Contemporary techniques and outcomes of surgery for locally advanced renal cell carcinoma with focus on inferior vena cava thrombectomy:The value of a multidisciplinary team

Objective:To report the outcomes of surgery for a contemporary series of patients with locally advanced non-metastatic renal cell carcinoma(RCC)treated at a referral academic centre,focusing on technical nuances and on the value of a multidisciplinary team.Methods:We queried our prospective institutional database to identify patients undergoing surgical treatment for locally advanced(cT3-T4 N0-1 M0)renal masses suspected of RCC at our centre between January 2017 and December 2020.Results:Overall,32 patients were included in the analytic cohort.Of these,12(37.5%)tumours were staged as cT3a,8(25.0%)as cT3b,5(15.6%)as cT3c,and 7(21.9%)as cT4;6(18.8%)patients had preoperative evidence of lymph node involvement.Nine(28.1%)patients underwent nephron-sparing surgery while 23(71.9%)received radical nephrectomy.A template-based lymphadenectomy was performed in 12 cases,with evidence of disease in 3(25.0%)at definitive histopathological analysis.Four cases of RCC with level IV inferior vena cava thrombosis were successfully treated using liver transplant techniques without the need for extracorporeal circulation.While intraoperative complications were recorded in 3(9.4%)patients,no postoperative major complications(Clavien-Dindo3)were observed.At histopathological analysis,2(6.2%)patients who underwent partial nephrectomy harboured oncocytoma,while the most common malignant histotype was clear cell RCC(62.5%),with a median Leibovich score of 6(interquartile range 5e7).Conclusion:Locally advanced RCC is a complex and heterogenous disease posing several challenges to surgical teams.Our experience confirms that provided careful patient selection,surgery in experienced hands can achieve favourable perioperative,oncological,and functional outcomes.

Anti-programmed cell death ligand 1-based immunotherapy in recurrent hepatocellular carcinoma with inferior vena cava tumor thrombus and metastasis:Three case reports

BACKGROUND Recurrent hepatocellular carcinoma(HCC)with inferior vena cava tumor thrombus is a great challenge for oncologists and has a poor prognosis.To date,the safety and efficacy of programmed cell death ligand 1(PD-L1)inhibitors are still unknown.CASE SUMMARY A 59-year-old male was identified as having a tumor thrombus in the inferior vena cava 3 years after surgery.The patient underwent a second surgery and adjuvant chemotherapy.However,the level of alpha-fetoprotein was elevated after 2 mo,and lung metastases and mediastinal lymph node metastases were identified.The expression of PD-L1 in HCC and inferior vena cava tumor thrombus tissues was analyzed by immunohistochemistry.Then,the patient received atezolizumab immunotherapy.The level of alpha-fetoprotein dropped to normal,the mediastinal lymph node metastases decreased in size and the lung metastases disappeared after 3 mo of immunotherapy.The patient had no signs of recurrence at 21 mo of follow-up.A 60-year-old male underwent left hepatic tumor resection,inferior vena cava incision and thrombus removal,followed by regular chemotherapy.The patient developed lung and splenic metastases after surgery.Pembrolizumab was used for six courses,and the splenic metastasis shrank,after which splenectomy was performed.The patient continued to receive pembrolizumab for thirteen courses,and the lung metastases showed no progression.A 34-year-old male was diagnosed with liver cancer with inferior vena cava tumor thrombus.The patient underwent right hepatectomy and received tislelizumab for three courses.He is still receiving immunotherapy and in good condition.CONCLUSION Anti-PD-L1 therapy in HCC patients with inferior vena cava tumor thrombus and metastasis is associated with relatively good patient outcomes.

Risk Factors That Affect Survival in Patients with Renal Cell Carcinoma Invading the Vena Cava

