肾癌伴静脉瘤栓术前肾动脉栓塞对手术的辅助作用

The benefit of preoperative renal artery embolization in patients with renal cell carcinoma and venous tumor thrombus

目的：评价术前肾动脉栓塞对肾癌伴静脉瘤栓患者手术的辅助作用。方法回顾性分析2000年1月至2014年12月收治的249例肾癌伴静脉瘤栓患者的临床资料，患者均行根治性肾切除术＋静脉瘤栓取出术。其中74例术前行肾动脉栓塞（栓塞组），175例行单纯手术（单纯手术组），分别对两组患者手术相关指标进行对比研究。根据美国梅奥医学中心静脉瘤栓分级法及本组的瘤栓位置和取出瘤栓的手术方式，以肝静脉为界分为两个亚组，即早期瘤栓组（瘤栓顶端位于肝静脉以下）208例和晚期瘤栓组（瘤栓顶端位于肝静脉以上）41例，对比分析两个亚组的相关指标。结果与单纯手术组相比，栓塞组的瘤体更大，瘤栓级别更高，手术时间相对较长[（4.8±2.1） h vs.（4.1±2.2）h， P＜0.05]，术中出血量多[900 ml（100～12800 ml）vs.500 ml（30～12000 ml），P＜0.05]，术中输血量增加[400 ml（0～6500 ml）vs.100 ml（0～10000 ml），P＜0.05]，说明术前肾动脉栓塞在减少术中出血及缩短手术时间方面并无益处。亚组分析结果显示，对于晚期瘤栓患者，与单纯手术组相比，栓塞组同样瘤体更大，但手术时间短[（7.0±1.7）h vs.（8.2±1.8）h，P＜0.05]，术中出血量少[2000 ml（400～5800 ml） vs.3000 ml（1000～12000 ml），P＜0.05]，术中输血量少[1525 ml （0～3300 ml） vs.2050 ml（800～10000 ml），P＞0.05]。结论术前肾动脉栓塞对于肾癌伴肝静脉以上瘤栓患者意义较大，有助于缩短手术时间、减少术中出血，从而提高手术的安全性。

Objective To evaluate the impact of preoperative renal artery embolization in renal cell carcinoma patients with venous tumor thrombus.Methods A total of 249 RCC patients with venous tumor thrombus underwent radical nephrectomy and thrombectormy in our hospital.Seventy-four patients received preoperative renal artery embolization while other 175 patients did not.The related items were analyzed.The tumor thrombus level was divided into 5 groups with American Mayo clinic classification system.Considering the significant difference in tumor situation and treatment strategies, we took the hepatic vein as a cut-off line, dividing patients into two subgroups, the early and advanced tumor thrombus groups.There were 208 patients in the early tumor thrombus group and 41 patients in the advanced group.The related items were analyzed respectively.Results Patients in the embolization group tended to have larger tumors and higher percentage of advanced tumor thrombus.For all patients, the embolization group had longer operation time [（4.8 ±2.1） h vs.（4.1 ±2.2） h ,P 〈0.05] and greater median blood loss （900ml vs 500 ml,P 〈0.05）, compared to the non-embolization patients, and RAE did not show benefits on perioperative outcomes seemingly.However, subgroup analysis of patients with advanced tumor thrombus （ above hepatic vein） , in spite of the larger size of tumor, preoperative RAE showed significant benefits on reducing operation time [（7.0 ±1.7）h vs.（8.2 ±1.8）h, P〈0.05）] and intraoperative blood loss （2 000 ml vs.3 000 ml, P〈0.05） and decreasing blood transfusion （1 525 ml vs.2 050 ml ,P〉0.05）.Conclusion Preoperative RAE may be more appropriate for patients with advanced tumor thrombus because of its benefits in reducing operation time, intraoperative blood loss and elevating the operative security.