不阻断肾动脉腹腔镜肾部分切除术(附12例报告)

Laparoscopic partial nephrectomy without renal artery clamping(Report of 12 cases)

目的:评估不阻断肾动脉腹腔镜肾部分切除术治疗肾肿瘤的可行性和临床效果。方法:2016年1~11月于我院行不阻断肾动脉腹腔镜肾部分切除术的肾肿瘤患者12例,收集所有患者临床资料。其中男7例(58.33%),女5例(41.67%),平均年龄55.6(34~75)岁,平均体重指数27.4(21.5~32.3)kg/m2,所有患者均为单侧单发肾肿瘤,对侧肾功能正常,肿瘤均为部分外生性生长,平均直径2.9(1.5~5.0)cm,肾实质内深度≤2cm,肿瘤边缘距集合系统距离≥7mm,R.E.N.A.L.评分为4.6(4~6)分。术中常规置入辅助Trocar,由助手使用吸引器保持视野清晰。瘤体较大者,在切缘外预缝线,缩短进针、持针时间以减少出血量。对于创面内血管分支可预先以Hem-o-Lock夹闭,出血明显处用吸引器压迫待肿瘤切除后再行处理。结果:除2例患者因术中出血难以控制暂时阻断肾动脉后完成手术,其余10例患者均未阻断肾动脉,无中转开放手术。其中8例经后腹腔途径完成,4例采用经腹途径完成。手术时间75~121min,平均108min;出血量50~400ml,平均150ml;术后住院时间5~8d,平均6.6d;术后无肾脏继发出血、漏尿等外科并发症。病理报告肾透明细胞癌11例,肾错构瘤1例。结论:不阻断肾动脉腹腔镜肾部分切除术对于经过R.E.N.A.L.评分系统筛选过的低度复杂性肿瘤患者安全可行,可以通过避免肾脏缺血而保护肾功能,有较好的临床应用价值。

Objective： To investigate the feasibility and clinical results of laparoscopic partial nephrectomy without renal artery clamping in patients with renal carcinoma. Method： Twelve cases （seven males and five fe- males） with unilateral single renal cell carcinoma undergoing laparoscopic partial nephrectomy without renal artery clamping were retrospectively analyzed from January 2016 to November 2016. The average age was 55.6 （range, 34-75） years old. The average BMI was 27.4 （range, 21.5-32.3） kg/m2. The contralateral kidney function was normal and tumors were partial exogenous. The average diameter of tumor was 2.9 （range, 1.5-5.0） cm, with the depth in renal parenchyma lower than 2 centimeter and the distance from tumor margin to renal collecting sys- tem was at least 7 milimeter. The R. E. N. E. L. score was 4.6 （range, 4-6）. Conventional placement of auxiliary Trocar in surgery, the assistant surgeon used the aspirator to maintain a clear vision. As for lager tumour, pre- stitching outside the cutting edge and shortening the into-needle and holding-needle time to reduce the amount of bleeding were needed. For the intravascular branch of the wound, hem-o-lock was pre-used to clamp it. Bleeding was firstly marked with aspirator compression and treated after tumor resection. Result： The operations were com- pleted by one doctor without conversion to open surgeries. Ten cases were succeed without renal artery clamping, while the renal artery of the other two was temporarily blocked in the surgery due to troublesome bleeding. Four cases were performed by transperitoneal approach and eight cases were performed by retroperitoneal approach. The average amount of bleeding was 150 （range, 50-400） ml, and average operation time was 108 （range, 75-121） min. The average postoperative hospital stay was 6.6 （range, 5-8）d. No hemorrhage or urine leakage was ob- served after surgery. The pathology findings： 11 cases was renal clear cell carcinoma, and one case was renal ham- artoma. Conclusion： Laparoscopic partial nephrectomy without renal artery clamping is safe and feasible for pa- tients with low-complexity tumors who had been screened by the R. E. N. A. L scoring system, which can protectrenal function by avoiding renal ischemia and have a better clinical application value.