Objectives: To determine which risk factors are associated with overall survival in patients with T3b or T3c renal cell carcinoma. Materials and Methods: Retrospective chart review was performed on all patients who underwent a nephrectomy at Lahey Hospital from 1971-2014 and had a diagnosis of pathologic T3b or T3c renal cell carcinoma. Twenty-one potential risk factors were examined and analyzed using Cox Proportional Hazard Survival models. Additional factors examined in this cohort included rate of complications, tumor recurrence, intra-operative death rate, and 30-day mortality rate. Results: One-hundred eighty-two patients with stage T3b or T3c renal cell carcinoma met inclusion criteria. Of these, 124 (68%) were stage T3b and 58 (32%) were stage T3c. Median follow-up was 18.5 months. One-hundred and six (58%) patients experienced a complication from surgery. The intra-operative death rate was 1.1% (2 patients). The 30-day mortality rate was 7.1% (13 patients). Seventy-one (39%) patients had disease recurrence at a median of 7 months (range 1 - 232 months). The 5-year disease-specific survival was 40% and the 5-year overall survival was 32%. Of the 21 risk factors analyzed, clear cell histology, positive lymph nodes, and peri-nephric fat involvement were all significant at the p 0.05 level using unadjusted modeling. On multivariable analysis, fully adjusting for all three significant variables, only positive lymph nodes and peri-nephric fat involvement remained significant. Conclusions: In patients with T3b or T3c renal cell carcinoma overall survival is associated with lymph node positivity and peri-nephric fat involvement and not tumor thrombus level.

Calcification of the Renal Vein and Inferior Vena Cava on a Renal Tumor: An Exceptional Case

Background: A thrombus of the inferior vena cava and renal vein makes the management of renal cancer more difficult. Aim: The aim is to highlight and discuss the management of a case of renal cancer with an unusual thrombus in our context. Case Presentation: We report the case of a 49-year-old female with left kidney cancer, complicated by a calcified thrombus of the renal vein and inferior vena cava. A calcification of renal vein and vena cava was discovered during surgery, even though the diagnosis prior to surgery was a renal tumor with partial thrombus of the IVC. We performed a thrombectomy and left nephrectomy. The post-operative course was marked by the death of the patient a month later. Conclusion: Renal vein and inferior vena cava (IVC) calcifications are uncommon. Preoperative diagnosis is difficult but guided by medical imaging. Renal cancer is one of the causes. A thrombus or calcification of the vena cava worsens the prognosis of cancer.

Budd-Chiari syndrome secondary to caval recurrence of renal cell carcinoma

BACKGROUND:Renal cell carcinoma(RCC)involves the inferior vena cava(IVC)in a minority of patients.Less commonly,it presents with Budd-Chiari syndrome.If untreated, the condition progresses towards liver failure and death.METHOD:We report a case of Budd-Chiari syndrome due to infiltration of the IVC and right atrium by recurrence of RCC 7 years after successful treatment by primary resection.RESULTS:Surgery was performed with a combined abdominal and thoracic approach with cardio-pulmonary by-pass and cardioplegia.The tumor was removed and a cadaveric iliac vein graft used to re-establish venous continuity between the right atrium and hepatic veins.CONCLUSIONS:Although it is a complex and high-risk procedure,aggressive surgery performed by an experienced team with liver transplant and cardiothoracic skills may enable resection of apparently advanced caval tumors.The case is discussed in the light of the current literature.

Imaging predictors for assessment of inferior vena cava wall invasion in patients with renal cell carcinoma and inferior vena cava tumor thrombus:a retrospective study

Background:Renal cell carcinoma(RCC)has the propensity to lead to venous tumor thrombus(VTT).Nephrectomy with tumor thrombectomy is an effective treatment option but is a technically challenging surgical procedure that is accompanied by a high rate of complications.The aims of this study were to investigate pre-operative imaging parameters for the assessment of inferior vena cava(IVC)wall invasion due to a tumor thrombus in patients with RCC and to identify predictors from the intra-operative findings.Methods:Clinical and imaging data were collected from 110 patients who underwent nephrectomy with IVC tumor thrombectomy(levels Ⅰ-Ⅳ)for RCC and IVC tumor thrombus at the Peking University Third Hospital between May 2015 and March 2018.Univariable and multivariable logistic regression and receiver operating characteristic curves were used to assess the correlations between pre-operative imaging features and intra-operative macroscopic invasions of the IVC wall by tumor thrombus.Results:Among the 110 patients,41 underwent partial or segmental resection of IVC.There were univariate associations of pre-operative imaging parameters that could be used to predict the need for IVC resection,including those of the Mayo classification,maximum anterior-posterior(AP)diameter of the renal vein at the renal vein ostium(RVo),maximum AP diameter of the VTT at the RVo and IVC occlusion.For the multivariable analysis,the AP diameter of the VTT at the RVo and IVC occlusion were associated with a significantly increased risk of invasion of the IVC wall by tumor thrombus.The optimum imaging thresholds included an AP diameter of the VTT at the RVo larger than 17.0 mm and the presence of IVC occlusion,with which we predicted invasions of the IVC wall requiring IVC resection.The probabilities of intra-operative IVC resection for patients without both independent factors,with an AP diameter of the VTT at the RVo larger than 17.0 mm,with IVC occlusion,and with both concurrent factors were 5%,23%,56%,and 66%,respectively.Conclusion:An increase in the AP VTT diameter at the RVo and the presence of complete occlusion of the IVC are independent risk factors for a high probability of IVC wall invasion by tumor thrombus.

