腹腔镜与机器人辅助腹腔镜肾部分切除术治疗肾门肿瘤的疗效比较

Laparoscopic versus robot-assisted partial nephrectomy for renal hilar tumors: comparison of perioperative, functional and oncological outcomes

目的:比较腹腔镜下肾部分切除术(LPN)与机器人辅助腹腔镜下肾部分切除术(RAPN)对于处理肾门肿瘤的临床疗效及安全性。方法:回顾性分析2015年8月~2018年12月在我院行肾部分切除手术的109例肾门肿瘤患者的临床资料,根据手术方式不同分为LPN组(n=59)和RAPN组(n=50)。LPN组男38例,女21例;年龄(56.4±14.2)岁;BMI(25.1±3.8) kg/m^2;肿瘤中位最大径3.8(1.7~5.8) cm;R.E.N.A.L.评分(8.6±1.9)分;术前肌酐(68.1±24.5)μmol/L,估算肾小球滤过率(eGFR)为(91.3±22.4) ml/min。RAPN组男28例,女22例;年龄(58.5±11.6)岁;BMI(24.7±4.2) kg/m^2;肿瘤中位最大径4.3(1.4~6.9);R.E.N.A.L.评分(9.3±1.8)分;术前肌酐(64.5±19.7)μmol/L,eGFR(94.3±23.5) ml/min。LPN组和RAPN组患者在年龄、性别、BMI、术前肌酐、术前eGFR、肿瘤最大径及R.E.N.A.L.评分方面比较差异均无统计学意义(P>0.05)。分析两组患者术中手术方式改变、术中手术时间、肾脏热缺血时间、出血量、术中术后输血等围手术期和随访情况方面的差异。结果:LPN组59例中,3例因术中发现肾门肿瘤与肾动脉粘连明显,2例因缝合后创面大量渗血无法很好止血,故予以行腹腔镜下根治性肾切除术;2例患者因术中出血明显致视野不清,遂改开放肾部分切除术。RAPN组50例中,仅1例(2.0%)因肾门肿瘤浸润肾动脉故改行根治性肾切除术。LPN组术中更改手术方式的比例明显高于RAPN组[11.9%(7/59)vs.2.0%(1/50),P<0.05]。剔除术中手术方式改变病例后,LPN组(52例)和RAPN组(49例)在手术时间[(204.5±64.7) min vs.(156.8±54.9) min]、热缺血时间[(28.5±9.2) min vs.(22.4±6.5)min]、术中出血量[(258.4±88.6) ml vs.(154.6±78.8) ml]和术中术后输血率[30.8%(16/52)vs.10.2%(5/49)]方面比较差异均有统计学意义(P<0.05)。此外,RAPN组患者术后引流管留置时间和术后住院时间均明显短于LPN组(P<0.05)。LPN组和RAPN组随访时间比较差异无统计学意义[21.5(1.2~39.2)个月vs.16.5(0.8~30.1)个月,P>0.05]。术后LPN组的eGFR降低值明显高于RAPN组[(17.8±13.1) ml/min vs.(6.8±12.6) ml/min,P<0.05]。LPN组肿瘤复发及远处转移率要明显高于RAPN组[17.3%(9/52) vs.4.1%(2/49),P<0.05]。结论:与LPN相比,RAPN对于肾门肿瘤在减少手术创伤、降低热缺血损伤、减少术中出血、保护肾功能、缩短住院时间及控制肿瘤复发方面均具有明显优势,RAPN是一种治疗肾门肿瘤微创、安全性高、疗效确切的手术方法。

Objective: To compare the clinical efficacy and safety between laparoscopic partial nephrectomy(LPN) and robot-assisted partial nephrectomy(RAPN) for renal hilar tumors. Method: A retrospective analysis was conducted based on the perioperative clinical data of 109 patients who underwent nephron sparing surgery(RAPN versus LPN) for renal hilar tumor at the first affiliated hospital of Nanjing Medical University between August 2015 and December 2018. There were 38 males and 21 females in LPN group. Their age was(56.4±14.2) years old. The body mass index(BMI) was(25.1±3.8) kg/m^2. The median tumor size was 3.8(1.7-5.8) cm. The R.E.N.A.L.score was(8.6±1.9). The preoperative serum creatinine was(68.1±24.5) μmol/L and the estimated glomerular filtration rate(eGFR) was(91.3±22.4) ml/min. There were 28 males and 22 females in RAPN group. Their age was(58.5±11.6) years old. BMI was(24.7±4.2) kg/m^2. The median tumor size was 4.3(1.4-6.9) cm. The R.E.N.A.L. score was(9.3±1.8). The preoperative serum creatinine was(64.5±19.7) μmol/L and eGFR was(94.3±23.5) ml/min. There was no difference in the age, gender, BMI, preoperative serum creatinine, eGFR, tumor size or R.E.N.A.L. score. The operating time, warm ischemia time(WIT), intraoperative blood loss, blood transfusion, the change of surgery, pathological result and follow-up status were compared between LPN and RAPN group. Result: In LPN group(n=59) the surgery type was changed due to several reasons. Three cases of renal hilar tumor and renal artery adhesion were found during operation. In 2 cases,a large amount of bleeding happened and was not able to stop after suturing. Therefore, laparoscopic radical nephrectomies were performed. Two patients were performed with open partial nephrectomy because of intraoperative bleeding and unclear vision. Of the 50 patients in the RAPN group, only 1(2.0%) had a radical nephrectomy due to invasion of the renal tumor into the renal artery. The rate of intraoperative changes in the LPN group was significantly higher than that in the RAPN group [11.9%(7/59) vs.2.0%(1/50), P<0.05]. We excluded the cases whose surgical methods were changed during the operation process. In the LPN(n=52) and RAPN(n=49) group, there was significant difference in operating time [(204.5±64.7) min vs.(156.8±54.9) min], mean WIT [(28.5±9.2) min vs.(22.4±6.5) min], intraoperative blood loss [(258.4±88.6) ml vs.(154.6±78.8) ml], and blood transfusion rate [30.8%(16/52) vs.10.2%(5/49)]. In addition, postoperative drainage tube indwelling time and postoperative hospital stay were significantly shorter in the RAPN group than those in the LPN group(P<0.05). There was no significant difference in the follow-up time between the LPN group and the RAPN group [21.5(1.2-39.2) months vs.16.5(0.8-30.1) months, P>0.05]. The eGFR reduction in the LPN group was significantly higher than that in the RAPN group [(17.8±13.1) ml/min vs.(6.8±12.6) ml/min, P<0.05]. The rate of tumor recurrence and distant metastasis in the LPN group were significantly higher than those in the RAPN group [17.3%(9/52) and 4.1%(2/49), P<0.05].Conclusion: Compared with LPN, RAPN has obvious advantages in reducing renal trauma, reducing thermal ischemic injury, reducing intraoperative bleeding, protecting kidney function, shortening hospital stay and controlling tumor recurrence, so RAPN is a minimally invasive, safe and effective surgical procedure for the treatment of renal hilar tumor.