肾肿瘤伴静脉瘤栓“301分级系统”及手术策略(附100例病例分析)

The "301 classification" system and surgical strategies for treatment of renal tumor and venous thrombus:report of 100 cases

目的:介绍肾肿瘤伴静脉瘤栓"301分级系统"以及对应的手术策略,并评价其安全性及可行性。方法:总结中国人民解放军总医院泌尿外科2013年6月~2017年8月对100例肾肿瘤伴静脉瘤栓形成患者手术治疗经验,提出"301分级系统"。右肾静脉瘤栓为0级,手术策略为右肾根治性切除术;左肾静脉瘤栓根据是否超过肠系膜上动脉分为0a及0b级。下腔静脉瘤栓分为四级:第一肝门以下的下腔静脉瘤栓为Ⅰ级,第一肝门以上至第二肝门Ⅱ级,第二肝门至膈肌水平为Ⅲ级,膈肌以上为Ⅳ级。按瘤栓分级不同手术策略包括是否需要术前肾动脉栓塞,是否需要翻肝、阻断肝脏血流和是否需要采用静脉转流或体外心肺循环。回顾性分析患者临床病理资料,手术时间、出血量、住院时间及手术并发症等指标。结果:100例肾肿瘤伴静脉瘤栓患者纳入分析,其中男77例,女23例,平均年龄56岁(23~81岁)。按"301分级系统"分级,0(左侧0a)级40例,0b级6例,Ⅰ级32例,Ⅱ级15例,Ⅲ级6例,Ⅳ级1例。100例手术均按照"301分级系统"对应的手术策略顺利完成手术,其中开放手术13例,腹腔镜手术19例,机器人手术68例,无术中瘤栓脱落致死病例,1例出现肠道损伤,2例损伤脾脏。中位手术时间164 min(43~465 min),其中0a级为109.5 min(43~324min),0b级196 min(120~348 min),Ⅰ级170 min(76~422 min),Ⅱ级240min(130~360 min),Ⅲ级337 min(255~465 min),Ⅳ级336 min,各组间差异有统计学意义(P<0.001)。中位出血量400 ml(20~7 000 ml),0a级为100 ml(20~2 000 ml),0b级450 ml(100~3 000 ml),Ⅰ级425 ml(20~4 500 ml),Ⅱ级1 200 ml(100~4 000 ml),Ⅲ级2 600 ml(500~7 000 ml),Ⅳ级3 000 ml。各组间差异有统计学意义(P<0.001)。术后所有患者均恢复良好出院,中位术后住院时间7 d(3~30 d)。术后病理提示透明细胞癌79例,乳头状细胞癌9例,其余类型12例。结论:根据"301分级系统"制定肾肿瘤伴静脉瘤栓手术策略处理是安全可行的,但仍须多中心及更多病例进行验证。

Objective: To describe and evaluate the safety and feasibilityof a novel classification named "301 classification" and its corresponding surgical technique in the treatment of renal tumor and venous extension.Methods: From June 2013 to August 2017,a total of 100 cases of renal neoplasm and venous tumor thrombus underwent surgical treatment in Chinese PLA General Hospital. A novel classification named "301 classification" was established to make decision of surgical strategy. Renal vein tumor thrombus on the right side was classified as level 0,and renal vein tumor thrombus on the left side as level 0 a or 0 b depending on whether the thrombus exceeds the superior mesenteric artery or not. The IVC thrombi were classified into 4 levels: Level Ⅰ referred to the thrombus in the IVC but below the first porta hepatis; Level Ⅱ referred to the retrohepatic thrombus between the first and the second porta hepatis; Level Ⅲ referred to the suprahepatic thrombus at the level or above the hepatic vein but below the diaphragm; Level Ⅳ referred to the thrombus exceeding the diaphragm. Surgical strategies include the necessity of angioembolization of renal artery, position changing, liver mobilization, liver hilum vessels clamp,and veno-venous or cardiopulmonary bypass,which depend on the level of venous tumor thrombus. The perioperative data such as operation time,estimated blood loss, hospital stay and complications were retrospectively analyzed. Results: A total of 100 patients were analyzed. including 77 males and 23 females. The median age was 56 years(23-81 years). Grouped by the noval classification, 6 cases were classified as level 0 b, 40 cases as levels 0 or 0 a, 32 cases as Level Ⅰ,15 cases as Level Ⅱ, 6 cases as Level Ⅲ, and only one case of Level Ⅳ. One hundred operations were successfully performed using the strategies divided by "301 classification", which included 68 cases given robotic surgery, 19 cases given laparoscopic surgery and 13 cases given open surgery. There was no intraoperative pulmonary embolism, however, there was one case of intestinal injury and 2 cases of spleen injury. The median operation time was 164 min(range, 43 to 465 min) for all patients, 109. 5 min(range,43-324 min) for level 0/0 a, 196 min(range, 120-348 min) for level 0 b, 170 min(range. 76-422 min) for level Ⅰ, 240 min(range,130-360 min) for level Ⅱ, 337 min(range, 255-465 min) for level Ⅲ, and 336 min for level Ⅳ, respectively. The median estimated blood loss was 400 mL(range,20-7 000 mL),100 mL(range, 20-2 000 mL)for 0 a, 450 mL(range, 100-3 000 mL) for level 0 b, 425 mL(range, 20-4 500 mL) for level Ⅰ, 1 200 mL(range, 100-4 000 mL) for level Ⅱ, 2 600 mL(range, 500-7 000 mL) for level Ⅲ,3 000 mL for level Ⅳ, respectively. There was significant difference in operation time and estimated blood loss among levels(P<0. 001).All the patients recovered well after discharge,and the median postoperative hospital stay was 7 days(range, 3-30 days). The common tumor type was clear cell renal cell carcinoma(79 cases),followed by papillary renal cell carcinoma(9 cases) and others(12 cases). Conclusions: The "301 classification" and its corresponding strategies were established based on the experience of Chinese PLA General Hospital and it is feasible and safe for surgical treatment of renal neoplasm and venous tumor thrombus. However,more cases from multicenters are needed to confirm the conclusion.