Value of abdominal ultrasound scan, CT and MRI for diagnosing inferior vena cava tumour thrombus in renal cell carcinoma

Background We used abdominal ultrasound scan （USS）, computed tomography （CT） and magnetic resonance imaging （MRI） findings in venous spread of renal cell carcinoma （RCC） to determine the superior extent of inferior vena cava （IVC） thrombus and IVC wall invasion and compared them with surgical and pathological reports. Methods From January 1999 to August 2007, 25 patients were diagnosed with RCC with IVC tumour thrombus. Before their operation, all patients had USS, contrast enhanced CT and MRI to find the superior extent of tumour thrombus and IVC wall invasion. All postprocessing techniques were performed by experienced radiologists. Two pathologists reported on all pathology specimens. The superior extent of tumour thrombus was confirmed by the senior surgeon at each operation, using the levels of thrombus defined according to 2004 Mayo Clinic classification. The radiographic results were compared with surgical and pathological findings. Results All patients had radical nephrectomy and tumour thrombus excision. Eight patients had RCC on the left side and 17 on the right side. According to the clinical and pathological findings, 6 patients had level I tumour thrombus, 9 level II, 5 level III and 5 level IV. Six patients had IVC wall invasion. No patient had evidence of lymph node or distant metastases. Of the 25 patients, USS correctly diagnosed the superior extent of tumour thrombus in 18/25, CT 23/25 and MRI 23/25. USS found 1 case of IVC wall invasion preoperatively. Conclusions Multidectector computed tomography and magnetic resonance imaging are comparable and more effective than abdominal ultrasound in diagnosing inferior vena cava tumour thrombus in renal cell carcinoma. None of the three methods can detect inferior vena cava wall invasion.

Surgical complexity and prognostic outcome of small volume renal cell carcinoma with high-level venous tumor thrombus and large volume renal cell carcinoma with low-level thrombus

Background:Radical nephrectomy with thrombectomy is one of the most difficult and complicated urological operations.But the roles of renal tumor volume and thrombus level in surgical complexity and prognostic outcome are not clear.This study aimed to evaluate the surgical complexity and prognostic outcome between the volume of renal cell carcinoma (RCC) and the level of venous tumor thrombus.Methods:The clinical data of 67 RCC cases with renal vein or inferior vena cava (IVC) tumor thrombus from January 2015 to May 2018 were retrospectively analyzed.Among these 67 cases,21 (31.3%) were small tumors with high-level thrombus (tumor ≤7 cm in diameter and thrombus Neves Level Ⅱ-Ⅳ),while 46 (68.7%) were large tumors with low-level thrombus group (tumor >7 cm in diameter and thrombus Level 0-Ⅰ).Clinical features,operation details,and pathology data were collected.Univariable and multivariable logistic regression analyses were applied to evaluate the risk factors for small tumor with high-level thrombus.Results:Patients with small tumors and high-level thrombus were more likely to have longer operative time (421.9 ± 135.1 min vs.282.2 ± 101.9 min,t=4.685,P < 0.001),more surgical bleeding volume (1200 [325,2900] mL vs.500 [180,1000] mL,U =270.000,P =0.004),more surgical blood transfusion volume (800 [0,1400] mL vs.0 [0,800] mL,U =287.500,P =0.004),more plasma transfusion volume (0 [0,800] mL vs.0 [0,0] mL,U =319.000,P =0.004),higher percentage of open operative approach (76.2% vs.32.6%,x2 =11.015,P =0.001),higher percentage of IVC resection (33.3% vs.0%,x2 =17.122,P < 0.001),and higher percentage of post-operative complications (52.4% vs.19.6%,x2 =7.415,P =0.010) than patients with large tumors and low-level thrombus.In multivariate analysis,decreased hemoglobin (Hb)(odds ratio [OR]:0.956,95 % confidence interval [CI]:0.926-0.986,P =0.005) and non-sarcomatoid differentiation (OR:0.050,95% CI:0.004-0.664,P =0.023) were more likely to form small tumors with high-level tumor thrombus rather than large tumor with small tumor thrombus.The estimated mean cancerspecific survival times of small tumor with high-level thrombus and large tumor with low-level thrombus were 31.6 ± 3.8 months and 32.5 ± 2.9 months,without statistical significance (P =0.955).After univariate and multivariate Cox proportional hazard survival regression analyses,only distant metastasis (hazard ratio [HR]:3.839,P =0.002),sarcomatoid differentiation (HR:7.923,P < 0.001),alkaline phosphatase (HR:2.661,P =0.025),and severe post-operative complications (HR:10.326,P =0.001) were independent predictors of prognosis.Conclusions:The level of the tumor thrombus was more important than the diameter of the primary kidney tumor in affecting the complexity of surgery.In the same T3 stage,neither the renal tumor diameter nor the tumor thrombus level was an independent risk factor for prognosis.

