不同保留肾单位术式对T2肾癌疗效及安全性评价

The comparative study on clinical effects of different nephron-sparing surgical methods for T2a renal cell carcinoma

目的对比经腹腹腔镜、后腹腔镜和开放手术3种保留肾单位手术方式治疗局限性肾癌的临床效果。方法回顾分析2008年3月~2015年3月于我院泌尿外科诊治的局限性肾癌患者99例,根据术式分为经腹腹腔镜保留肾单位肿瘤切除组35例(A组)、后腹腔镜手术组30例(B组)和开放手术组32例(C组)。对比3组患者手术时间、肾脏热缺血时间、术中出血量、住院时间、术后复发、转移情况,术中及术后并发症及治疗前后肾功能指标,并进行统计学分析。结果经腹组和腹膜后组各1例,因肿瘤周围广泛粘连中转开放手术,给予除外本研究,最终纳入97例。3组手术中,经腹腹腔镜组和后腹腔镜组手术时间差异无统计学意义,两组手术时间均高于开放手术组(P>0.05)。3组术中出血量比较差异均有统计学意义(P<0.05),输血例数比较差异无统计学意义(P>0.05),腹腔引流管留置时间比较差异无统计学意义(P<0.05)。而经腹腹腔镜组和后腹腔镜组术后住院时间明显低于开放手术组,有统计学意义(P<0.05)。术前及术后三组肾功能指标GFR、BUN及Scr比较,差异无统计学意义(P>0.05)。R.E.N.A.L评分与平均手术时间、失血量、肾缺血时间直接差异有统计学意义(P<0.05),而与术后肌酐变化无相关性(P>0.05)。结论不同保留肾单位术式在治疗选择性临床T2期肾癌安全,可以取得较好的肿瘤控制效果并能保护肾功能,R.E.N.A.L评分是评估T2期肾癌保留肾单位手术可行性的一个重要指标。

Objective To compare the clinical effect of three different nephron-sparing surgical methods including peritoneal laparoscopy,retroperitoneal laparoscopy and open surgery for localized renal carcinoma.Methods The clinical data of 99 patients with localized renal carcinoma from March 2008 to March 2015 were retrospectively analyzed. According to the methods of operation,they were divided into three groups,group A(35 patients, underwent peritoneal laparoscopic excision), group B(30 patients, underwent retroperitoneal laparoscopic excision) and group C(32 patients, underwent open surgery). The operating time, renal warm ischemia time, blood loss, hospital stay, postoperative recurrence and metastasis were compared among the three groups and were statistically analyzed.Results 1 cases in the abdominal group and the retroperitoneum group were transferred to open surgery because of extensive adhesion around the tumor, except for this study, and 97 cases were eventually included. The operation time of group A, group B and group C were(145.3±32.4)min and(126.4±33.1)min and(114±31.3)min, respectively. There was no significant difference in operative time between the abdominal laparoscopy group and the laparoscopic group. The operative time in the two groups was higher than that in the open operation group(P<0.05). The bleeding volume in group A, group B and group C were(111.3±36.2) ml,(124±52.7) ml and(192.6±78.1) ml, respectively, and the difference between the three groups was statistically significant(P<0.05). The number of blood transfusion in group A, group B and group C were 8 cases, 6 cases and 10 cases, respectively. There was no significant difference between the three groups(P>0.05). The indwelling time of abdominal drainage tube of group A, group B and group C were(7.1±3.2) d,(5.4±2.4) d and(5.3±1.6) d, respectively, and there was no significant difference between the three groups(P<0.05). The hospitalization time of were were(11.6±4.3) d,(10.1±3.6)d and(13.8±3.2) d, respectively. The time of hospitalization in the abdominal laparoscopy group and the retroperitoneoscope group was significantly lower than that in the open operation group, with statistical significance(P<0.05). There was no significant difference in renal function indexes GFR, BUN and Scr between the three groups before and after operation(P>0.05).There was a significant difference between the R.E.N.A.L score and the average operation time, blood loss and renal ischemia time(P<0.05), but no correlation with creatinine changes(P>0.05). The postoperative complications were classified by Clavien system, 16 cases were I grade(including postoperative fever, pain, vomiting, 10 cases in the open group, 3 cases in the abdominal group and the retroperitoneal group), 7 cases were II(including the addition of antibiotics, blood transfusion, 3 cases in the open group, 2 cases in the abdominal group and the retroperitoneum group) in 2 cases(the double J tube was placed under the leak urine endoscope after the operation. All of them were endoscopy, 1 case in the abdominal group and the retroperitoneal group. The pathological results were 82 cases of clear cell carcinoma, 1 cases of multi chamber cystic renal carcinoma, 11 cases of papillary cell carcinoma and 3 cases of chromophobe cell carcinoma. The incision margin was negative after operation. No recurrence or metastasis was observed after three years follow-up. Conclusion In the treatment of selective clinical T2 stage renal carcinoma, the different kidney preservation methods can achieve better control effect and protect the renal function. The R.E.N.A.L score is an important index for evaluating the feasibility of renal unit operation in T2 stage renal cell carcinoma.