分支阻断技术在机器人辅助腹腔镜肾部分切除术治疗肾门部肿瘤中的应用

Application of selective clamping of renal arterial branches in robotic-assisted laparoscopic partial nephrectomy for renal hilar tumors

目的:探讨分支阻断技术在机器人辅助腹腔镜肾部分切除术(RAPN)治疗肾门部肿瘤中应用的安全性和临床疗效。方法:回顾性分析上海仁济医院2017年4月至2019年6月收治的14例在RAPN术中实施肾动脉分支阻断技术治疗肾门部肿瘤患者的临床资料。男8例,女6例。中位年龄55.5(45~69)岁。肾门部肿瘤位于左肾9例,右肾5例。中位肿瘤最大径3.7(2.0~6.0)cm。肿瘤分期T 1a期8例,T 1b期6例。中位R.E.N.A.L.评分9(6~10)分。中位术前肌酐73(50~92)μmol/L。中位术前估算肾小球滤过率(eGFR)92.97(74.97~117.24)ml/(min·1.73 m 2)。14例均全麻下行"球冠状"RAPN,肾脏腹侧肿瘤选择经腹腔入路,背侧肿瘤选择经后腹腔入路。术中暴露肾动脉主干、目标分支动脉和肾静脉,结合术前影像阻断目标分支动脉。结果:本组14例中,13例顺利完成分支阻断RAPN,1例术中中转阻断肾动脉主干,无中转开放术式或根治手术者。中位手术时间120(60~190)min。中位术中失血量120(10~400)ml,无术中输血病例。中位热缺血时间21.5(13~35)min。中位术后住院时间2.5(2~4)d。患者术后均未出现严重并发症。术后病理诊断为肾透明细胞癌9例,乳头状肾细胞癌1例,低度恶性潜能的多房囊性肾肿瘤1例,MiT家族易位相关性肾细胞癌1例,肾血管平滑肌脂肪瘤1例,后肾腺瘤1例。所有肿瘤切缘均阴性。中位随访时间为17(2~28)个月,无局部复发及远处转移者,术后末次随访肌酐中位值为79(54~129)μmol/L,中位eGFR为84.24(55.53~122.47)ml/(min·1.73 m 2)。结论:分支阻断技术应用于RAPN治疗肾门部肿瘤,具有术中视野清晰、可精确完整切除肿瘤、创伤小、安全性高、术后肾功能保护好、疗效确切等优点,适用于经过选择的肾门部肿瘤患者。

Objective To investigate the effect of selective clamping of renal arterial branches in robotic-assisted laparoscopic partial nephrectomy(RAPN)for renal hilar tumors.Methods 14 patients with renal hilar tumor who received robotic-assisted laparoscopic partial nephrectomy from April 2017 to June 2019 in our hospital were retrospectively analyzed.8 males and 6 females were included.The median age was 55.5 years,ranged from 45 to 69 years.The median diameter of the tumor was 3.6 cm with 9 on the left and 5 on the right.8 cases with T1a tumors and 6 cases with T1b tumors were included.The median preoperative serum creatine and estimated glomerular filtration rate(eGFR)was 73μmol/L and 92.97 ml/(min·1.73 m2),respectively.The spherical hat RAPN was performed in 14 cases under the general anesthesia.The surgical approach was chosen based on the localization of kidney.The main renal artery,target arterial branch and venous branch were exposed.According to the preoperative image,the target arterial branch was blocked.Results Robotic-assisted partial nephrectomy with clamping of renal arterial branches was successfully completed in 13 cases,with 1 converted to the conventional method in which the main renal artery was clamped.No case was converted to open surgery or radical nephrectomy.The median operation time was 120(90-160)min.The median blood loss was 120(10-400)ml.There was no intraoperative blood transfusion.The median warm ischemic time was 21.5(13-35)min.The median postoperative hospital stay was 2.5(2-4)days.No major complication was observed after surgery.Pathologic studies revealed 9 cases of clear cell carcinoma,1 case of papillary cell carcinoma,1 case of multilocular cystic renal neoplasm of low malignant potential,1 case of MiT family translocation renal cell carcinoma,1 case of renal angioleiomyolipoma and 1 case of metanephric adenoma.Surgical margins were negative in all cases.The median follow-up period was 17(2-28)months with no recurrence or metastasis.The median postoperative serum creatine and eGFR was 79(54-129)μmol/L and 84.24(55.53-122.47)ml/(min·1.73 m2),respectively.Conclusions Selective clamping of renal arterial branches in robotic-assisted laparoscopic partial nephrectomy for renal hilar tumors has the advantage of minimal invasion,high safety,preservation of postoperative renal function and good effect.