完全腹腔镜手术治疗肾细胞癌合并下腔静脉癌栓的临床分析

Clinical analysis of pure laparoscopic surgery for renal cell carcinoma with inferior vena cava tumor thrombus

目的探讨完全腹腔镜手术治疗肾细胞癌合并下腔静脉癌栓的安全性和可行性。方法回顾性分析2010年12月至2014年10月收治的6例采用完全腹腔镜手术治疗的肾细胞癌合并下腔静脉癌栓患者的临床资料。患者均为男性，年龄50～69岁。体质指数21．6～30．9kg／m2。临床表现为无痛性肉眼血尿4例，腰痛1例，体检发现1例。影像学检查提示右肾占位4例，左肾占位2例，肿瘤最大径为4．0～10．6cm。癌栓分级：I级3例，Ⅱ级3例，其中Ⅱ级癌栓长度为4．0—4．2cm。6例均采用完全腹腔镜下根治性肾切除＋下腔静脉癌栓取出术，右肾占位者采用单纯后腹腔镜方式处理肾动脉及下腔静脉癌栓，左肾占位者采用后腹腔镜处理肾动脉，联合经腹腹腔镜处理下腔静脉癌栓。结果本组6例手术均顺利完成，未发生癌栓脱落。手术时间224～873rain。术中失血量200～5000ml，4例输血，输悬浮红细胞400—2800ml。其中1例左肾癌合并Ⅱ级下腔静脉癌栓患者的手术时间为873min，术中失血量5000ml，输悬浮红细胞2800ml。术后住院时间7—14d。病理诊断均为肾透明细胞癌，Fuhrman分级Ⅱ～Ⅲ级。6例术后均采用靶向药物治疗。随访6—48个月，6例均无肿瘤复发和转移。结论完全腹腔镜手术治疗右肾细胞癌合并下腔静脉癌栓以及左肾细胞癌合并I级下腔静脉癌栓安全、可行；对于左肾细胞癌合并Ⅱ级下腔静脉癌栓，完全腹腔镜手术需要更长的学习曲线。

Objective To assess the safety and feasibility of pure laparoscopic surgery for renal cell carcinoma with inferior vena eava tumor thrombus. Methods We retrospectively analyzed 6 cases of renal cell carcinoma with inferior vena cava tumor thrombus from December 2010 to October 2014. The patients were all male. Their age ranged from 50 to 69 years and the body mass index ranged from 21.6 to 30. 9 kg/ m2. Clinical manifestations included painless hematuria in 4 cases, low back pain in 1 cases and physical examination noticing in 1 cases. Imaging suggested the fight renal tumor in 4 cases and left renal tumor in 2 eases. The tumor size ranged from 4.0 to 10. 6 era. The inferior vena cava tumor thrombus was found in all patients, including type I thrombus in 3 cases and type Ⅱthrombus in 3 cases. The length of type Ⅱ tumor thrombus ranged from 4. 0 to 4. 2 cm. We completed pure laparoscopic nepbrectomy and inferior vena eava tumor thrombectomy in all patients. We chose retroperitoneal laparoscopic surgery to treat fight renal tumor with inferior vena cava thrombus and chose retroperitoneal combined with transperitoneal laparoseopic surgery to treat left renal tumor with inferior vena cava thrombus. Results All surgery were successful. Cancer embolus defluxion didn＇t occur during the opearation. The operation time was 224 - 873 rain and the intraoperative blood loss was 200 -5 000 ml. There were 4 patients get transfusion, which the transfusion volume ranged from 400 to 2 800 ml. For 1 case of left renal cell carcinoma with level Ⅱ inferior vena eava tumor,the operation time was 873 min, the blood loss was 5 000 ml, and the transfusion volume was 2 800 ml. Postoperative hospital stay was 7 - 14 days. And the pathological results were all renal clear cell carcinoma. In those patients, the Fuhrman grade classification was Ⅱ - Ⅲ. All patients were treated by targeted medicine to control tumor recurrence and metastasis. During the 6 - 48 months following up, no recurrence and metastasis were reported. Conclusions Pure laparoscopic surgery for right renal cell carcinoma with inferior vena cava tumor thrombus and left renal cell carcinoma with level I inferior vena cava tumor thrombus is safe and feasible. However, long learning curve should be necessary for performing the left renal cell carcinoma with level 11 inferior vena cava tumor thrombus. The effect of total laparoscopic surgery for renal cell carcinoma with inferior vena cava tumor thrombus is definite.