经腹腔与腹膜后间隙腹腔镜肾癌根治术肾周筋膜及脂肪切除完整性的比较

A Comparative Study on the Integrity of Perirenal Fascia and Lipotomy in Laparoscopic Radical Nephrectomy by Peritoneal and Retroperitoneal Approaches

目的比较经腹腔和腹膜后间隙途径腹腔镜肾癌根治术切除肾周筋膜及脂肪的完整性。方法前瞻性比较2018年11月~2020年1月腹腔镜手术治疗的57例肾癌的临床资料。肿瘤最大径2.6~18.0(7.4±3.5)cm。肿瘤位于左侧23例,右侧34例。术前临床分期T1~T3a期。腹膜后间隙途径33例,经腹腔途径24例。2组年龄、性别、肿瘤大小和肿瘤位置差异均无统计学意义(P>0.05)。术后标本完整性分为0~6分7个等级:0分,肾肿瘤完全破裂,内容物(肿瘤坏死组织或感染脓性分泌物)破溃流入术野,种植复发风险高;1分,肾肿瘤一极肾周筋膜、脂肪囊均打开,肾实质及肿瘤表面均可见,肿瘤包膜不完整或部分破裂;2分,肾肿瘤一极肾周筋膜、脂肪囊均打开,肾实质及肿瘤表面均可见,但肿瘤包膜完整;3分,肾肿瘤一极肾周筋膜打开,脂肪囊完整,肾实质及肿瘤表面均不可见;4分,肾肿瘤另一极肾周筋膜、肾周脂肪囊均打开,肾实质可见,但肿瘤一极肾周筋膜未打开;5分,肾肿瘤另一极肾周筋膜打开,脂肪囊完整切除,肾实质不可见,但肿瘤一极肾周筋膜未打开;6分,肾周筋膜没有打开,完整切除,肾周脂肪囊、肾实质均不可见。比较2组标本评分。结果经腹腔组与经腹膜后间隙组标本完整性0~6分分别为0、0、2、3、8、6、5例和1、1、19、8、2、1、1例,经腹腔组评分明显高于经腹膜后间隙组(Z=-4.907,P=0.000)。57例术后病理诊断均为肾细胞癌。结论经腹腔途径腹腔镜肾癌根治术肾周筋膜及脂肪切除的完整性明显优于经腹膜后间隙途径。

Objective To compare the integrity of perirenal fascia and lipotomy in laparoscopic radical nephrectomy for renal cancer via peritoneal and retroperitoneal approaches.Methods A prospective comparison was made on clinical data of 57 cases of renal carcinoma treated by laparoscopic surgery from November 2018 to January 2020.The maximum diameter of the tumor was 2.6-18.0(7.4±3.5)cm.There were 22 tumors on the left and 34 on the right side.Preoperative clinical stage was T1-T3a.The retroperitoneal approach was used in 33 cases and the peritoneal approach was used in 24 cases.There were no statistically significant differences in age,gender,tumor size and tumor location between the two groups(P>0.05).Postoperative specimen integrity was divided into 0-6 points(7 grades):0 points,complete rupture of renal tumor,rupture of contents(necrotic tumor tissues or infected purulent secretions)into the operative field,high risk of implant recurrence;1 point,the fascia and adipose capsule around the pole of renal tumor were opened,the renal parenchyma and tumor surface were visible,and the tumor capsule was incomplete or partially ruptured;2 points,the fascia and adipose capsule around the pole of renal tumor were opened,the renal parenchyma and tumor surface were visible,but the tumor capsule was intact;3 points,the fascia around the pole of renal tumor was opened,the adipose capsule was intact,and the renal parenchyma and tumor surface were not visible;4 points,the fascia and adipose capsule around the other pole of renal tumor were opened,and the renal parenchyma was visible,but the fascia around the pole of renal tumor was not opened;5 points,the perirenal fascia of the other pole of the tumor was opened,the adipose capsule was completely removed,and the renal parenchyma was not visible,but the perirenal fascia of the pole of the tumor was not opened;6 points,the perirenal fascia was not opened,complete resection was performed,and perirenal adipose capsule and renal parenchyma were not visible.The specimen scores of the two groups were compared.Results The integrity score of 0-6 points in the peritoneal group and the retroperitoneal group was 0,0,2,3,8,6,5 cases and 1,1,19,8,2,1,1 case,respectively.The score of the peritoneal group was higher than that of the retroperitoneal group,and the difference was statistically significant(Z=-4.907,P=0.000).All the 57 patients were diagnosed as renal cell carcinoma.Conclusion The integrity of peritoneal fascia and lipotomy in laparoscopic radical nephrectomy for renal cancer is better than that in retroperitoneal approach.