根治性肾切除联合下腔静脉癌栓取出机器人辅助与开放手术的临床疗效对比

Clinical efficacy of robot-assisted laparoscopic versus open radical nephrectomy plus inferior vena cava thrombectomy

目的总结机器人辅助腹腔镜下根治性肾切除(robot-assisted laparoscopic radical nephrectomy,RARN)联合下腔静脉癌栓取出术和开放根治性肾切除(open radical nephrectomy,ORN)联合下腔静脉癌栓取出术的手术技巧和临床经验,比较两种术式的临床效果及安全性。方法采用回顾性队列研究设计方案,收集2012年1月至2022年12月我院收治的26例行根治性肾切除联合下腔静脉癌栓取出术的肾脏肿瘤伴下腔静脉瘤栓患者的临床资料。其中开放手术12例(3例采用体外循环);机器人辅助下手术14例(2例中转开放)。对比分析2种手术方式的手术时间、术中腔静脉阻断时间、术中失血量、术中输血率、术后转ICU率、术后住院时间等临床手术特征的差异。结果26例患者手术平均时间(394±141)min。除3例体外循环外,术中阻断腔静脉时间(23.90±6.95)min。将12例机器人辅助下手术与9例开放手术纳入数据分析:两组患者年龄、体质指数(BMI)、原发肿瘤最大直径、肿瘤T分期和Mayo分级等无显著性差异。机器人辅助下手术的术中失血量中位值为600(50~1600)mL,明显少于开放手术术中失血量1100(600~3800)mL,差异有统计学意义(P=0.049);机器人辅助下手术的手术时间为(323±102)min,开放手术时间为(401±95)min(P=0.089);机器人辅助下手术的术中腔静脉平均阻断时间为(26.10±7.03)min,开放手术的时间为(20.20±6.16)min(P=0.057);两组间术中输血率差异无统计学意义(8/12 vs 8/9,P=0.338);机器人辅助下手术的术后转ICU率为3/12,开放手术的为6/9(P=0.087);机器人辅助下手术的术后住院时间中位值为7(4~14)d,开放手术为8(7~20)d(P=0.091)。结论机器人辅助腹腔镜下根治性肾切除联合下腔静脉癌栓取出术安全、有效;较之开放手术术中出血明显更少。

Objective To summarize our surgical techniques and clinical experience of robot-assisted laparoscopic radical nephrectomy(RARN)and open radical nephrectomy(ORN)plus inferior vena cava thrombectomy(IVCT),and compare the clinical outcomes and safety of the 2 procedures.Methods A retrospective cohort study was conducted on 26 patients diagnosed with renal tumor complicated with inferior vena cava tumor thrombus who underwent radical nephrectomy plus inferior vena cava thrombectomy in our department from 2012 to 2022.Among them,12 patients were conducted with ORN plus IVCT(O-IVCT),including 3 cases having cardiopulmonary bypass,and the other 14 patients received RARN plus IVCT(RA-IVCT),of them 2 cases experienced conversion to open surgery.Surgical characteristics,such as operative time,intraoperative duration for blocking the vena cava,intraoperative bleeding volume,postoperative length of hospital stay and rates of intraoperative blood transfusion and postoperative conversion to ICU were compared between the 2 groups.Results The average operative time was 394±141 min in all cases,and the time of blocking the inferior vena cava was 23.90±6.95 min excluding 3 cases undergoing cardiopulmonary bypass.There were no significantly differences in the average age,body mass index(BMI),tumor size,pathological T stage,or tumor thrombus level by Mayo classification between the RA-IVCT and O-IVCT group.The patients from the RA-IVCT group had a median intraoperative bleeding volume of 600(50~1600)mL,significantly less than that in the O-IVCT group[1100(600~3800)mL,P=0.049].No statistical differences were observed between the RA-IVCT group and O-IVCT group in following indicators:mean operative time(323±102 vs 401±95 min,P=0.089),mean duration of blocking the inferior vena cava(26.10±7.03 vs 20.20±6.16 min,P=0.057),rate of blood transfusion(8/12 vs 8/9,P=0.338),rate of ICU admission(3/12 vs 6/9,P=0.087),or median length of hospital stay after surgery[7(4~14)vs 8(7~20)d,P=0.091].Conclusion RA-IVCT is a safe and effective operation,with the advantage of less intraoperative bleeding volume when compared with O-IVCT.