五类微创技术在局限性肾肿瘤保留肾单位手术中的临床应用特点和效果

Comparison of perioperative outcomes of five minimally invasive approaches in nephron-sparing surgery for localized renal tumor

目的比较5类微创技术在局限性肾肿瘤保留肾单位手术中的临床应用特点和价值。方法回顾性分析2009年8月-2013年4月上海长海医院泌尿外科肾肿瘤临床诊治与研究专业组完成的196例肾肿瘤保留肾单位手术患者的临床资料，其中开放肾部分切除术30例（开放组）、普通腹腔镜下肾部分切除术82例（普通腹腔镜组）、后腹腔镜辅助小切口肾部分切除术28例（腹腔镜小切口组）、单孔腹腔镜下肾部分切除术7例（单孔腹腔镜组）、机器人外科手术系统辅助腹腔镜下肾部分切除术33例（机器人腹腔镜组）、肾脏肿瘤冷冻消融术16例（冷冻消融术组）。男129例，女67例，平均年龄为（51．0±12．9）岁，平均BMI为（24．3±3．11）kg／m^2，平均美国麻醉医师协会（ASA）分级为（1．9±0．4）级，平均肿瘤最大径为（3．3±1．3）cm，平均肿瘤DAP（Diameter-Axiab-Polar）评分为（5．8±1．5）分，Charlson全身合并症指数（CCI）0～6，中位CCI为0，平均估算肾小球滤过率（eGFR）为（103．1±33．1）mL·min^-1·1．73m^-2。分别以开放组和普通腹腔镜组为对照，两两比较各组间临床指标的差异。结果与开放组比较，普通腹腔镜组的肿瘤最大径和DAP评分、术中出血量、疼痛视觉模拟评分（VAS评分）、术后住院天数均显著减少（P值均〈0．01），缺血时间和标化缺血时间均显著延长（P值均〈0．01）；单孔腹腔镜组的BMI、肿瘤最大径和DAP评分、术中出血量、疼痛VAs评分均显著减少（P值分别〈0．05、0．01），标化缺血时间显著延长（P〈0．05）；机器人腹腔镜组的手术时间、标化缺血时间均显著延长（P值均〈0．01），术中出血量、疼痛VAS评分均显著减少（P值均〈0．01）；冷冻消融术组的年龄、CCI均显著增加（P值分别〈0．05、0．01），肿瘤最大径和DAP评分、术中出血量、疼痛VAS评分、术后住院天数均显著减少（P值分别〈0．01、0．05）；腹腔镜小切口组与开放组间各项指标的差异均无统计学意义（P值均〉0．05）。与普通腹腔镜组比较，腹腔镜小切口组的肿瘤DAP评分、术中出血量均显著增加（P值均〈0．01），缺血时间、标化缺血时间、疼痛VAS评分均显著降低（P值均〈0．01）；单孔腹腔镜组的肿瘤最大径、疼痛VAS评分均显著降低（P值均〈0．01）；机器人腹腔镜组的肿瘤DAP评分、手术时间、术后住院天数、病理学检查恶性构成均显著增加（P值分别〈0．01、0．05），标化缺血时间显著缩短（P〈0．01）；冷冻消融术组的年龄、CCI均显著增加（P值均〈0．01），疼痛VAs评分、术后住院天数、eGFR下降百分比均显著减少（P值分别〈0．01、0．05）。结论普通腹腔镜肾部分切除术适合肿瘤较小且复杂程度较低的肾部分切除术，患者术后疼痛轻，恢复快，但术后热缺血时间较长。后腹腔镜辅助小切口肾部分切除术可完成与开放手术相同难度的肾部分切除术，切口长度较短，费用低，但微创化程度不够彻底。单孔腹腔镜下肾部分切除术适合肿瘤较小且复杂程度较低的肾部分切除术，微创效果好，但手术难度大。机器人外科手术系统辅助腹腔镜下肾部分切除术可完成与开放手术类似难度的肾部分切除术，安全性高，可完成普通腹腔镜难以完成的高难度肾部分切除术。冷冻消融术适用于年龄较大、全身合并症较多的肾肿瘤患者，手术创伤小，肾功能保护好。只有综合肿瘤特点、患者因素和技术特点，取长补短，优势互补，才能更好地发挥微创保留肾单位手术在局限性肾肿瘤治疗中的临床应用价值。

