荧光腹腔镜根治性膀胱切除术中不同途径注射吲哚菁绿识别盆腔淋巴结的应用效果

Application of different ways of ICG injection in the identification of pelvic lymph nodes under fluorescencelaparoscopy

目的探讨荧光腹腔镜根治性膀胱切除术中,通过不同途径注射吲哚菁绿(ICG)识别盆腔淋巴结的应用效果。方法回顾性分析2021年9月至2022年9月山西医科大学第一医院收治的54例男性膀胱癌患者的病例资料,年龄(52.7±6.5)岁。术前膀胱镜活检病理诊断均为尿路上皮癌。所有患者均接受荧光腹腔镜根治性膀胱切除术+盆腔淋巴结清扫术。根据ICG注射途径将患者分为3组:内踝注射组6例,年龄68(61,73)岁;会阴注射组4例,年龄67(59,74)岁;内踝和会阴联合注射组44例,年龄64(45,78)岁。全麻,患者取平卧位,术前1.0~1.5h均由皮下注射ICG溶液(2.5mg/ml)0.3~0.5ml。内踝注射组,分别于两侧内踝上方2cm皮下注射0.3~0.5ml(0.75mg处);会阴注射组,分别于会阴处肛门上方左右对称的两处皮下注射0.3~0.5ml(0.75mg/处)。内踝和会阴联合注射组采用上述两种方法注射。术中采用4K荧光腹腔镜先体外观察注射位点、淋巴管走行的显影情况,然后体内观察盆腔淋巴结显影情况。结果3组注射ICG后30min左右腹股沟淋巴结体外显影,1h后体内观察盆腔淋巴结均可显影,最长可保持(4.5±0.3)h的良好显影效果。内踝注射组可显影外血管和总血管淋巴结,会阴注射组可显影闭孔淋巴结,内踝和会阴联合注射组的腹股沟、闭孔、外血管、髂内血管、骶前、总血管淋巴结均可显影。本研究54例,术后病理检查证实切除的荧光标记组织均为淋巴结组织,淋巴结检出率100%。术后病理分期pT_(2)期14例,pT_(3)期32例,pT_(4)期8例;pN_(x)期4例,pN_(0)期44例,pN_(1)期5例,pN_(2)期1例。内踝注射组术后病理分期pT_(2)期2例,pT_(3)期3例,pT_(4)期1例;pN_(x)期1例,pN_(0)期4例,pN_(1)期1例。会阴注射组4例术后病理分期均为pT_(3)N_(0)期;内踝和会阴联合注射组,术后病理分期pT_(2)期12例,pT_(3)期25例,pT_(4)期7例;pN_(x)期3例,pN_(0)期36例,pN_(1)期4例,pN_(2)期1例。结论经会阴和内踝皮下注射ICG可实现对盆腔淋巴结的荧光标记,单纯内踝或会阴注射不能够完全显影盆腔淋巴结,联合注射可全面显影盆腔淋巴结,能准确引导术者定位、识别和切除盆腔淋巴结。

Objective To explore the effect of identifying pelvic lymph nodes by diferent injection of indocyanine green(ICG)during fluorescent laparoscopic radical cystectomy.Methods The data of 54 male bladder cancer patients admitted to the First Hospital of Shanxi Medical University from September 2021 to September 2022 were analyzed.Preoperative cystoscopic biopsy all revealed a pathological diagnosis of urothelial carcinoma.All patients underwent fluorescent laparoscopic radical cystectomy plus pelvic lymph node dissection.They were divided into 3 groups according to the annotated route:6 in the medial malleolus injection group,68(61,73)years;4 in the perineal injection group,67(59,74)years;44 in the medial malleolus and perineum,64(45,78)in the combined injection group.Under general anesthesia,patients were placed in the supine position with 0.3 to 0.5 ml of subcutaneous ICG solution(2.5 mg/ml)injected from 1.0 to 1.5 h before surgery.In the medial malleolus injection group,0.3 to 0.5 ml(0.75 mg/place)was injected at 2 cm above the medial malleolus and 0.3 to 0.5 ml(0.75 mg/place)at two symmetrical sites above the anus.Intraoperatively,4K fluorescent laparoscopy was used to observe the color development of the injection site and lymphatic vessels in vitro,and then to observe the development of pelvic lymph nodes in vivo.Results In 3 groups,inguinal lymph nodes were developed about 30 min after ICG injection,and 1 h later,the longest(4.5±0.3)h.The external iliac and common iliac lymph nodes,the obturatorius lymph nodes in the perineal injection group,and the inguinal,obturatorius,external iliac,internal,anterior sacral,and common iliac lymph nodes in the medial malleolar and perineal injection group.In this study,in 54 cases,the postoperative pathological examination confirmed that the removed fluorescently labeled tissue was lymph node tissue,and the lymph node detection rate was 100%.The postoperative stage was pT_(2),14,32 pT_(3)and 8 pT_(4);4 pN_(x),44 pN_(0),5 pN_(1)and 1 pN_(2).In the medial malleolar injection group,2 patients staged pT_(2),3 stage pT_(3),1 stage pT_(4);lstage pN_(x)stage,4 stage pN_(0)and 1 stage pN_(1)stage.In the perineal injection group,4 patients had postoperative pathological stage pT_(3)N_(0);in the medial malleolar and perineal injection group,12 pT_(2),25 and 7 pT_(3);3 pN_(x),36 pN_(0),4 pN,and 1pN_(2).Conclusions ICC injection through the perineum and subcutaneous labeling of pelvic lymph nodes,and the simple malleolus or perineal injection can not completely develop the pelvic lymph nodes.The combined injection could fully develop the pelvic lymph nodes,which may accurately guide the operator to locate,identify and remove pelvic lymph nodes.