Piggyback liver transplant techniques in the surgical management of urological tumors with inferior vena cava tumor thrombus

Background An important characteristic of renal cell carcinomas and adrenal tumors is that these tumors may expand into the renal vein and inferior vena cava, and transform into tumor thrombi. This study was to evaluate the use of piggyback liver transplant techniques for surgical management of urological tumors with inferior vena cava tumor thrombus. Methods Nineteen patients with renal cell carcinomas or adrenal tumors with inferior vena cava tumor thrombus were treated from November 1995 to April 2008. Their ages ranged from 29 years to 76 years （mean 54 years）. The extent of tumor thrombus was infrahepatic （level Ⅰ） in 2, retrohepatic （level Ⅱ） in 7, suprahepatic （level Ⅲ） in 6, and intra-atrial （level Ⅳ） in 4 patients. We used cardiopulmonary bypass with deep hypothermic circulatory arrest to remove the thrombi in 3 cases of level IV and in 2 cases of level Ⅲ. In all level Ⅱ, 4 level Ⅲ, and 2 level IV cases, we used piggyback liver transplant techniques to mobilize the liver off of the inferior vena cava and to separate the inferior vena cava from the posterior abdominal wall. Results Mean operative time was 5.1 hours, mean estimated blood loss was 2289 ml and mean blood transfusion was 12.84 U. One patient with adrenal cortical carcinoma and level Ⅳ thrombus died in the immediate postoperative period. Three patients were lost to follow up, and the other 15 survivors were followed from 5 months to 56 months. Eight of these 15 patients died due to metastasis; however 7 were still alive at the last follow-up. Conclusions An aggressive surgical approach is the only hope for curing patients diagnosed with urological tumors combined with inferior vena cava tumor thrombus. The use of piggyback liver transplant techniques to mobilize the liver off of the inferior vena cava provides excellent exposure of the inferior vena cava. Patients with a level Ⅱ or level Ⅲ inferior vena cava thrombus may be treated without using cardiopulmonary bypass.

循环旁路技术在肾癌合并下腔静脉癌栓外科治疗中的应用进展

肾细胞癌(renal cell carcinoma,RCC)合并MayoⅢ~Ⅳ级下腔静脉癌栓的外科治疗难度极高,切除此类癌栓常需阻断肝门血管和下腔静脉。体外循环(cardiopulmonary bypass,CPB)和深低温停循环(deep hypothermic circulatory arrest,DHCA)等循环旁路技术能够建立新的循环通路以维持机体循环系统的正常运转,保护机体重要器官,从而保证手术的安全性。使用CPB和DHCA可能出现出血、神经系统功能障碍等并发症,其应用存在一定局限性。本文对以CPB和DHCA为代表的循环旁路技术在肾癌合并下腔静脉癌栓外科治疗中的应用进展进行综述,并讨论其并发症和应对策略。

