腹腔镜手术治疗肾癌伴静脉癌栓的初步经验

Initial experience in the treatment of renal cell carcinoma with venous tumor thrombus using laparoscopic surgery

探讨腹腔镜手术(包括普通腹腔镜和机器人辅助腹腔镜)在治疗肾癌伴静脉癌栓患者中的安全性和有效性。方法回顾性分析上海长征医院2016年2月至2018年12月期间共18例接受腹腔镜手术(包括普通腹腔镜和机器人辅助腹腔镜)的肾癌伴静脉癌栓患者的临床资料。其中男14例、女4例;年龄32~77岁,平均(59.7±10.1)岁;术前肌酐53~147 μmol/L,平均(94.2±26.2)μmol/L。静脉癌栓Mayo分级:0级5例、Ⅰ级6例、Ⅱ级7例。普通腹腔镜手术6例、机器人辅助腹腔镜手术12例;左侧肾癌6例、右侧肾癌12例。结果所有患者手术均顺利完成,无中转开腹。术中均采用经腹腔途径,具体手术步骤根据癌栓分级、肿瘤方向而有所不同;手术时间165~615 min,平均(295.2±123.7)min;术中出血量100~1 500 ml,平均(458.3±431.8)ml;术中输血6例。术后病理:透明细胞癌13例、乳头状细胞癌4例、肾嫌色细胞癌与嗜酸性细胞肿瘤的混合肿瘤1例。18例患者均获随访,随访1~34个月,平均14个月,其中1例术后20个月死亡。结论腹腔镜手术(包括普通腹腔镜和机器人辅助腹腔镜)对肾癌伴静脉癌栓患者,特别是Ⅱ级及以下的癌栓患者,是安全、有效的治疗方法。但具体的手术方案需结合患者的肿瘤位置、癌栓分级及术者腹腔镜手术熟练度来制订,从而使患者得到最大的收益。

Objective To investigate the safety and efficacy of laparoscopic surgery, including conventional laparoscopy and robot-assisted laparoscopy, in the treatment of renal cell carcinoma with vein tumor thrombosis. Methods A retrospective analysis was performed on the clinical data of 18 patients of renal cell carcinoma with vein tumor thrombosis under laparoscopic surgery including conventional laparoscopy and robot-assisted laparoscopy in Shanghai Changzheng Hospital from Feb. 2016 to Dec. 2018, with an average age of (59.7±10.1) years (range 32-77, 14 men and 4 women);Their average preoperative creatinine level was (94.2±26.2)μmol/L (ranged 53- 147 μmol/L);The tumors were located on the left side in 6 patients and the right side in 12 patients;There were 5 cases of grade 0, 6 cases of grade Ⅰ and 7 cases of grade Ⅱ for venous tumor thrombus based on Mayo Grading System. Conventional laparoscopic surgeries were performed in 6 patients and 12 patients were under robot-assisted laparoscopic surgeries. Results All surgeries were completed successfully without conversion to laparotomy. Transabdominal approach was adopted during the surgery and the specific surgical procedures were different according to the grade of tumor thrombus and tumor location. The mean operation time was(295.2±123.7)minutes (range165-615 min). The average blood loss was(458.3±431.8)ml (range 100-1 500 ml), and 6 patients were intraoperative blood transfused. The final pathology revealed clear-cell, papillary and composed of an eosinophilic subtype of chromophobe renal cell carcinoma in 13, 4 and 1 patient, respectively. The mean follow-up period was 14 months(range 1-34 months) of all 18 patients and 1 patient died after 20 months. Conclusions Laparoscopic surgery, including conventional laparoscopy and robot-assisted laparoscopy, is a safe and effective treatment for patients of renal cell carcinoma with vein tumor thrombosis, especially those with grade Ⅱ or below. However, the specific operation scheme should be formulated by combination with the patient′s tumor location, the grade of the tumor thrombus and the proficiency of the surgeon, so as to maximize the benefits for the patient.