腔镜时代选择开放术式治疗肾癌伴下腔静脉癌栓的影响因素

Factors associated with open surgery in the management of patients with renal carcinoma and inferior vena cava tumor thrombus in the laparoscope time

目的探讨在腔镜时代选择开放根治性肾切除术＋下腔静脉癌栓取出术的影响因素。 方法回顾性分析2015年1月至2017年3月我院收治的47例肾癌伴下腔静脉癌栓患者的临床资料。男37例，女10例。年龄29～84岁，平均61岁，其中≤65岁者33例，〉65岁者14例。肿瘤位于左侧10例，右侧37例。肿瘤最大径3.6～23.0 cm，平均9.1 cm，其中≥10 cm者17例，〈10 cm者30例。腹部增强CT检查示5例肿瘤侵犯邻近器官（包括腹膜、肝脏、十二指肠、结肠、腰大肌及肾上腺）。术前影像检查示腹膜后淋巴结肿大29例。癌栓Mayo分级：Ⅰ级13例，Ⅱ级21例，Ⅲ级9例，Ⅳ级4例。下腔静脉内癌栓长径1.0～20.0 cm，平均6.2 cm，其中〉7.0 cm者17例，≤7.0 cm者30例。47例均行根治性肾切除术＋下腔静脉癌栓取出术，其中行开放手术31例，腹腔镜手术16例。 结果多因素回归分析结果显示，术前癌栓分级Ⅲ级与选择开放手术显著相关（OR＝13.476，95%CI 1.044～173.882，P＝0.046），而患者年龄〉65岁（P＝0.679）、肿瘤最大径≥10 cm（P＝0.330）、肿瘤侧别（P＝0.220）、腹膜后淋巴结肿大（P＝0.308）及可疑邻近器官侵犯（P＝0.255）与选择开放手术无显著相关性。 结论肾癌伴Mayo≥Ⅲ级静脉癌栓是选择开放手术的决定性因素，而患者年龄〉65岁、肿瘤最大径≥10 cm、肿瘤侧别不是决定因素，腹膜后淋巴结肿大及可疑邻近器官侵犯是否与开放手术的选择相关仍需加大样本量后进一步探讨。

ObjectiveTo analyze clinical factors influencing the choice of open radical nephrectomy and inferior vena cava thrombus excision surgery. Methods47 patients who received open radical nephrectomy and inferior vena cava thrombus excision were enrolled between January, 2015 to March, 2017 retrospectively. Among the 47 patients, 37 were male, 10 were female. The average age was 61 years （29-84 years）, with 33 patients younger than 65-year old, 14 above this age. The tumor located in left in 10 patients, right in 37 patients. The average maximum diameter of tumor was 9.1 cm （3.6-23.0 cm）, with ≥10 cm in 17 patients, less than 10 cm in 30 patients. The enhanced abdominal CT showed 5 patients with suspected of extra-organ invasiveness. Pre-surgery images showed 29 patients were suspected of enlarged lymph nodes. 13, 21, 9 and 4 patients haveⅠ, Ⅱ, Ⅲ or Ⅳ grade tumor thrombus respectively. The average major axis of tumor thrombus was 6.2 cm（1.0-20.0 cm）, 〉7.0 cm in 17 patients, ≤7.0 cm in 30 patients. ResultsThere were 31 patients underwent open surgery, and the other 16 underwent laparoscopic surgery. Multivariate analysis showed Ⅲ or Ⅳ grade of tumor was associated with the choice of open surgery（OR=13.476, 95%CI 1.044-173.882, P=0.046）, but age〉65 years（P=0.679）, maximum diameter of tumor ≥10 cm（P=0.330）, the side of tumor（P=0.220）, suspected of enlarged lymph nodes（P=0.308） and suspected of extra-organ invasiveness（P=0.255） were not significantly associated with the choice of open surgery. ConclusionsⅢ or Ⅳ grade of tumor was the major factor affecting the choice of open surgery, while age〉65 years, maximum diameter of tumor ≥10 cm, the side of tumor were not the trigger for open sugery. Suspected of enlarged lymph nodes and suspected of extra-organ invasiveness remained to be studied.