双侧腹膜后途径治疗左肾癌伴0b级静脉癌栓手术运用体会

目的探讨腹腔镜下双侧腹膜后途径治疗左肾细胞癌伴0b级(301分级,癌栓超过肠系膜上动脉、未进入下腔静脉)静脉癌栓手术方式的技术要点及临床价值,并对其进行初步经验总结。方法回顾性分析2016年1月至2022年4月收治的14例左侧肾细胞癌伴0b级静脉癌栓患者的临床资料。术前行MRI、CT检查明确癌栓的位置,均为左肾静脉0b级癌栓。所有患者均经双侧腹膜后途径行腹腔镜肾癌根治术及癌栓剥除术治疗。结果所有手术均成功,无中转开放,手术时间(155.15±21.01)min,术中出血量(115.71±74.26)ml,术后住院天数中位数为5.50(IQR:5.00,6.25)d,术后引流管拔除时间中位数为3.00(IQR:3.00,4.00)d,术后平均排气时间中位数为1.50(IQR:1.00,2.00)d,术后视觉模拟评分中位数为3.00(IQR:2.75,4.00)分。结论双侧腹膜后途径的手术方式在完成治疗目的的同时,降低手术出血风险及并发症,达到快速康复的目的,是有效的处理方式。

改良机器人辅助腹腔镜下右肾癌根治术联合下腔静脉Ⅰ级癌栓切除术一例报道(英文)

下腔静脉癌栓切除术是泌尿系统最复杂和最具挑战性的手术之一。本文报道1例改良的机器人辅助腹腔镜下右肾癌根治术联合下腔静脉I级癌栓切除术。相比常规下腔静脉癌栓切除术,改良的机器人辅助腹腔镜下腔静脉癌栓切除术不需要完全分离下腔静脉,无需结扎腰静脉、肾上腺静脉,不用阻断下腔静脉、左肾静脉,也不需要切开下腔静脉和重建下腔静脉。本例手术先完全分离右肾,然后向侧面抬起右肾,使下腔静脉内的瘤栓降至肾静脉入下腔静脉处,然后用机械臂将瘤栓完全推进右肾静脉内,在不阻断下腔静脉的情况下完整切除瘤栓。此改良手术成功完成,无任何并发症,未进行输血。患者随访4年后无任何复发迹象。这表明此改良手术简单、安全、可行、值得推广,尤其适用于初学者。

机器人辅助肾癌根治联合腔静脉周围转移淋巴结切除术(“大家泌尿网”观看手术视频)

目的 总结机器人辅助肾癌根治联合下腔静脉周围转移淋巴结切除术的手术要点。方法 对2019年1月—2021年12月于我院收治的肾癌合并下腔静脉周围淋巴结转移机器人手术病例进行分析和随访,并以右侧肾癌合并下腔静脉周围巨大淋巴结转移为例阐述手术过程和要点。结果 共有5例患者顺利完成手术,4例为透明细胞癌,1例为乳头状癌,平均手术时间约135 min,平均术中出血300 mL,无重大手术并发症发生。结论 有条件的肾癌合并后腹膜淋巴结转移尤其是腔静脉周围大块淋巴结转移的患者,实施机器人辅助肾癌根治联合淋巴结清扫术是可行的,微创外科手术在肾癌综合治疗中的价值值得进一步重视和研究。

肾癌伴下腔静脉瘤栓合并血栓的多种影像学比较

目的:研究肾癌伴下腔静脉瘤栓合并血栓患者的临床及影像资料,分析下腔静脉超声、泌尿系增强CT及增强磁共振3种影像学检查方法对下腔静脉瘤栓伴血栓的诊断效能。方法:选择北京大学第三医院泌尿外科2014年1月至2018年7月的肾癌伴瘤栓病例56例进行回顾性分析,所有患者术前均同时行下腔静脉超声、泌尿系增强CT及增强磁共振检查并完成手术治疗,且术后病理诊断证实为肾癌伴下腔静脉瘤栓。结果:根据术中观察及术后病理诊断证实下腔静脉瘤栓是否合并血栓为标准,将56例患者分为合并血栓组(n=18)及不合并血栓组(n=38)。比较发现,瘤栓合并血栓的患者,瘤栓长度更长[(10.50±5.55)cmvs.(6.66±3.73)cm,P=0.014];瘤栓直径/下腔静脉(inferior vena cava,IVC)冠状最大径比值更接近1[1.0(0.7,1.0)vs.0.9(0.2,1.0),P=0.004];出现下肢水肿的比例更高[66.7%(12/18)vs.5.3%(2/36),P=0.005];行下腔静脉节段性切除或下腔静脉横断术的比例更高[66.7%(12/18)vs.15.8%(6/38),P<0.001]。对比下腔静脉超声、泌尿系增强CT及增强磁共振3种影像检查方法,鉴别瘤栓合并血栓,灵敏度最高的是增强磁共振(77.8%),特异性最高的是下腔静脉超声和增强CT(97.4%),准确性最高的是增强CT及增强磁共振(83.9%),阳性预测值最高的是增强CT(90.9%),阴性预测值最高的是增强磁共振(89.2%)。结论:肾癌伴下腔静脉瘤栓合并血栓的患者,下腔静脉瘤栓长度更长,瘤栓直径/IVC冠状最大径比值更接近1,更易出现下肢水肿。术前需综合多种影像方法,提高诊断的准确率。

