双波长激光腹腔镜下不阻断肾动脉保留肾单位手术的疗效

The efficiency of using dual laser system zero in off clamp nephron-sparing surgery

目的探讨应用双波长激光进行不阻断肾动脉（零缺血）保留肾单位手术（nephron－sparing surgery，NSS）的效果。 方法2016年1月至2017年4月我院收治的24例肾肿瘤患者。男16例，女8例。年龄32～62岁，平均49岁。左肾肿瘤13例，右肾肿瘤11例。肿瘤最大径0.8～3.2 cm，平均1.9 cm。R.E.N.A.L评分3～6分，平均3.8分。中山评分3～5分，平均3.5分。零缺血指数（zero ischemia index，ZII）1～4，平均1.6。24例均全麻下行双波长激光腹腔镜下零缺血NSS。采用Evolve双频激光系统发射双波长激光（980 nm/1 470 nm），采用连续发射模式，发射功率60 W。按照常规后腹腔镜手术体位和步骤，分离肾动脉后以标识带标记但不阻断，沿肿瘤边缘正常肾组织以激光烧灼标记，然后以双波长激光沿肿瘤包膜切割。在肿瘤基底部将激光切割由垂直方向改为水平方向。创面内较大的血管断端以激光点状凝固，创面以倒刺线单层或者双层连续缝合。 结果本组24例手术中，22例顺利完成腹腔镜下零缺血NSS，2例因术中创面出血而阻断肾动脉。手术时间50～100 min，平均（74.2±16.7）min。术中出血量10～200 ml，平均（52.9±55.6）ml。术后伤口引流量20～150 ml，平均（65.4±34.4）ml。术后住院时间4～7 d，平均（5.2±0.9）d。术后未发生严重外科并发症。术前血肌酐48～112 μmol/L，平均（76.2±21.5）μmol/L；术后为54～122 μmol/L，平均（81.5±19.0）μmol/L，差异无统计学意义（P〉0.05）。病理诊断：肾透明细胞癌20例，肾嫌色细胞癌3例，乳头状肾细胞癌1例。24例随访1～12个月，平均（7.2±3.2）个月，均未见复发和转移。 结论双波长激光提供了一种进行零缺血NSS的有效选择，该技术可以在肾功能保护、术中出血及肿瘤切除三者之间达到一个相对的平衡。

ObjectiveTo evaluate the efficacy of using dual laser system in off clamp nephron-sparing surgery. MethodsWe used dual laser system in the patients who underwent off-clamp NSS between Jan 2016 and Apr 2016 in our institution. There were 16 males and 8 females with average age of 49 years. Mean tumor size was 1.9 cm （range 0.8-3.2 cm）. The mean R. E.N.A.L. score was 3.8（range 3-6）. The mean Zhongshan score was 3.5（range 3-5）. The mean ZII（zero ischemia index）was 1.6（range 1-4）. The Evolve Dual （980 nm/1 470 nm） laser system set at 60 W in continuous mode was used. ResultsOff-clamp NSS was successfully performed in 22 patients except for renal artery occlusion in 2 case. Mean operative time was 74 min（range 50-100 min）; The average estimated blood loss was 52.9 ml（range 10-200 ml）; Mean postoperative drainage was 65.4 ml（range 20-150ml）; Mean postoperative hospital stay was 5.2 days （range： 4-7days）. No severe post-operative complication was found. The mean pre- and postoperative serum creatinine levels were 76.2 μmol/L（range： 48-112μmol/L） and 81.5μmol/L（range： 54-122 μmol/L） with no significant difference（P〉0.05）. The postoperative pathology indicated that 20 cases of clear cell carcinomas, 3 cases of chromophobe renal cell carcinomas, one case of papillary carcinoma. ConclusionsDual laser system can be used in off clamp nephron-sparing surgery safely and effectively.