后腹腔镜下根治性肾切除及静脉取栓术的效果分析  

Retroperitoneal laparoscopic radical nephrectomy and thrombectomy for renal tumor with renal vein and vena cava thrombus

作　　者：王文营[1] 吕文成[1] 张道新[1] 宋健[1] 杨培谦[1] 郭宇文[1] 田野[1] 杜林栋[1] 

机构地区：[1]首都医科大学附属北京友谊医院泌尿外科,100050

出　　处：《中华泌尿外科杂志》2013年第9期653-656,共4页Chinese Journal of Urology

摘　　要：目的 探讨后腹腔镜下根治性肾切除并肾静脉及腔静脉取栓术的可行性及手术效果. 方法 2008年11月至2012年3月收治肾肿瘤伴静脉瘤栓患者12例（右侧3例,左侧9例）.CT检查右肾静脉内充盈缺损3例,2例略突入腔静脉内,1例瘤栓尖部达右肾静脉、腔静脉交界处；左肾静脉瘤栓尖部位于肾脏与腹主动脉间5例,骑跨于腹主动脉上或跨过腹主动脉但未进入腔静脉4例.全麻下行后腹腔镜下根治性肾切除及静脉取栓术.手术放置4个穿刺套管.右肾肿瘤患者切断右肾动脉后游离腔静脉和肾静脉,血管阻断钳部分阻断腔静脉,切开取栓.左肾肿瘤患者切断左肾动脉后游离左肾静脉,必要时游离部分肠系膜上动脉、腹主动脉和下腔静脉,扩大空间直至可置入血管阻断钳. 结果 腹腔镜下完成手术11例,2例右肾静脉瘤栓长度分别为2.5 cm和3.7cm,9例左肾静脉瘤栓长度2.0～7.5 cm,平均4.1 cm.中转开放手术1例.患者术后恢复良好,术后4～11 d,平均7d出院.病理报告肾上皮样血管平滑肌脂肪瘤1例,肾透明细胞癌1级2例、1～2级2例、2级5例,肾嫌色细胞癌1例,1例肾盂尿路上皮癌2～3级.失访1例,11例术后随访5～42个月,平均20个月,1例术后14个月出现对侧肾上腺转移,其余患者未见复发和转移. 结论 在腔镜技术熟练的基础上,对肾肿瘤并肾静脉及腔静脉瘤栓的患者选择性行后腹腔镜下根治性肾切除及静脉取栓术安全可行,且手术可达到良好的肿瘤控制效果.Objective To evaluate the feasibility of retroperitoneal laparoscopic radical nephrectomy and thrombectomy for renal tumor with renal vein and vena cava thrombus. Methods Twelve cases of re- nal tumor with renal vein and vena cava thrombus were reported. Contrast-enhanced CT showed renal tumor extended to renal vein and vena cava in two cases, and filling defects were found in right or left renal vein in ten cases. All the patients received retroperitoneal laparoscopic radical nephrectomy and thrombectomy. Four trocars were placed during the procedure, early arterial division and ＂milking＂ of the thrombus away from the inferior vena cava may facilitate laparoscopic surgery, a laparoscopic clamp was used to occlude the vena ca- va partially containing the thrombus in two cases. Hem-o-lok was used to dissect the renal vein for left renal tumors. During the operation, inferior mesenteric artery, abdominal aorta and inferior vena cava were mobi- lized in order to expand the operating space. Results One patient was converted to open procedure. The two right tumor thrombi were 2.5 cm and 3.7 cm, respectively. The mean length of left tumor thrombi was 4.1 cm （2.0-7.5 cm）. Post-operative pathology showed renal epithelioid angiomyolipoma in one patient, clear cell carcinoma in 9 cases （ grade 1 in 2 cases, grade 1-2 in 2 cases, grade 2 in 5 cases） , chromophobe car- cinoma in 1 case and renal pelvic urothelial carcinoma in 1 case. Mean hospital stay was 7 d （4-11 d）. Con-tralateral adrenal metastasis occurred in one case 14 months after surgery. No tumor recurrence or metastasis occurred with a mean follow-up of 20 months （5-42 months） for others. Conclusion Retroperitoneal lap- aroscopic radical nephrectomy and thrombectomy can be applied safely and effectively with adherence to proper techniques in carefully selected patients.

关 键 词：肾肿瘤 瘤栓 腹腔镜 肾切除术 取栓术 

分 类 号：R699.2[医药卫生—泌尿科学]