肾癌根治性切除加癌栓取出术治疗Mayo Ⅲ级下腔静脉癌栓的手术技术及临床经验

Radical nephrectomy and thrombectomy for Mayo clinic stage Ⅲ tumor thrombus:a surgical technique and clinical experience

目的:探讨肾癌根治性切除加下腔静脉癌栓取出术治疗MayoⅢ级下腔静脉癌栓(inferior vena cava tumor thrombus,IVCTT)的有效性和安全性,总结手术技术及临床经验。方法:回顾性分析2014年10月至2016年9月北京大学第三医院泌尿外科收治的8例肾癌合并MayoⅢ级(美国Mayo医学中心分级法)IVCTT患者的临床资料。8例患者中男性3例,女性5例,年龄18~77岁,平均(58.0±18.7)岁,体重指数(body mass index,BMI)为15.2~30.8 kg/m^2,平均(22.7±4.4)kg/m^2。8例患者的肿瘤均位于右侧,肿瘤直径(7.9±2.5)cm。行开放肾癌根治性切除加下腔静脉癌栓取出术者5例,行腹腔镜下肾癌根治性切除加下腔静脉癌栓取出术者3例,其中1例患者行中转开放手术。结果:8例患者手术均顺利完成,无围术期死亡病例。手术时间272~567 min,平均(370.3±101.6)min。下腔静脉阻断时间17~55 min,平均(41.0±12.1)min。术中出血量200~3 000 m L,平均(1 181.3±915.7)m L。术中输注悬浮红细胞者5例,输入量800~2 000 m L,平均(850.0±783.8)m L。术中输注血浆者3例,输入量400~1 000 m L。术后住院时间9~23 d,平均(14.1±4.0)d。8例患者中4例因术中发现癌栓侵犯下腔静脉壁而行下腔静脉壁切除术。8例患者术前血肌酐值60~101μmol/L,平均(76.4±15.3)μmol/L,术后1周血肌酐值74~127μmol/L,平均(100.8±21.1)μmol/L。术后组织病理检查诊断为肾透明细胞癌(renal clear cell carcinoma,RCC)6例,肾乳头状腺癌(papillary adenocarcinoma)1例,Fuhrman分级为Ⅲ级6例、Ⅳ级1例,尤文肉瘤(Ewing’s sarcoma)1例。8例患者中,5例发生术后早期并发症,均为ClavienⅡ级并发症,未见严重并发症发生。8例患者均获随访,随访时间2~24个月,平均11.3个月。术前未发现远处转移的7例患者中,出现远处转移1例,为肺转移。结论:肾癌根治性切除加下腔静脉癌栓取出术治疗MayoⅢ级下腔静脉癌栓较为有效、安全。Ⅲ级静脉癌栓延伸范围广,手术技术难度较大,充分的术前准备、丰富的解剖学知识和手术操作经验可提高手术安全性。

Objective： To evaluate the effectiveness and safety of radical nephrectomy and inferior vena cava thrombectomy in the treatment of patients with Mayo Ⅲ tumor thrombus,and to introduce our experience and surgical technique. Methods： The clinical data of 8 patients with Mayo Ⅲ tumor thrombus from October 2014 to September 2016 were analyzed retrospectively. Of the 8 patients,3 were male and5 were female. The average age was（50. 8 ± 18. 7） years（18 to 77 years）. The average body mass index（BMI） was（22. 7 ± 4. 4） kg/m^2（15. 2 to 30. 8 kg/m^2）. Imaging suggested the right renal tumor in all the 8 cases. The average tumor size was（7. 9 ± 2. 5） cm. Open radical nephrectomy and inferior vena cava thrombectomy was conducted in 5 cases and laparoscopic surgery in 3 cases,and 1 case was converted to open surgery. Results： All the 8 surgeries were completed successfully with no death case. The average surgery time was（370. 3 ± 101. 6） min,ranging from 272-567 min. The average vena cava blocked time was（41. 0 ± 12. 1） min,ranging from 17-55 min. The blood loss volume was（1 181. 3 ±915. 7） m L,ranging from 200-3 000 m L. During the operation,5 cases were infused with suspended red blood cells,the amount of blood transfusion was 800-2 000 m L. 3 cases were infused of plasma with400-1 000 m L. The average hospital stay was 9-23 d,with an average of（14. 1 ± 4. 0） d. In the 8patients,4 cases underwent inferior vena cava wall resection because of invasion by tumor thrombus. Preoperative serum creatinine was 60-101 μmol/L,with an average of（76. 4 ± 15. 3） μmol/L. Serum creatinine 1 week after the operation was 74-127 μmol/L,with an average of（100. 8 ± 21. 1） μmol/L.Pathological diagnosis showed 6 cases of clear cell carcinoma,1 case of papillary carcinoma type Ⅱ,and1 case of Ewing＇s sarcoma. Among the 8 patients,early postoperative complications occurred in 5 cases.Postoperative complications were graded as level Ⅱ,according to the Clavien classifications. The 8 cases were followed up for 2 to 24 months with an average of 11. 3 months. There was 1 patient who suffered from lung metastasis. Conclusion： Our initial clinical results show that radical nephrectomy and inferior vena cava thrombectomy is safe and effective for patients with Mayo Ⅲ tumor thrombus. The wide extension of grade Ⅲ vein tumor thrombus leads to the difficulty of operation technique. Sufficient preoperative preparation,rich operative experience and skills can improve the safety of operation.