机器人辅助腹腔镜下根治性肾切除联合下腔静脉瘤栓取出术的临床研究

Clinical research of robot assisted laparoscopic nephrectomy with inferior vena caval thrombectomy

目的 探讨机器人辅助腹腔镜下根治性肾切除联合下腔静脉瘤栓取出术的安全性和可行性.方法 2013年5月至2014年3月收治6例肾癌伴下腔静脉瘤栓患者,均为男性.年龄45～ 69岁,中位年龄59岁.肿瘤位于右侧4例,左侧2例.Ⅰ级瘤栓2例、Ⅱ级瘤栓4例.腔静脉瘤栓长度为1 ～7 cm,平均3.5 cm.其中1例术前曾行1个月新辅助靶向药物治疗,4例术前行患侧肾动脉栓塞术.6例均行机器人辅助腹腔镜下根治性肾切除联合下腔静脉瘤栓取出术.术中环形游离下腔静脉、患肾静脉、对侧肾静脉及部分腰静脉.Ⅱ级瘤栓患者游离出肝短静脉和右侧肾上腺中央静脉,并将肝短静脉和右侧肾上腺中央静脉及腰静脉结扎离断,以保证止血带能安全地在瘤栓的上、下端阻断下腔静脉.依次阻断下腔静脉上端、对侧肾静脉（左肾癌患者在阻断右肾静脉的同时需阻断右肾动脉）和下腔静脉下端后,切开下腔静脉,完整取出瘤栓,缝合下腔静脉.最后按根治性肾切除术原则切除患肾.结果 本组6例手术均顺利完成,无中转开放手术.手术时间90～195 min,平均120 min.术中估计出血量100～400 ml,平均200 ml,均未输血.术中下腔静脉阻断时间7～15 min,平均11 min.术后均未放置引流管.术后1～3d（平均2d）拔除尿管并下床活动.术后4～7d（平均5d）出院.术后病理诊断均为透明细胞癌,其中Fuhrman分级Ⅱ级3例,Ⅱ～Ⅲ级1例,Ⅲ级2例.术中、术后无严重并发症发生.随访1～13个月,平均6个月,无疾病进展及死亡病例.结论 机器人辅助腹腔镜下根治性肾切除联合下腔静脉瘤栓取出术安全、可行,为可切除的肾癌伴静脉瘤栓患者提供了一种有效的微创治疗方法.但评价该术式的疗效和总体生存情况需要进一步、更大样本的研究和长时间的随访.

Objective To investigate the safety and feasibility of robot assisted laparoscopic radical nephrectomy with inferior vena caval thrombectomy.Methods From 2013 May to 2014 March,six patients with renal cell carcinoma and inferior vena cava thrombus were admitted to our hospital.The six were all male with a median age of 59 years （range 45 to 69 years）.Four cases had the tumor on the right side and two on the left side.The tumor embolism was level Ⅰ in 2 cases,level Ⅱ in 4 cases.The mean length of vena caval thrombus was 3.5 cm （range 1 to 7 cm）.One case received one month of preoperative neoadjuvant targeted therapy.Four cases received renal arterial embolization on the affected side preoperatively.These six patients underwent robot assisted laparoscopic radical nephrectomy with inferior vena caval thrombectomy.Bilateral renal vein,inferior vena cava （IVC） and part of lumbar vein were all annular dissociated.Accessory hepatic vein and right adrenal central vein also required isolation and ligation in cases with level Ⅱ thrombus in order to guarantee safe blockings on the IVC.After the sequential blocking of IVC upper end,contralateral renal vein （for the left cases,right renal artery was needed to be blocked at the same time） and IVC lower end,the IVC was incised and the thrombus was en bloc removed.Then the IVC was sutured.Finally,radical nephrectomy was performed on the ipsilateral kidney.Results The operations were all successfully performed without conversion to open surgery.The mean operation time was 120 min （range 90 to 195 min） and the mean intraoperative estimated blood loss was 200 ml （range 100 to 400 ml）.There were no tranfusion needed during the operation.The mean IVC blocking time was 1 1 min （range 7 to 15 min）.No drainage was required on all of the six cases.After the urinary catheter was removed two days after operation,patient was encouraged to ambulate out of bed.The mean postoperative hospital stay was 5 days （range：4 to 7 days）.Pathology analysis confirmed all tumors were clear cell renal cell carcinoma with Fuhrman level Ⅱ on 3 cases,Fuhrman level Ⅱ to Ⅲ on 1 case and Fuhrman level Ⅲ on 2 cases.During the perioperative period,there were no severe complications.All the cases received targeted therapy postoperatively and there were no death or recurrence occurring in the follow-up with a median time of six months （1 to 13 months）.Conclusions Robot assisted laparoscopic radical nephrectomy with inferior vena caval thrombectomy is safe and feasible for surgeons with robot operation experience.The operation provides an optional minimally invasive treatment for patients with resectable renal cell carcinoma with inferior vena caval thrombus.However,the therapeutic effect and the overall survival rate require further investigation with larger sample and longer follow-up.