实时超声监测后腹腔镜下肾部分切除术治疗完全内生型肾肿瘤的疗效分析

Analysis of the efficacy of laparoscopic partial nephrectomy in the treatment of complete endophytic renal tumors by real-time ultrasound monitoring

目的 探讨实时超声监测后腹腔镜下肾部分切除术治疗完全内生型肾肿瘤的安全性及有效性.方法 回顾性分析2014年2月至2016年8月行后腹腔镜下肾部分切除术治疗的33例完全内生型肾肿瘤患者的临床资料,所有病例术前影像学检查均确诊为内生型肾肿瘤.男23例,女10例.年龄28 ～ 78岁,平均50岁.肿瘤位于左侧16例,右侧17例.其中孤立肾1例.体重指数18 ～ 35 kg/m2,平均25.2 kg/m2.肿瘤直径为1.2～5.0 cm,平均2.5 cm.美国麻醉医师协会分级标准：Ⅰ级8例,Ⅱ级22例,Ⅲ级3例.均在超声监测下完成后腹腔镜下肾部分切除术,术中通过超声探头在肾脏表面寻找肿物位置,并在肾脏表面标记肿物的投影边界,完整切除肿瘤后缝合创面.其中1例有2个肿瘤,同时切除.结果 所有手术均在后腹腔镜下完成,无中转开放手术.手术时间61～314 min,平均155 min.肾动脉阻断时间11 ～ 50 min,平均26 min.术中出血量5～ 300 ml,平均53 ml.术后住院时间4～ 22d,平均7.5d.术后病理诊断：透明细胞癌23例（其中伴囊性变1例,伴神经内分泌分化1例）,乳头状肾癌Ⅱ型1例,血管平滑肌脂肪瘤3例（其中1例为2个肿物,均为上皮样血管平滑肌脂肪瘤）,多房囊性肾癌1例,嫌色细胞癌1例,炎性纤维母细胞瘤1例,肾囊肿3例;手术切缘均为阴性.术后随访0.5 ～30.0个月,平均12.2个月.26例恶性肿瘤患者中25例获得随访,均生存,无复发.结论 后腹腔镜下肾部分切除术是治疗内生型肾肿瘤的有效方法,术中超声实时监测是完整切除肿瘤、最大限度保留肾单位的关键,术前充分准备及术中仔细操作是手术成功的安全保障.

Objective To investigate the safety and efficacy of retroperitoneal laparoscopic partial nephrectomy in the treatment of complete endophytic renal tumors by real-time ultrasound monitoring.Methods Retrospective analysis of 33 cases of complete endophytic renal tumor treated by retroperitoneal laparoscopic partial nephrectomy from February 2014 to August 2016.Including 23 male and 10 female.16 cases were Left,and 17 cases were right,with 1 cases of solitary kidney.Age range was 28-78 years （mean 50 years）.BMI was18-35 kg/m2 （mean 25.2 kg/m2）.The tumor diameter was 1.2-5.0 cm,mean 2.5 cm.The American Society of Anesthesiologists （ASA） classification：8 cases of grade Ⅰ,22 cases of grade Ⅱ,and 3 cases of grade Ⅲ.Retroperitoneal laparoscopic partial nephrectomy was performed under ultrasound monitoring.The tumor was located on the surface of the kidney by ultrasonic probe,and the surface of the kidney was marked with the border of the tumor.The tumor was resected completely,and kidney was sutured.Results All operations were successful,and no conversion to open surgery.Operation time was 61-314min,average 155 rmin.Renal artery occlusion time 11-50min,average 26 min.The amount of bleeding during operation was 5-300ml,average 53 ml.Postoperative hospital stay was 4-22d,average 7.5 d.Surgical margins were negative,postoperative pathology：clear cell carcinoma in 23 cases （including with cystic change in 1 case,with neuroendocrine differentiation in 1 case）,1 case of papillary renal cell carcinoma type Ⅱ,3 cases of angiomyolipoma （which 1 case for the two masses were epithelioid angiomyolipoma）,1 case of multilocular cystic renal cell carcinoma,1 case of chromophobe carcinoma,1 cases of inflammatory myofibroblastic tumor,and 3 cases of kidney cyst.Patients were followed up for 0.5-30.0 months,average was 12.2 months.25 of 26 patients with malignant tumor were survival during followed up,without recurrence.Conclusions Retroperitoneal laparoscopic partial nephrectomy is effective for the treatment of endophytic renal tumor,intraoperative real-time ultrasound monitoring is key of complete resection of the tumor.Making full preoperative preparation and careful operation are the safety guarantee for the success of the operation.