微波消融辅助零缺血免缝合技术在肾门肿瘤剜除术中的疗效和安全性

The application of microwave ablation assisted clamp-lees suture-less technique in renal hilar tumorenucleation

目的探讨微波消融辅助零缺血免缝合技术应用于肾门肿瘤剜除术的疗效和安全性。方法回顾性分析2017年3月至2020年4月上海仁济医院收治的31例肾门肿瘤患者的临床资料。男23例, 女8例。中位年龄59(50, 71)岁。中位体质量指数22.0(19.7, 24.0)kg/m^(2)。美国东部肿瘤协作组评分0分28例, 1分3例。肿瘤位于左侧16例, 右侧15例。中位肿瘤最大径3.0(2.5, 4.0)cm。中位R.E.N.A.L.评分8(7, 8)分。中位术前估算肾小球滤过率(eGFR)91.9(78.4, 105.7) ml/(min·1.73 m^(2))。美国麻醉医师协会(ASA)分级Ⅰ级16例, Ⅱ级13例, Ⅲ级2例。31例均行后腹腔镜微波消融辅助零缺血肾肿瘤剜除术(MACS-LTE)。微波消融采用MTC-3C微波消融仪, 经操作孔道将消融探针插入肿瘤与肾交界面且靠近肿瘤基底部。消融功率为70 W, 每个周期消融时间1~3 min, 共消融1~3个周期。消融结束后, 沿肿瘤假包膜行肿瘤剜除术。结果本组31例, 29例顺利完成MACS-LTE, 1例缝合修补集合系统;1例因术中出血中转传统肾部分切除术, 阻断肾动脉主干10 min。无中转开放或根治手术者。中位手术时间100(80, 120)min。中位术中出血量50(50, 80)ml, 术后无输血病例。中位术后住院时间3(3, 4)d。术后发生尿瘘1例, 发热1例, 均经保守治疗治愈。所有肿瘤切缘均阴性, 病理诊断为透明细胞癌27例, 嫌色细胞癌3例, 乳头状肾细胞癌1例。中位随访时间25(16, 28)个月, 术后6个月中位eGFR为90.0(79.2, 100.3) ml/(min·1.73 m^(2))。所有患者均无局部复发和远处转移。结论微波消融辅助零缺血免缝合技术用于腹腔镜肾肿瘤剜除术治疗部分肾门肿瘤, 具有出血少、并发症可控的特点。

Objective To investigate the efficacy,safety of the microwave ablation assisted clamplees suture-less tumor enucleation technique in the management of renal hilar tumors.Methods From March 2017 to April 2020,data of 31 consecutive patients with renal hilar tumors who underwent microwave ablation assisted clamp-lees suture-less laparoscopic tumor enucleation(MACS-LTE)were retrospectively analyzed.There were 23 males and 8 females with a median age of 59(50,71)years old.The median BMI was 22.0(19.7,24.0).There were 28 cases with ECOG score 0 and 3 with score 1.The median diameter of the tumor was 3.0(2.5,4.0)cm with 16 located on the left and 15 on the right side.The median R.E.N.A.L.score was 8(7,8)and the median eGFR was 91.9(78.4,105.7)ml/(min·1.73 m^(2)).The American Society of Anesthesiology(ASA)graded 16 cases as grade 1,13 as grade 2 and 2 as grade 3.MACS-LTE was performed for all patients.The MWA probe was introduced via the laparoscopic trocar and inserted into the tumor,which was close to the renal parenchyma.Then all tumors were enucleated along the pseudocapsule after microwave ablation was performed for 1 to3 cycles lasting 1 to3 minutes for each tumor with a power output of 70 W using an MTC-3C Microwave Ablation System.Results Laparoscopic MWA assisted clampless tumor enucleation was successfully performed in 30 case(29 underwent MACS-LTE and 1 required collecting system suturing).Another one converted to conventional laparoscopic partial nephrectomy because of intraoperative bleeding with 1Omin main renal artery clamped.No case converted to open surgery or radical nephrectomy.The median operative time was 100(80,120)min,with a median estimated blood loss of 50(50,80)ml.The median length of postoperative hospital stay was 3(3,4)d.No case required perioperative transfusion.One case with fever and urine leakage were observed postoperatively and recovered after conservative treatment.Pathologic results revealed 27 cases of clear cell carcinoma,3 of chromophobe cell carcinoma,and 1 of papllary cell carcinoma with all negative surgical margins.The median eGFR at 6 months postoperative was 90.0(79.2,100.3)ml/(min·1.73 m^(2)).No local recurrence and distant metastasis was observed with a median follow-up of 25(16,28)months.Conclusions MACS-LTE which has the advantages of less blood loss with controllable complications could be an alternative,technique for selective renal hilar tumors.