腹腔镜和开放肾癌根治性切除+Mayo Ⅱ级下腔静脉癌栓取出术11例临床分析

Clinical experience of laparoscopic and open radical nephrectomy plus Mayo Ⅱ inferior vena cava thrombectomy(report of 11 cases)

目的总结腹腔镜和开放肾癌根治性切除+下腔静脉癌栓取出术治疗MayoⅡ级下腔静脉癌栓(IVCTT)的手术技巧及临床经验。方法回顾性分析2015年2月至2016年8月北京大学第三医院泌尿外科收治的11例肾癌合并MayoⅡ级IVCTT患者的临床资料。11例患者中男性9例,女性2例;年龄29~84岁,平均(60.5±14.5)岁。体重指数(BMI)16.4~33.3,平均25.7±5.3。9例患者肿瘤位于右侧,2例位于左侧。肿瘤直径4.5~21.1cm,平均(9.3±4.7)cm。本组中行开放手术4例。行完全腹腔镜手术6例,其中完全经后腹腔途径腹腔镜手术者4例,经后腹腔途径联合经腹腔途径腹腔镜手术者2例。1例患者先在后腹腔途径腹腔镜下行右肾根治性切除术,后中转开放行下腔静脉癌栓取出术。结果本组11例患者手术均顺利完成,无术中及围术期死亡病例。11例患者手术时间171~567 min,平均(365.5±149.8)min;术中出血量200~2 000 mL,平均(1 077.3±684.6)mL。术中输注悬浮红细胞者7例,输血量400~1 600mL,平均(857.1±427.6)mL。术中输注血浆者3例,输血量为400~800mL。术后住院日期5~28d,平均(12.7±6.4)d。11例患者中7例行同侧肾上腺切除术。4例患者因术中发现癌栓侵犯下腔静脉壁而行下腔静脉壁切除术。11例患者术前血肌酐值51~195μmol/L,平均(104.1±36.2)μmol/L,术后1周血肌酐值53.0~414.0μmol/L,平均(159.5±126.2)μmol/L。术后病理诊断为肾透明细胞癌(RCC)9例,肾乳头状腺癌2例。Fuhrman分级Ⅱ级4例,Ⅲ级4例,Ⅳ级3例。本组中5例发生术后早期并发症,改良Clavien分级系统Ⅱ级2例,IVa级3例。结论肾癌根治性切除+下腔静脉癌栓取出术虽然手术难度大、技术复杂,但治疗MayoⅡ级IVCTT较为有效、安全。对于合适的患者可选择腹腔镜手术方式。

Objective To introduce our experience and surgical technique of radical nephrectomy and inferior vena cava thrombectomy for Mayo Ⅱ inferior vena cava tumor thrombus（IVCTT）.MethodsThe clinical data of 11 cases of IVCTT treated during Feb.2015 and Aug.2016 were retrospectively analyzed,including 9 males and 2 females.The patients’ average age was（60.5±14.5）（29-84）years,and the average body mass index（BMI） was 25.7±5.3（16.4 to 33.3）.Imaging indicated right renal tumor in 9 cases and left tumor in 2 cases.The average tumor size was（7.9±2.5）（4.5 to 21.1）cm.Open radical nephrectomy was conducted in 4 cases.Laparoscopic radical nephrectomy plus Inferior vena cava thrombectomy was conducted in 6 cases,4 of which were through retroperitoneal approach and 2 through retroperitoneal combined with transperitoneal approach.One case underwent laparoscopic radical nephrectomy first and then converted to open surgery.ResultsAll 11 operations were completed successfully without intraoperative and perioperative mortality.The average operation time was （365.5±149.8）min,ranging 171-567 min.The blood loss volume was （1 077.3±684.6）mL,ranging 200-2 000 mL.During the operation,suspended red blood cells were infused in 7 cases,with the amount of 400-1 600 mL.Plasma was infused in 3 cases,with the amount of 400-800 mL.The hospital stay was 5-28 d,with an average of（12.7±6.4） d.Of all 11 cases,7 underwent ipsilateral adrenal gland resection,and 4 cases underwent inferior vena cava wall resection due to invasion.Preoperative serum creatinine was 51-195 μmol/L,with an average of（104.1±36.2） μmol/L.Serum creatinine 1 week after the operation was 53.0-414.0 μmol/L,with an average of（159.5±126.2） μmol/L.Pathological diagnosis showed 9 cases of clear cell carcinoma,2 cases of papillary carcinoma type Ⅱ,Fuhrman grade Ⅱ in 4 cases,grade Ⅲ in 4 cases,and grade Ⅳ in 3 cases.Early postoperative complications occurred in 5 cases,graded as level Ⅱ in 2 cases and level Ⅳa in 3 cases according to the Clavien classifications.ConclusionsAlthough technically complex and challenging,radical nephrectomy plus inferior vena cava thrombectomy is safe and effective in the treatment of Mayo Ⅱ IVCTT.Different laparoscopic approach can be selected to yield the optimal results.