后腹腔镜肾部分切除术个体化方案在小肾癌治疗中的应用

Application of laparoscopic partial nephrectomy with individual operation plan in treatment of small renal cell carcinoma

摘要:

目的 探讨后腹腔镜下肾部分切除术（RLPN）个体化方案治疗小肾癌的可行性、安全性。 方法 回顾性分析2012 年6 月-2016 年6 月收治的98 例实行RLPN 治疗的小肾癌患者，男57 例，女41 例， 年龄28 ～ 75 岁，平均52 岁，肿瘤位于左肾46 例，右肾52 例，直径0.8 ～ 4.5 cm，平均3.1 cm。87 例（A 组） 小肾癌采用标准阻断肾动脉的状态下实施肾部分切除；7 例（B 组）外突性生长的小肾癌采用术中游离肾动脉， 套橡皮条备用，试行不阻断肾动脉零缺血的状态下实施肾部分切除；4 例（C 组）影像学检查提示内生性小肾癌， 采用腔内超声术中精确探查定位肾动脉阻断下实施肾部分切除。从术中情况、术后随访结果等分析其可行性、 安全性。结果 A 组87 例中2 例转开放手术，1 例切缘阳性，改腹腔镜下肾根治性切除术，术中出血量30 ～ 350 ml，平均93 ml，手术时间70 ～ 245 min，平均127 min，术中热缺血时间20 ～ 42 min，平均26 min。B 组 7 例外突性生长的肾癌，6 例未阻断肾动脉，1 例出血明显，切除肿瘤过程中，再阻断肾动脉15 min，完成肾部 分切除术，出血量160 ～ 380 ml，平均220 ml，手术时间85 ～ 215 min，平均143 min。C 组4 例中内生性小 肾癌全部手术过程顺利，出血量35 ～ 250 ml，平均85 ml，手术时间110 ～ 235 min，平均175 min，术中热缺 血时间25 ～ 40 min，平均28 min。随访6 ～ 48 个月，中位时间26 个月，1 例（肾门处3.0 cm 透明细胞癌） 术后18 个月发现局部复发及肺部转移，予索拉非尼分子靶向治疗。结论 RLPN 个体化方案治疗小肾癌安全、 有效，但尚需增加例数和长期随访观察明确其远期疗效。

Abstract:

Objective To evaluate the feasibility and clinical efficacy of retroperitoneal laparoscopic partial nephrectomy (RLPN) with individual operation plan in treatment of small renal cell carcinoma (RCC). Methods 98 patients with small RCC who was treated by RLPN from June 2012 to June 2016 were retrospectively analyzed. There were 57 males and 41 females with a mean age of 52 years old (ranging 28 ~ 75 years old). 52 cases were located on the right side while 46 cases were left. The mean tumor size was 3.1 cm in diameter (ranging 0.8 ~ 4.5 cm). 87 patients (A group) were underwent standard RLPN with clamping main renal artery. 7 patients (B group) with exophytic RCC were performed without clamping renal artery, but with separating main renal artery and prepared for possible clamping. 4 patients (C group) with endophytic RCC were performed with clamping renal artery underultrosound monitoring. The feasibility and outcomes were evaluated by surgical and oncological outcomes. Results 84 cases among A group were underwent standard RLPN successfully, with 2 cases converted to open surgery and 1 case failed to excising tumor completely and converted to laparoscopic radical nephrectomy. The amount of bleeding during operation was 30 ~ 350 ml, average 93 ml, operation time was 70 ~ 245 min, average 127 min, warm ischemia time 20 ~ 42 min, average 26 min. 6 cases among B group were performed successfully without clamping renal artery with 1 case converted to clamp renal artery for 15 min during the operation because of obvious bleeding. The amount of bleeding was 160 ~ 380 ml, average 220 ml, operation time was 85 ~ 215 min, average143 min. 4 cases of C group were all performed successfully, The amount of bleeding was 35 ~ 250 ml, average 85 ml, operation time was 110 ~ 235 min, average 175 min, warm ischemia time 25 ~ 40 min, average 28 min. With a mean follow up of 28 months (ranging 18 ~ 42 months), there was only 1 case of A group occured local recurrence and lung metastases and accepted molecular targeted therapy with Sorafenib. Conclusion RLPN with individual operation plan in treatment of small RCC is safe and effective, the long-term effect of the procedure needs further investigation.