MRI对肾细胞癌静脉瘤栓侵犯下腔静脉壁的术前评估

目的:评价MRI对肾细胞癌下腔静脉瘤栓侵犯下腔静脉壁的诊断价值。方法:回顾性分析2010—2018年在北京大学第一医院行肾根治性切除术及下腔静脉取栓术的肾细胞癌患者,术前行1.5T或3.0TMRI检查的56例患者被纳入本研究。由两位影像科医生测量术前MRI图像瘤栓所在水平肾静脉及下腔静脉最大径、下腔静脉瘤栓的长度,并评判瘤栓是否充满下腔静脉腔达两侧缘、瘤栓边缘是否光滑、瘤栓与下腔静脉壁分界是否清晰、下腔静脉壁正常信号是否改变等征象。基于病理证实下腔静脉壁受累与否将患者分为两组,对临床资料及MRI征象进行单因素分析及多因素回归分析。结果:56例患者中男性43例、女性13例,平均年龄(55.64±0.43)岁,有17例(30.4%)病理证实下腔静脉壁受累,大部分为透明细胞癌。下腔静脉壁受累组与非受累组比较,下腔静脉瘤栓的长度更长[(7.91±3.59)cmvs.(5.94±3.57)cm,P=0.049]、瘤栓充满下腔静脉腔(P=0.002)、瘤栓边缘不光滑(P=0.005)、瘤栓与下腔静脉壁分界不清晰(P=0.001)、下腔静脉壁正常信号改变(P<0.001)出现的概率更大,结合这五个指标诊断下腔静脉壁受累的敏感性及特异性为94.12%和79.49%。结论:MRI可作为评估下腔静脉瘤栓侵犯静脉壁的方法,结合下腔静脉瘤栓的长度及MRI征象可以获得较高的诊断敏感性及特异性。

腹腔镜和开放肾癌根治性切除+Mayo Ⅱ级下腔静脉癌栓取出术11例临床分析

目的总结腹腔镜和开放肾癌根治性切除+下腔静脉癌栓取出术治疗MayoⅡ级下腔静脉癌栓(IVCTT)的手术技巧及临床经验。方法回顾性分析2015年2月至2016年8月北京大学第三医院泌尿外科收治的11例肾癌合并MayoⅡ级IVCTT患者的临床资料。11例患者中男性9例,女性2例;年龄29~84岁,平均(60.5±14.5)岁。体重指数(BMI)16.4~33.3,平均25.7±5.3。9例患者肿瘤位于右侧,2例位于左侧。肿瘤直径4.5~21.1cm,平均(9.3±4.7)cm。本组中行开放手术4例。行完全腹腔镜手术6例,其中完全经后腹腔途径腹腔镜手术者4例,经后腹腔途径联合经腹腔途径腹腔镜手术者2例。1例患者先在后腹腔途径腹腔镜下行右肾根治性切除术,后中转开放行下腔静脉癌栓取出术。结果本组11例患者手术均顺利完成,无术中及围术期死亡病例。11例患者手术时间171~567 min,平均(365.5±149.8)min;术中出血量200~2 000 mL,平均(1 077.3±684.6)mL。术中输注悬浮红细胞者7例,输血量400~1 600mL,平均(857.1±427.6)mL。术中输注血浆者3例,输血量为400~800mL。术后住院日期5~28d,平均(12.7±6.4)d。11例患者中7例行同侧肾上腺切除术。4例患者因术中发现癌栓侵犯下腔静脉壁而行下腔静脉壁切除术。11例患者术前血肌酐值51~195μmol/L,平均(104.1±36.2)μmol/L,术后1周血肌酐值53.0~414.0μmol/L,平均(159.5±126.2)μmol/L。术后病理诊断为肾透明细胞癌(RCC)9例,肾乳头状腺癌2例。Fuhrman分级Ⅱ级4例,Ⅲ级4例,Ⅳ级3例。本组中5例发生术后早期并发症,改良Clavien分级系统Ⅱ级2例,IVa级3例。结论肾癌根治性切除+下腔静脉癌栓取出术虽然手术难度大、技术复杂,但治疗MayoⅡ级IVCTT较为有效、安全。对于合适的患者可选择腹腔镜手术方式。

