高功率侧出绿激光辅助腹腔镜无阻断肾部分切除术治疗T_(1a)期肾肿瘤的初步应用体会

High power lateral green laser assisted non-blocking laparoscopic partial nephrectomy for T_(1a) renal tumors

目的探讨应用高功率侧出绿激光辅助腹腔镜无阻断肾部分切除术治疗T_(1a)期肾肿瘤的安全性和疗效。方法回顾性分析2021年2—4月海军军医大学附属公利医院收治的10例T_(1a)期外生型肾肿瘤患者的临床资料,男7例,女3例。平均年龄(58.8±9.7)(47.0~74.0)岁。肿瘤直径(3.1±0.6)(2.0~3.8)cm。肿瘤位于左侧6例,右侧4例;位于腰侧9例,腹侧1例;R.E.N.A.L.评分(5.0±0.8)(4.0~6.0)分。术前肌酐(75.1±9.0)(66.9~90.1)μmol/L。术前患侧肾小球滤过率(GFR)(56.7±7.7)(44.6~67.3)ml/min。术前血红蛋白(135.8±11.4)(119.0~156.0)g/L。所有患者均全麻下采用180W侧出绿激光辅助行腹腔镜无阻断肾部分切除术,其中经后腹腔途径9例,经腹腔途径1例。术中充分游离肿瘤周边区域,完全显露肾肿瘤。将激光光纤通过绿激光手件置入,光纤连接生理盐水冲洗皮条,设置起始绿激光汽化功率为80W,止血功率为35W。于肿瘤边缘约3 mm、距肾实质1个光纤头高度,以80W功率切开肾实质,边汽化边通过光纤高压冲水降低烟雾干扰,并以吸引器推剥肿瘤,术中遇出血可改用止血功率封闭出血点,逐步推进至将肿瘤完整切除。用倒刺线分1~3层连续缝合肾内层髓质和外层皮质创面。记录手术时间、术后血红蛋白下降值、拔除负压引流时间、术后住院时间、术后病理结果和术后并发症情况。术后1个月随访血肌酐和患侧GFR水平。结果本组10例手术均无中转开放或改行根治性肾切除术者,1例因术中出血严重,改行腹腔镜下剪刀快速切除后缝合止血完成手术。手术时间(104.5±9.0)(90.0~120.0)min。术后血红蛋白(115.2±11.8)(96.0~132.0)g/L,与术前比较差异有统计学意义(P<0.05)。术后血红蛋白下降值为(20.6±4.6)(12.0~25.0)g/L。术后拔除负压引流时间(5.7±0.7)(5.0~7.0)d。术后住院时间(6.7±0.7)(6.0~8.0)d。所有患者术后无出血、漏尿等并发症发生。术后病理诊断为透明细胞癌7例,乳头状肾细胞癌2例,血管平滑肌脂肪瘤1例;手术切缘均阴性。术后1个月肌酐(76.8±8.3)(66.0~90.4)μmol/L,GFR(55.5±4.7)(45.1~60.8)ml/min,与术前比较差异均无统计学意义(P>0.05)。结论对于T_(1a)N_(0)M_(0)期、外生型生长的肾肿瘤,应用侧出绿激光辅助行腹腔镜无阻断肾部分切除术安全可靠,疗效满意。

Objective To explore the safety and efficacy of laparoscopic non-blocking partial nephrectomy assisted by high power lateral green laser in the treatment of T_(1a) renal tumor.Methods The clinical data of 10 patients with T_(1a) stage renal tumor from February 2021 to April 2021 in department of urology,Gongli hospital affiliated to Naval Military Medical University were retrospectively analyzed.There were 7 males and 3 females,aged 47.0-74.0 years,with average of(58.8±9.7)years old.The diameter of the tumor ranged from 2.0 cm to 3.8 cm,with an average of(3.1±0.6)cm.There were 6 cases on the left side and 4 cases on the right side,locate on lumbar side in 9 cases and ventral sied in 1 case.The R.E.N.A.L score was 4.0-6.0,with an average of(5.0±0.8).The preoperative creatinine was 66.9-90.1μmol/L,with an average of(75.1±9.0)μmol/L,preoperative GFR of 44.6-67.3 ml/min,with an average of(56.7±7.7)ml/min,preoperative hemoglobin level of 119.0-156.0g/L,with an average of(135.8±11.4)g/L.All patients underwent laparoscopic non-blocking partial nephrectomy assisted by 180w lateral green laser,free the surrounding area of the tumor fully and completely expose the renal tumor.The laser fiber was placed through the green laser hand piece,and the fiber was connected with normal saline to wash the strip.The initial green laser vaporization power was set at 80W,and the hemostasis power at 35W.About 3mm away from the edge of the tumor,and one optical fiber away from the renal parenchyma,the renal parenchyma was cut with 80W power.In order to reduce the interference by smoke,high-pressure flushing was used through the optical fiber while vaporizing,and an attractor was used to push and peel the tumor.In case of bleeding during operation,hemostatic power can be used to close the bleeding point and gradually advance until the tumor was completely removed.The wounds of renal inner medulla and renal outer cortex were continuously sutured in 1-3 layers with barbed suture.It involved 9 cases via retroperitoneal approach and 1 case via abdominal approach.The operation time,postoperative hemoglobin decrease,extraction time of negative pressure drainage,postoperative hospital stay,postoperative pathology and postoperative complications were recorded,and the serum creatinine level and GFR level of the affected side were followed up 1 month after operation.Results All the operations were successfully completed,and there was no conversion to open surgery or radical nephrectomy.One case changed to scissors fast resection and sutured hemostasis due to severe intraoperative bleeding.The operation time was 90.0-120.0 min,with the average of(104.5±9.0)min.The postoperative hemoglobin level was 96.0-132.0g/L,with an average of(115.2±11.8)g/L,and the difference was statistically significant(P<0.05).The postoperative hemoglobin decreased from 12.0g/L to 25.0g/L,with an average of(20.6±4.6)g/L.The time of vacuum drainage was 5.0-7.0 days,with an average of(5.7±0.7)d.Postoperative hospital stay was 6.0-8.0 days,with an average of(6.7±0.7)d.No bleeding,urinary leakage and other complications occurred in all patients.There were 7 cases of clear cell carcinoma,2 cases of papillary renal cell carcinoma and 1 case of angiomyolipoma.All margins were negative.One month after operation,creatinine ranged from 66.0 to 90.4μmol/L,with an average of(76.8±8.3)μmol/L,which was not significantly different compared with that before operation(P>0.05).One month after operation,GFR was 45.1-60.8 ml/min,and with an average of(55.5±4.7)ml/min,and there was no significant difference compared with preoperative data(P>0.05).Conclusions For T_(1a)N_(0)M_(0) stage and exophytic renal tumors,laparoscopic non-blocking partial nephrectomy assisted by lateral green laser is safe and effective.