影响腹腔镜下无阻断肾部分切除术实施的危险因素分析

Analysis of risk factors affecting the application of off-clamp procedure during laparoscopic partial nephrectomy

目的探讨影响无阻断技术在腹腔镜下肾部分切除术(LPN)中应用的危险因素。方法回顾性分析94例拟行无阻断LPN手术患者的围手术期资料。采用单变量分析筛选影响无阻断技术实施的变量。利用Logistic回归分析筛选出影响无阻断技术实施的独立危险因素,采用受试者工作特征曲线对危险因素的预测效力进行评价。结果 32例(34.0%)患者因明显出血而中止无阻断技术转为动脉阻断。阻断组术后3个月患肾估算肾小球滤过率(eGFR)的下降稍高于无阻断组。年龄、体重指数、糖尿病史、eGFR以及肿瘤直径、部位和R.E.N.A.L.评分与无阻断技术的中止显著相关( P <0.3)。年龄较轻( OR 值0.78)、eGFR较高( OR 值3.31)、肿瘤直径较大( OR 值2.19)、肾门部肿瘤( OR 值4.62)、内生性肿瘤( OR 值3.15)以及R.E.N.A.L.评分较高( OR 值2.72)被认为是独立的危险因素。年龄、eGFR、肿瘤直径以及R.E.N.A.L.评分的曲线下面积分别为0.674、0.725、0.826及0.892。结论肾功能较好和肿瘤较复杂会增加无阻断技术的失败率。患者年龄、eGFR、肿瘤直径和R.E.N.A.L.评分可以作为在LPN中采用无阻断技术的术前筛选标准。

Objective To find out risk factors impeding the application of off-clamp technique during laparoscopic partial nephrectomy (LPN). Methods The perioperative data of 94 patients who have undergone LPN with initial intention of off-clamp technique have being collected. Univariate analyses were used to determine variables having correlation with the conversion of off-clamp into on-clamp during surgery. Afterwards, Logistic regression has been applied to find out independent risk factors, whose predictive value were evaluated by receiver operating characteristic curve finally. Results Off-clamp technique has discontinued in 32 patients (34.0%) due to severe hemorrhage, and the rate of estimated glomerular filtration rate (eGFR) decline 3 months post-surgery in these patients was slightly higher than those with off-clamp technique. Age, body mass index, history of diabetes mellitus, eGFR, as well as tumor size, location and R.E.N.A.L. nephrectomy score (RENAL-NS) had significant correlation with conversion ( P <0.3). Younger age ( OR =0.78), higher eGFR ( OR =3.31), larger tumor ( OR =2.19), hilar tumor ( OR =4.62), endophytic tumor ( OR =3.15), as well as higher RENAL-NS ( OR =2.72) were found to be the independent risk factors. The areas under curve were 0.674 for age, 0.725 for eGFR, 0.826 for tumor size, and 0.892 for RENAL-NS. Conclusions Better renal function and more complexity of tumor were associated with higher risk of off-clamp failure. Age, eGFR, tumor size and RENAL-NS have favorable predictive value and can be used as inclusion criteria for off-clamp LPN.