腹腔镜下微波消融辅助零缺血免缝合技术在囊性肾癌保肾手术中的应用初探

Initial application experience of laparoscopic microwave ablation assisted clamp-less suture-less nephron sparing surgery technique in cystic renal cell carcinoma

目的探讨腹腔镜下微波消融辅助零缺血免缝合技术应用于囊性肾癌保肾手术中的疗效及安全性。方法回顾性分析2017年1月至2020年12月上海交通大学医学院附属仁济医院采用后腹腔镜下微波消融辅助零缺血免缝合保留肾单位手术(MACS-LNSS)治疗的21例囊性肾癌患者的临床资料。男17例,女4例;年龄(58.0±2.6)岁;美国东部肿瘤协作组(ECOG)评分0分19例,1分2例。肿瘤位于左侧12例,右侧9例;肿瘤最大径(3.6±0.4)cm(1.5~7.0cm);与集合系统的距离(10.7±0.9)mm(6~20mm)。Bosniak分型Ⅲ型5例,囊液CT值(27.6±4.6)HU(16~40HU);Ⅳ型16例。术前估算肾小球滤过率(eGFR)(84.1±4.1)ml/(min·1.73m^(2)),美国麻醉医师协会(ASA)评分1分17例,2分3例,3分1例。21例均采用后腹腔镜下MACS-LNSS治疗。微波消融采用MTC-3C微波消融仪,经操作孔道将消融探针插人肿瘤内;消融功率为60~100W,每个周期消融时间2~5min,共消融1~3个周期;消融结束后,行肾肿瘤切除术。分析患者围手术期指标、术后并发症及随访情况。结果本组21例中,20例顺利完成MACS-LNSS;1例因术中出血中转传统肾部分切除术,肾动脉阻断时间14min。无中转开放或根治手术者。21例手术时间(92.0±6.3)min。术中出血量(60.0±7.2)ml。术后住院时间(2.7±0.1)d。术后无输血病例,术后发热1例(Clavien-Dindo分级Ⅰ级),尿瘘1例(Clavien-Dindo分级Ⅰ级),均经保守治疗后治愈。术后病理结果示低度恶性潜能的多房囊性肾肿瘤3例,透明细胞癌18例。21例术后6个月eGFR为(82.9±3.8)ml/(min·1.73m^(2))。术后随访时间为(41.3±1.5)个月(32~58个月),无局部复发及远处转移病例。结论微波消融辅助零缺血免缝合技术应用于直径<7 cm、肿瘤基底规则且与集合系统距离>5mm的囊性肾癌的保肾手术中,无严重不良反应,无肿瘤复发或转移,是一种安全有效的、可供选择的术式。

Objective To investigate the efficacy and safety of the application of microwave ablation assisted clamp-less suture-less nephron sparing surgery technique in the management of cystic renal cell carcinoma.Methods The data of 21 consecutive patients with cystic renal cell carcinoma who underwent microwave ablation assisted clamp-less suture-less laparoscopic nephron sparing surgery(MACS-LNSS)in Renji Hospital,Shanghai Jiaotong University School of Medicine from January 2017 to December 2020,were retrospectively analyzed.There were 17 males and 4 females with a mean age of(58.0±2.6)years old.There were 19 cases with Eastern Cooperative Oncology Group(ECOG)score 0 and 2 with score 1.The mean diameter of the tumor was(3.6±0.4)cm,and the mean distance from the collecting system was(10.7±0.9)mm with 12 located on the left and 9 on the right side.There were 5 cases of BosniakⅡwith mean CT value(27.6±4.6)HU and 16 of BosniakⅣand the mean estimated glomerular filtration rate(eGFR)was(84.1±4.1)ml/(min·1.73 m^(2)).The American Society of Anesthesiology(ASA)graded 17 cas as grade 1,3 cases as grade 2 and 1 cases as grade 3.MACS-LNSS was performed for all patients.The microwave ablation probe was introduced via the laparoscopic trocar and inserted into the tumor.Then all tumors were resected after microwave ablation was performed for 1 to 3 cycles lasting 2 to 5 minutes for each tumour with a power output of 60 to 100 W using an MTC-3C microwave ablation system.Results MACS-LNSS was successfully performed in 20 cases.Another one converted to conventional laparoscopic partial nephrectomy because of intraoperative bleeding with 14 min renal artery branch clamped.No case converted to open surgery or radical nephrectomy.The mean operative time was(92.0±6.3)min,with a mean estimated blood loss of(60.0±7.2)ml.The mean length of postoperative hospital stay was(2.7±0.1)d.No case required perioperative transfusion.One case with fever and one case with urine leakage were observed postoperatively and recovered after conservative treatment.Pathologic results revealed 18 cases of clear cell carcinoma,3 of low grade malignant potential multilocular cystic renal cell tumors.The median eGFR at 6 months postoperative was(82.9±3.8)ml/(min·1.73 m^(2)).No local recurrence and distant metastasis was observed with a mean follow-up of(41.3±1.5)(range from 32 to 58)months.Conclusions MACS-LNSS which has the advantages of controllable complications is an alternative,safe and feasible technique for cystic renal cell carcinoma less than 7 cm,with regular tumor base,and the distance from the collecting system more than 5 mm.