腹腔镜肿瘤切除联合吸除术治疗中央型肾血管平滑肌脂肪瘤的疗效分析

Analysis of therapeutic effect of laparoscopic tumor resection combined with aspiration in the treatment of central renal angiomyolipoma

目的探讨腹腔镜肿瘤切除联合吸除术治疗中央型肾血管平滑肌脂肪瘤(RAML)的临床疗效。方法回顾性分析2015年11月至2018年8月收治的11例中央型RAML患者的临床资料,男3例,女8例。年龄35~58岁,平均(45.3±4.8)岁。体质指数22~27 kg/m^2,平均(24.9±1.8)kg/m^2。肿瘤位于左侧4例,右侧7例。内生型肿瘤4例,外生型肿瘤7例。肿瘤最大径4.2~8.9 cm,平均(6.7±2.4)cm。术前血清肌酐53~85μmol/L,平均(64.6±16.4)μmol/L。患侧肾小球滤过率(GFR)42~55 ml/min,平均(45.5±3.6)ml/min,对侧肾功能正常。其中8例接受后腹腔镜肿瘤切除联合吸除术,3例接受经腹腔入路腹腔镜肿瘤切除联合吸除术。根据术前检查结果先预判肿瘤成分,如以脂肪成分为主,血供不丰富,则先不阻断肾动脉,用剪刀或超声刀切开肿瘤包膜,用吸引器吸除肿瘤组织,待出血较多影响视野时再行肾动脉阻断,继续用吸引器吸除残留肿瘤组织;若肿瘤血供丰富,则阻断肾动脉,用剪刀切除大部分肿瘤后,用吸引器吸除残留的基底肿瘤。记录手术时间、热缺血时间、术中出血量、术后住院时间、术后并发症及手术效果。结果11例手术均顺利完成,无中转开放病例,1例术中损伤肾集合系统。手术时间95~126 min,平均(110.5±12.8)min。热缺血时间22~31 min,平均(27.6±3.3)min。出血量120~200 ml,平均(155.6±38.4)ml。术后住院时间5~7 d。术后病理诊断均为RAML。术后均无并发症发生。术后1个月复查血清肌酐为(66.7±15.5)μmol/L(P=0.380),患肾GFR为(43.2±3.3)ml/min(P=0.067),与术前比较差异均无统计学意义。术后随访13.9个月,11例均无肿瘤复发。结论腹腔镜肿瘤切除联合吸除术是治疗中央型RAML的一种安全、有效、微创的方法。

Objective To explore the clinical efficacy of laparoscopic tumor resection combined with aspiration for central renal angiomyolipoma(RAML).Methods Retrospective analysis of clinical data of 11 patients with central RAML between November 2015 and August 2018,including 8 females and 3 males,aged 35-58 years,mean(45.3±4.8)years;4 cases on the left side,7 cases on the right side,including 4 endophytic tumors,7 exophytic tumors;body mass index(BMI)22-27 kg/m^2,mean(24.9±1.8)kg/m^2.The maximum diameter of these tumors were 4.2-8.9 cm,with an average of(6.7±2.4)cm.The preoperative serum creatinine was 53-85μmol/L,with an average of(64.6±16.4)μmol/L,and the glomerular filtration rate(GFR)of the affected side was 42-55 ml/min,with an average of(45.5±3.6)ml/min.Lateral kidney function is normal.8 patients underwent retroperitoneal laparoscopic surgery and 3 cases underwent laparoscopic surgery.Based on the preoperative imaging,tumor tissue was aspirated as much as possible by suction device if the tumor got maximal fat component and had not abundant blood supply.Clamp the renal artery in case of bleeding affected the surgery vision.On the contrary,if the tumor had abundant blood supply,the renal artery was clamped first,then removed the section of tumor with scissor and the remaining basal tumor was aspirated totally by suction device.The operation time,warm ischemia time,intraoperative blood loss,postoperative hospital stay,postoperative complications and surgical results were analyzed.Results All the 11 cases were successfully completed without conversion to open surgery,only one case got injury of renal collection system.The operation time was 95-126 min,mean(110.5±12.8)min,and the blood loss was 120-200 ml,mean(155.6±38.4)ml.The warm ischemia time was 22-31 min,mean(27.6±3.3)min,and the postoperative hospital stay was 5-7 days.RAMLs were diagnosed by the postoperative pathological examination.The renal function was normal and no recurrence occurred in these patients at a mean follow-up of 13.9 months.All the 11 cases were successfully completed.Postoperative pathological diagnosis was RAML.There was no complication in the 11 cases.Preoperative serum creatinine and serum creatinine in the first month after surgery[(64.6±16.4)μmol/L vs.(66.7±15.5)μmol/L,P=0.38]and preoperative renal GFR and GFR in the first month after surgery[(45.5±3.6)ml/min vs.(43.2±3.3)ml/min,P=0.067],the difference was not statistically significant.No recurrence was observed in the 11 cases with an average follow-up of 13.9 months.Conclusions Our initial experience suggests that laparoscopic tumor resection combined with aspiration is a safe,effective and minimally invasive method for the treatment of central RAML.