腹腔镜下肾部分切除术在cT_(1)期完全内生型肾肿瘤治疗中的临床应用与疗效分析

Clinical application of laparoscopic partial nephrectomy in the treatment of cT_(1) completely endophytic renal tumors

目的:探讨腹腔镜下肾部分切除术(laparoscopic partial nephrectomy,LPN)治疗完全内生型肾肿瘤的可行性、安全性及临床疗效。方法:回顾性分析2016年12月—2020年12月上海交通大学医学院附属仁济医院收治的61例LPN治疗完全内生型肾肿瘤患者的临床资料。分析手术时间、热缺血时间、术中出血量、围术期并发症情况、术后病理结果及预后等指标。结果:本研究共纳入61例患者,其中男35例,女26例;年龄25~75岁,平均(54.96±11.70)岁。所有患者均为常规体格检查中偶然发现。肿瘤位于左肾24例,右肾37例,均为单侧单发肿瘤;肿瘤最大径1.2~5.5 cm,平均(2.79±1.06) cm;R.E.N.A.L.评分6~11分,中位R.E.N.A.L.评分9.0(2.0)分,其中6分1例,7分10例,8分18例,9分12例,10分14例,11分6例;术前血清肌酐56~118μmol/L,平均(71.50±18.35)μmol/L。本研究中61例手术均未中转开放手术,其中60例行LPN顺利完成,1例因术中发现肿瘤质地松软且包膜边界不清晰,怀疑肿瘤侵犯肾实质,中转行根治性肾切除术,LPN手术成功率98.4%。61例手术均经后腹腔入路完成,20例术前留置输尿管导管,39例应用术中超声定位肿瘤,47例行集合系统重建,11例重建时行单独集合系统缝合修补。手术时间60~140 min,平均(101.74±20.47) min。术中出血20~600 mL,平均(105.00±110.03) mL。4例术后出血,其中2例表现为术后持续血尿,另2例表现为假性动脉瘤形成。3例行DSA栓塞治疗,1例采取输血、卧床制动、等待观察等保守治疗。本组随访时间8~61个月,中位随访时间22个月,除1例患者出现骨转移予以靶向治疗外,其余患者均未见肿瘤复发或转移,本组患者3年疾病无进展生存率为97.6%。结论:对于完全内生型肾肿瘤,在完善充分术前准备与评估的前提下,LPN是安全、可行的。

Objective:To investigate the feasibility,safety and clinical efficacy of laparoscopic partial nephrectomy(LPN) in the treatment of completely endophytic renal tumors.Methods:The clinical data of 61 patients with completely endophytic renal tumors treated by LPN from December 2016 to December 2020 were retrospectively analyzed.The operation time,warm ischemia time,intraoperative blood loss,perioperative complications,postoperative pathological results and prognosis were analyzed.Results:There were 35 males and 26 females.The age ranged from 25 to 75 years old,with an average of(54.96±11.70) years old.All patients were found incidentally during routine physical examination.The tumors were located in the left kidney in 24 cases and in the right kidney in 37 cases,all of which were unilateral single tumor.The maximum diameter of the tumor was 1.2-5.5 cm,with an average of(2.79±1.06) cm.The R.E.N.A.L.score was 6-11 points,with a median of 9.0(2.0) points,including 1 case with 6 points,10 cases with 7 points,18 cases with 8 points,12 cases with 9 points,14 cases with 10 points,and 6 cases with 11 points.Preoperative serum creatinine ranged from 56 to 118 μmol/L,with an average of(71.50±18.35) μmol/L.In this study,no case was converted to open surgery,and 60 cases of LPN were successfully completed.Only 1 case was converted to radical nephrectomy because the tumor was found to be soft and the capsule boundary was not clear during the operation,and the tumor was suspected to invade the renal parenchyma.All 61 operations were completed through the retroperitoneal approach.Twenty patients underwent preoperative indwelling ureteral catheter.Thirty-nine patients were used intraoperative ultrasound to locate the tumor.Forty-seven patients underwent reconstruction of the collecting system,and 11 patients underwent separate suture repair of collecting system during reconstruction.The operation time was 60-140 minutes,and the average time was(101.74±20.47) minutes.The intraoperative blood loss was 20-600 mL,and the average blood loss was(105.00±110.03) mL.Postoperative bleeding occurred in 4 cases.Persistent hematuria was found in 2 cases,and pseudoaneurysm formation was found in the other 2 cases.Three cases received DSA embolization,and 1 case received conservative treatment such as blood transfusion,bed immobilization,and waiting for observation.The group was followed up for 8 to 61 months,with a median follow-up duration of 22 months.One patient was found bone metastasis and received systemic therapy.All patients survived till the end of follow-up.Conclusion:For completely endophytic renal tumors,LPN is safe and feasible under the premise of complete preoperative preparation and evaluation.