双侧肾母细胞瘤单侧根治术后二次手术治疗

Contralateral nephron-sparing surgery after unilateral nephrectomy for bilateral Wilms tumor

目的探讨双侧肾母细胞瘤单侧根治术后第二次手术术中处理及围手术期管理。方法对2012年1月至2018年12月北京儿童医院肿瘤外科及保定病区肿瘤科收治的13例双侧肾母细胞瘤单侧根治性切除术后的患儿临床资料进行回顾,分析总结二次手术术中的处理及围手术期的管理。13例患儿中,男7例,女6例,年龄最大为42个月,最小为5个月。11例为同时性肾母细胞瘤,2例为异时性肾母细胞瘤,初次手术均为单侧瘤肾根治性切除术,二次手术均采用保留肾单位肿瘤剥除手术,其中化疗后手术12例,1例未经化疗而直接手术。二次术中11例采用阻断肾蒂血管方法止血,局部压迫止血2例。结果术后3例患儿出现少尿症状,其中1例合并肺水肿及高血压;1例出现单纯性高血压;1例出现尿瘘。13例患儿二次术后病理均为肾母细胞瘤或肾母细胞瘤病;3例患儿切缘阳性,其中2例为肾母细胞瘤病,1例为肾母细胞瘤。结论双侧肾母细胞瘤单侧瘤肾根治性切除术后,二次手术须行保留肾单位手术,术中应精细操作,尽量完整切除肿瘤,避免过度或长时间影响肾脏血运。术后短期内应严格观察出入量情况,监测血压及肌酐变化情况,必要时给予利尿等对症治疗。

Objective To explore the contralateral surgery and perioperative management after unilateral nephroectomy for bilateral Wilms tumor.Methods Retrospective reviews were performed for 13 children with bilateral Wilms tumor undergoing unilateral nephroectomy from January 2012 to December 2018.Among them,there were 7 boys and 6 girls with an age range of 6 to 42 months.Eleven cases were diagnosed as synchronous Wilms tumor and another 2 cases meatachronous tumor.Unilateral nephroectomy was performed initially and followed by nephron-sparing surgery(NSS).Twelve children received preoperative chemotherapy and one case had NSS directly.Eleven children received vascular occlusion during operation and another 2 cases had compression hemostasia.Results Complications included oliguria(n=3),acute pulmonary edema(n=1),hypertension(n=1)and urine leakage(n=1).All of them were diagnosed as Wilms tumor or nephroblastomatosis according to the histopathological examination.Three margins were positive,including a Wilms tumor.Conclusions NSS is recommended for bilateral Wilms tumor.Contralateral surgery after unilateral nephroectomy should be carefully performed by complete resection and avoiding excessive extrusion of kidney blood flow.Body fluid,blood pressure,urine volume and creatinine should be closely observed.Furosemide and symptomatic treatment are offered if necessary.