肾部分切除术与根治性肾切除术治疗老年cT1~2期肾肿瘤围手术期指标及肾功能随访分析

Analysis of perioperative parameters and renal function in elderly patients with clinical T1-T2 renal masses treated by partial nephrectomy and radical nephrectomy

目的比较≥65岁cT1~2期肾肿瘤患者接受肾部分切除术(PN)与根治性肾切除术(RN)的围手术期指标及肾功能随访情况。方法回顾性分析2012年1月至2018年11月收治的469例≥65岁cT1~2期肾肿瘤患者的临床资料。根据手术方式分为2组,RN组247例,PN组222例。RN组男170例,女77例;年龄(70.96±5.21)岁;肿瘤位于左侧126例,右侧121例;肿瘤直径(4.93±2.03)cm;体质指数(24.4±3.1)kg/m2;R.E.N.A.L.评分(8.39±1.45)分;术前估算肾小球滤过率(eGFR)(80.23±15.14)ml/(min·1.73m2)。PN组男150例,女72例;年龄(70.23±4.62)岁;肿瘤位于左侧108例,右侧114例;肿瘤直径(3.17±1.41)cm;体质指数(23.5±3.2)kg/m2;R.E.N.A.L.评分(6.69±1.81)分;术前eGFR(82.83±14.36)ml/(min·1.73m2),两组患者的年龄、性别、肿瘤侧别、体质指数差异无统计学意义(P>0.05),肿瘤直径、R.E.N.A.L.评分差异有统计学意义(P<0.05)。比较两组的手术时间、术中失血量、围手术期输血率、引流管留置时间、术后住院时间、病理结果,以及及术后即刻,1个月,1、2、3、4、5年的肾功能情况。结果 RN组的手术时间短于PN组[(115.70±39.69)min与(132.26±49.02)min,P<0.05],术中出血量少于PN组[(45.85±55.93)ml与(66.60±61.55)ml,P<0.05],但两组的围手术期输血例数[27例(10.93%)与20例(9.01%)]差异无统计学意义(P>0.05)。RN组引流管留置时间[(4.38±1.71)d与(4.86±1.61)d]、术后住院时间[(5.14±1.65)d与(5.52±1.32)d]均短于PN组(P<0.05)。RN组术后病理确诊为肾细胞癌231例(93.5%),其中透明细胞癌196例,非透明细胞癌35例;PN组术后病理确诊为肾细胞癌192例(86.5%),其中透明细胞癌164例,非透明细胞癌28例,RN组诊断肾细胞癌的比例显著高于PN组(P<0.05),两组肾透明细胞癌所占比例差异无统计学意义(P>0.05)。PN组术后即刻[(74.08±18.31)ml/(min·1.73m2)与(52.58±14.21)ml/(min·1.73m2)]、术后1个月[(76.11±18.34)ml/(min·1.73m2)与(53.78±15.03)ml/(min·1.73m2)]及末次随访时[(73.92±18.59)ml/(min·1.73m2)与(52.35±16.13)ml/(min·1.73m2)]的eGFR均显著优于RN组(P<0.001)。PN组术后即刻[9.01%(20/222)与31.9%(79/247)]、1个月[7.87%(14/178)与27.31%(62/227)]、1年[8.96%(13/145)与38.75%(62/160)]、2年[9.89%(9/91)与31.57%(42/133)]、3年[13.21%(7/53)与30.61%(30/98)]、4年[16.21%(6/37)与30.26%(23/76)]、5年[18.18%(4/22)与31.11%(14/45)]出现eGFR<45 ml/(min·1.73m2)患者的比例均显著低于RN组(P<0.001)。结论与RN相比,PN治疗≥65岁cT1~2期肾肿瘤患者的围手术期风险可控,并能保留较多的肾功能,降低术后慢性肾功能不全的发生率。

Objective To compare the perioperative parameters and renal function in patients, whose aged was 65 year-old or above, with clinical T1-2 renal tumors undergoing partial nephrectomy (PN) or radical nephrectomy (RN). Methods A retrospective review of 469 patients, who underwent RN and PN in our center, was conducted from January 2012 to November 2018, icluding 247 in the RN group and 222 in the PN group. The RN group consisted of 170 male and 77 female patients, with the mean age of (70.96±5.21) year-old. 126 cases were found that the tumor located on the right side, with the median diameter of (4.93±2.03)cm. The median BMI, median R. E.N.A.L. score and pre-operation eGFR of the RN group were (24.4±3.1)kg/m2, 8.39±1.45) and (80.23±15.14) ml/(min·1.73m2), respectively. The PN group consisted of 150 male and 72 female patients, with the mean age of (70.23±4.62) years old. 108 patients had tumors on the left side while 114 on the right side, with the median diameter of (3.17±1.41) cm. The median BMI, median R. E.N.A.L score and pre-operation eGFR of the PN group were (23.5±3.2) kg/m2,(6.69±1.81) and (82.83±14.36) ml/(min·1.73m2), respectively. No statistical difference was noticed in the age, gender, tumor location and BMI between RN group and PN group(P>0.05). The PN group had smaller tumors and lower R. E.N.A.L. scores than the RN group(P<0.05). Various parameters were compared between the PN and RN groups, including operative duration, surgical procedure, intraoperative blood loss, perioperative blood transfusion, drainage tube removal time, postoperative duration of hospitalization, pathological results, the renal function immediately after surgery and at 1 month, 1 year, 2 years, 3 years, 4 years, 5 years after surgery, and the incidence of chronic renal dysfunction.Results Significant differences were found in multiple variables between the two cohorts, such as operative duration [(115.70±39.69)min in RN vs.(132.26±49.02) min in PN], estimated intraoperative blood loss [(45.85±55.93)days in RN vs.(66.60±61.55)ml in PN], drainage tube removal time [(4.38±1.71)days in RN vs.(4.86±1.61)days in PN], duration of postoperative hospitalization [(5.14±1.65)days in RN vs.(5.52±1.32)days in PN](P<0.05). Furthermore, higher proportion of RCC was detected in the RN cohort (93.5% in RN vs. 86.5% in PN, P<0.05). There was no significant difference in perioperative blood transfusion rate between the two cohorts (10.93% vs. 9.01%, P>0.05). Compared with the RN cohort, the PN cohort had higher eGFR immediately after surgery [(74.08±18.31)ml/(min·1.73m2) vs.(52.58±14.21) ml/(min·1.73m2)], 1 month after surgery [(76.11±18.34)ml/(min·1.73m2) vs.(53.78±15.03)ml/(min·1.73m2)] and at the last follow-up [(73.92±18.59)ml/(min·1.73m2)vs.(52.35±16.13)ml/(min·1.73m2)](P<0.001). Compared with those of the RN cohort, the incidences of eGFR<45 ml/(min·1.73m2) of the PN cohort were lower immediately after surgery [9.01%(20/222) vs. 31.9%(79/247)], 1 month after surgery [7.87%(14/178) vs. 27.31%(62/227)], 1 year after surgery [8.96%(13/145) vs.38.75%(62/160)], 2 years after surgery [9.89%(9/91) vs. 31.57%(42/133)], 3 years after surgery [13.21%(7/53) vs. 30.61%(30/98)], 4 years after surgery [16.21%(6/37) vs. 30.26%(23/76)] and 5 years after surgery [18.18%(4/22) vs. 31.11%(14/45)](P<0.001). Conclusion The perioperative risk of PN in the treatment of elderly patients aged 65 and above with clinical cT1-2 renal tumor is controllable. PN could better retain renal function for those patients and reduce the risk of postoperative chronic renal insufficiency.