Objective To compare clinical outcomes of five minimally invasive approaches in nephron- sparing surgery （NSS） for localized renal tumor. Methods A total of 196 NSS patients who underwent surgical treatment by the specialized team of renal tumor at our institution between August 2009 and April 2013 were enrolled in this retrospective study. There were 30 cases of open partial nephrectomies （group A）, 82 cases of conventional laparoscopic partial nephrectomies （group B）, 28 cases of retroperitoneal laparoscope assisted miniincision partial nephrectomies （group C）, 7 cases of laparoendoscopic single-site partial nephrectomies （group D）, 33 cases of robot assisted laparoscopic partial nephrectomies （group E）, and 16 cases of cryoablation （group F）. There were 129 males and 67 females with an average age of （51.0 ±12.9） years. Their mean body mass index （BMI） was （24.3 ± 3.11 ） kg/m^2 , mean ASA score was 1.9 ±0.4, mean maximal diameter of the tumor was （3.3±1.3） cm, mean DAP score was 5.8- 1.5, median Charlson comorbidity index （COl） was 0 （0- 6）, and mean preoperative estimated glomerular filtration rate （eGFR） was （ 103. 1 ±33. 1 ） mL · min^-1· 1.73 m^-2 . Group A and B were taken as control groups. Comparisons of perioperative outcomes between the control and study groups were conducted. Results Compared with those in the group A, maximal tumor diameter, DAP score, intraoperative blood loss, VAS score and postoperative hospital stay were significantly decreased （all P〈 0.01）, while ischemia time and standardized ischemia time were significantly increased in group B （both P 〈0.01）, BMI, maximal tumor diameter, DAP score, intraoperative blood loss and VAS score were significantly decreased （ P〈0.05 or P〈0.01 ）, while standardized ischemia time was significantly increased in group D （ P〈 0.05）; operative time and standardized ischemia time were significantly increased （both P 〈0. 01 ）, while intraoperative blood loss and VAS score were significantly decreased in group E （both P〈0.01 ） ; patient＇s age and COl were significantly increased （ P 〈 0. 05 or P 〈 0.01）, while maximal tumor diameter, DAP score, intraoperative blood loss, VAS score and postoperative hospital stay were significantly decreased in group F （P〈 0.01 or P〈0.05）. There were no significant differences in these parameters between group A and group C （all P〉0.05）. Compared with those in the group B, DAP score and intraoperative blood loss were significantly increased （both P〈〈0.01 ）, while ischemia time, standardized ischemia time and VAS score were significantly decreased in group C （all P〈0.01）; maximal tumor diameter and VAS score were significantly decreased in the group D （both P〈0.01）; DAP score, operative time, postoperative hospital stay, and pathological outcomes （malignant/benign） were significantly increased （P〈0.01 or P〈0.05）, while standardized ischemia time was significantly decreased in the group E （ P〈0.01 ） ; patient＇s age and CCI were significantly increased （both P〈 0.01 ）, while VAS score, postoperative hospital stay and eGFR decline in percentage were significantly decreased in group F （P〈0.01 or P〈0. 05）. Conclusion Conventional laparoscopic partial nephrectomy is indicated for small renal tumors with low anatomical complexity. It has lower postoperative pain, shorter convalescence and longer ischemia time. Retroperitoneal laparoscope assisted mini-incision partial nephrectomy duplicates the procedure of open partial nephrectomy with a shorter incision and lower medical cost despite of its compromise in minimal invasiveness. Laparoendoscopic single-site partial nephrectomy is currently the most thorough modality in minimally invasive partial nephrectomy, but is restricted to very small, less complex tumors with high technical demanding. Robot assisted laparoscopic partial nephrectomy recapitulates the open approach with high degree of safety and it gives early access to high-complexity tumors which is beyond the conventional laparoscopic technique. Cryoablation is appropriate for aged renal tumor patients with multiple comorbidities. Tumor features, patient characteristics and surgical technology must be incorporated into the entire clinical picture so that the minimally invasive NSS procedure will play a better role in the treatment of localized renal tumors.