.0±17.0）、（70.0±15.5） ml,需输血例数分别为1、2例,术后恢复进食时间分别为（39.7±6.2）、（52.3±5.8）h,两组比较差异均无统计学意义（P＞0.05）.C、D组手术时间分别为（100.8±21.4）、（106.4±20.5） min,估计出血量分别为（40.0±9.5）、（48.5±9.0） ml,均无输血病例,术后恢复进食时间分别为（41.3±6.4）、（53.7±5.2）h,两组比较差异均无统计学意义（P＞0.05）.4组均未出现术中脏器损伤和术后肠梗阻等严重并发症,术后3.526.3 d出院.4组随访3～ 84个月,A组1例复发、B组1例新发均行根治性肾切除术后无瘤生存;C组无复发,2例出现肺转移,其中1例死亡,1例行靶向药物治疗6个月带瘤生存;D组无复发,2例因肺转移死亡.结论 经腰腹联合途径腹腔镜手术能够安全有效地完成肾部分切除术和根治性肾切除术,尤其适合位于腹侧或较大的肾肿瘤.

Objective To explore the safety and efficacy of a new trans-lumbar-and-peritoneally joint （TLPJ） approach for treating renal cell carcinoma by laparoscopic operation.Methods From January,2007 to December,2013,one hundred patients with renal tumor were divided into 4 groups according to the size of tumors and operative approaches.And the clinic information was compared retrospectively.Group A （TLPJ laparoscopic partial nephrectomy） included 17 male and 13 female with average age （49.7±14.5） years old and average weight （65.2± 14.1） kg.The location of tumor included 16 in left kidney and 14 in right kidney.The mean size of tumor was （4.2±0.9） cm.Group B （trans-peritoneal laparoscopic partial nephrectomy） included 16 male and 14 female with average age （48.5±13.9） years old and average weight （63.9±15.0） kg.The location of tumor included 17 in left kidney and 13 in right kidney.The mean size of tumor was （4.3±1.0） cm.Forty patients with tumor size over than 7cm were divided into group C and group D.Group C （TLPJ laparoscopic radical nephrectomy） included 11 male and 9 female patients,with average age （52.3± 13.1） years old and average weight （64.4± 13.5） kg.The mean tumor size was （8.5±0.9） cm.12 tumors were located in the left kidney and 8 in right kidney.average tumor size.Group D （trans-peritoneal laparoscopic radical nephrectomy） included 12 male and 8 female patients with average age （53.5± 12.8） years old and average weight （65.0± 13.6） kg.10 tumors were located in the left kidney and 10 in right kidney.The average tumor size was （8.7±0.9） cm.General anesthesia was applied in all groups.The body position and the surgical approach in group A and C were similar to the retroperitoneal approach.However,the entire side peritoneum was opened to connect the retroperitoneal space with the abdominal space,which largely extended the operative space and was particularly appropriate for the manipulation of the tumors with large size or in special location.Results All patients experienced successful operation without the open approach conversion.For patients in group A and B,the operative duration were （109.5±22.5） and （110.7±23.6） mins.The time of warm ischemia were （24.0±2.5） and （24.8±2.4） min.The estimated blood loss （EBL） were （61.0± 17.0） and （70.0± 15.5） ml with one patient and two patients needed blood transfusion,respectively.The time for gastrointestinal function restoration were （41.3±6.4） and （53.7±5.2）h.There were no significant differences between the two groups in comparing those parameters mentioned above （P＞0.05）.For patients in group C and D,the operative duration were （100.8±21.4） and （106.4± 20.5） min.The EBL were （40.0±9.5） and （48.5±9.0） ml without any case needed blood transfusion.The time for gastrointestinal function restoration were （39.7±6.2） and （52.3±5.8） h.There were no significant differences between the two groups in comparing those parameters mentioned above （P＞0.05）.All patients gained a satisfactory recovery after a hospital stay of 3.5 to 6.3 days,without any severe postoperative complications,such as intra-abdominal organ injury and intestinal obstruction.During a follow up from 3 to 84 months,one patient was found recurrence in group A and a new occurrence of renal tumor appeared in one patient in group B.Both of them presented survivals of non-neoplasm after an immediately radical nephrectomy.In group C,no recurrence was reported.2 cases were diagnosed as pulmonary metastases,in which one died due to this disease.The other one survived with tumor after 6 months therapy of targeted drugs.Two cases died due to the pulmonary metastases in group D.Conclusions Partially or radically laparoscopic nephrectomy could be completed safely and efficiently with TLPJ approach.This approach is especially suitable for large renal neoplasms or the neoplasms nearby peritoneum.