肾癌合并肾静脉或下腔静脉癌栓的诊断和治疗体会

目的总结肾癌合并肾静脉或下腔静脉癌栓的诊断、治疗体会,评价其预后和治疗价值。方法对1994年7月—2006年7月接受诊治的15例肾癌合并肾静脉或下腔静脉癌栓患者的诊断、治疗方法和预后进行回顾性分析。结果14例患者术前CT或MRI检查明确诊断合并肾静脉或下腔静脉癌栓。单纯左肾静脉癌栓2例,下腔静脉癌栓Ⅰ型(肾旁型)9例,Ⅱ型(肝下型)3例,Ⅲ型(肝内型)1例。12例患者接受手术治疗.其中11例完成肾肿瘤切除、静脉癌栓取除和淋巴清扫,1例左肾肿瘤因与周围粘连仅作姑息切除。3例未手术患者因癌症死亡,中位存活时间为7个月。12例手术患者中失访3例,其余9例随访4个月～6年,无瘤生存5年以上者3例.1～3年3例,因癌症转移1年内死亡3例。结论CT、MRI检查是目前无创诊断肾癌合并肾静脉或下腔静脉癌栓的最佳方法。术前肾动脉栓塞可以非常有效地减少术中出血,方便手术完成。无转移患者行根治手术加癌栓切除能获得相对满意的治疗效果。

下腔静脉节段性切除术在肾癌伴下腔静脉癌栓中的应用

目的探讨下腔静脉节段性切除术在治疗肾癌伴下腔静脉癌栓患者中的安全性和有效性。方法回顾性分析2016年1月至2017年6月收治的10例肾癌合并下腔静脉癌栓而行下腔静脉节段性切除术患者的临床资料。10例患者中,合并MayoⅡ级者5例,Ⅲ级者4例,Ⅳ级者1例。男9例,女1例。年龄31~73岁,平均(53.9±10.9)岁。肿瘤位于右侧者6例,左侧者4例。结果 10例手术均顺利完成,无术中死亡病例。7例患者行开放途径下的下腔静脉癌栓取出术+下腔静脉节段性切除术;2例行腹腔镜下手术;1例患者先采用经后腹腔途径联合经腹腔途径下手术,术中探查肾肿瘤与周围组织粘连较重,遂中转开放手术。手术时间288~556min,平均(399.2±91.5)min。术中出血量300~4 000mL,平均(1 450.0±1 136.5)mL。术后住院时间8~39d,平均(16.7±9.6)d。本组10例患者中,6例发生术后早期并发症。ClavienⅡ级并发症4例。ClavienⅣa级并发症2例。10例患者随访时间2~14个月,中位随访时间8个月。10例患者中发生远处转移1例,为骨转移合并肺转移。1例(10%)出现肿瘤特异性死亡。结论下腔静脉节段性切除术使肿瘤切除更彻底,但存在术后并发症发生的可能。下腔静脉节段性切除术在治疗肾癌伴下腔静脉癌栓患者中较为安全有效。

根治性肾切除术联合Mayo 0-Ⅱ级静脉癌栓取出术的临床麻醉管理

目的:探讨根治性肾切除术联合Mayo 0-Ⅱ级静脉癌栓取出术临床麻醉管理的安全性和可行性。方法:回顾性分析2015年2月至2017年1月北京大学第三医院泌尿外科单中心收治的40例肾癌合并Mayo0-Ⅱ级静脉癌栓患者的临床资料。其中男性35例,女性5例。年龄25~84岁,平均(60.1±11.5)岁。本组40例肾癌患者中,合并Mayo 0级癌栓者13例,MayoⅠ级癌栓者10例,MayoⅡ级者17例。ASA I级者4例,Ⅱ级者32例,Ⅲ级者4例。分析40例患者麻醉时间、术中出入量、术中血流动力学变化、术后转归情况等。结果:本组40例Mayo 0-Ⅱ级肾癌伴静脉癌栓患者手术均顺利完成。行开放手术10例,行完全腹腔镜手术30例。1例患者先在后腹腔途径腹腔镜下行右肾根治性切除术,后中转开放取栓手术。40例患者手术平均时间(305.7±114.1)min,麻醉平均时间(368.3±115.1)min。术中出血量为(823.3±930.2)ml,术中输注悬浮红细胞平均(546.9±687.3)ml。27例MayoⅠ-Ⅱ级癌栓(下腔静脉癌栓)患者行术中下腔静脉阻断,下腔静脉阻断时间为10~60 min,平均(24.2±12.4)min。与阻断前即刻比较,下腔静脉阻断后10 min心率显著增快(P<0.05)。下腔静脉阻断后5 min呼气末二氧化碳分压(end tidal carbon dioxide partial pressure,PETCO_2)较阻断前显著降低,阻断开放后5 min、10 min,PETCO_2较阻断前显著升高(P<0.05)。其他血流动力学指标稳定,较阻断前指标变化无统计学差异(P>0.05)。所有病例术中、术后无肺栓塞等严重并发症发生,无疾病进展及死亡病例。结论:根治性肾切除术联合Mayo 0-Ⅱ级静脉癌栓取出术麻醉管理安全可行,手术中行下腔静脉阻断和开放期间循环相对稳定。

多学科综合治疗模式在肾癌伴静脉癌栓患者临床诊治中的作用

目的通过分析北京大学第三医院肾癌伴静脉癌栓肿瘤多学科综合治疗(MDT)模式的开展情况,总结泌尿系肿瘤MDT模式在肾癌伴下腔静脉癌栓患者临床诊治中的作用。方法回顾性分析2015年2月至2018年7月我院收治的149例肾癌合并下腔静脉癌栓患者的临床资料,所有患者均行MDT模式学术讨论。MDT模式由泌尿外科、肿瘤放疗科、放射科、超声诊断科、病理科、麻醉科、普通外科、心脏外科、肿瘤化疗科等多学科专家围绕一个肾癌伴下腔静脉癌栓患者进行讨论,在综合各学科意见的基础上为患者提供诊疗方案。149例患者中,男性109例,女性40例。年龄2.5~83岁,平均(57.2±13.8)岁。肿瘤侧别左侧53例,右侧95例,双侧1例。合并Mayo:0级者32例、Ⅰ级者37例、Ⅱ级者46例、Ⅲ级者20例、Ⅳ级者13例,其中1例双侧肾癌伴静脉癌栓患者,左侧Mayo 0级,右侧MayoⅠ级。结果 149例患者在MDT的协作下进行临床诊治,包括诊断、治疗计划和随后的手术。根据放射科、超声诊断科、麻醉科、普通外科、心脏外科及泌尿外科多学科讨论分析,获得精确术前评估,从而使得更多的患者获得手术机会,同时降低术后并发症的发生风险。根据病理科的患者术后病理回报情况以及肿瘤化疗科、肿瘤放疗科的联合讨论,决定下一步随访策略及术后辅助治疗。所有患者均根据MDT团队的讨论结果进行临床治疗决策,手术均顺利完成,未出现术中死亡病例。行腹腔镜手术66例,开放手术70例,腹腔镜联合开放途径13例。平均手术时间(332.8±121.3)(136~561)min,平均术中出血(1 367.6±1 610.4)(20~10 000)mL,平均输注悬浮红细胞(1 586.1±1 377.7)(0~10 400)mL。术后平均住院时间(10.6±5.4)(4~39)d。36例(24.2%)患者出现术后并发症,其中严重并发症(改良Clavien分级≥3级)9例。术后随访方面,共139例(93.3%)患者获得随访,10例患者失访。平均随访时间(11.3±8.6)(1~37)个月。术后行靶向治疗患者50例。随访期内,患者因肿瘤死亡12例,肿瘤复发5例,肿瘤转移28例。结论对肾癌伴下腔静脉癌栓患者应用MDT模式能有效发挥各个学科的优势,提高诊治效率,使患者得到优化的多学科治疗方案。