肾动脉低温灌注机器人辅助腹腔镜下肾部分切除术治疗完全内生型肾肿瘤的疗效分析  

Robot-assisted laparoscopic partial nephrectomy using renal artery cold perfusion for completely intraparenchymal tumors：the outcome and initial experience

作　　者：马鑫[1] 黄庆波[1] 刘启明[1] 李宏召[1] 陈光富[1] 徐阿祥[1] 王保军[1] 郭刚[1] 瓦斯里江·瓦哈甫[2] 史涛坪[1] 朱捷[1] 李新涛[1] 杜松良 张旭[1] 

机构地区：[1]解放军总医院肾脏疾病国家重点实验室解放军总医院泌尿外科,100853 [2]首都医科大学附属北京朝阳医院泌尿外科

出　　处：《中华泌尿外科杂志》2016年第10期721-725,共5页Chinese Journal of Urology

基　　金：国家高新技术研究发展计划（863计划）（2014AA020607）

摘　　要：目的 初步探讨肾动脉低温灌注机器人辅助腹腔镜下肾部分切除术治疗完全内生型肾肿瘤的安全性和可行性.方法 回顾性分析2013年3月至2016年5月采用肾动脉低温灌注机器人辅助腹腔镜下肾部分切除术治疗的10例完全内生型肾肿瘤患者的临床资料.男6例,女4例.年龄46～70岁,平均53岁.肿瘤直径2.0～4.0 cm,平均2.8 cm.肿瘤位于左侧7例,右侧3例.术前CT/MRI检查显示肿瘤完全位于肾内,其中3例为孤立肾肿瘤,R.E.N.A.L评分9～10分,平均9.8分.术前患肾GFR 42.3 ～61.9 ml/min,平均53.9 ml/min.术前行经股动脉穿刺留置肾动脉球囊导管,术中采用球囊阻断患肾动脉,动脉血管钳在近心端阻断肾静脉,开放生殖静脉（左）或剪开肾静脉（右）建立流出道,经肾动脉导管灌注4℃乳酸钠林格液,降低肾实质的温度,采用术中超声探测肾肿瘤位置及边界,沿标志线切开肾实质,在肿瘤假包膜外游离并完整剥离肿瘤,分两层缝合创缘,如损伤血管或集合系统则单独重建.结果 本组10例手术均顺利完成,术中肾实质温度22.1～26.2℃.手术时间78～184 min,平均152 min.冷缺血时间35～102 min,平均61 min.出血量100～500 ml,平均265 ml.术后住院时间4～14d,平均8.6d.术后病理诊断：9例为肾透明细胞癌,1例为血管平滑肌瘤,均无切缘阳性.1例患者术后出现血尿,于术后3d缓解.1例发生漏尿,术后1周缓解.术后3个月复查ECT肾图,术后患肾GFR 31.4～ 57.1 ml/min,平均41.2 ml/min,比术前略降低.中位随访时间23.5个月（3～37个月）,无肿瘤复发及转移.结论 肾动脉低温灌注机器人辅助腹腔镜下肾部分切除术充分利用了肾动脉灌注的良好降温效果及机器人手术术野清晰、操作精细的技术优势,是治疗完全内生型肾肿瘤安全、可行、有效的方法.该术式对肾功能保留良好,近期肿瘤控制效果满意,远期疗效有待进一步增加例数并观察.Objective To investigate the safety and feasibility of robot-assisted laparoscopic partial nephrectomy using renal artery cold perfusion for completely intraparenchymal tumors.Methods From March 2013 to May 2016,a total of 10 patients underwent robot-assisted laparoscopic partial nephrectomy using renal artery cold perfusion for completely intraparenchymal tumors were analyzed.These included 6 males and 4 female with a mean age of 53 years old（rang from 46 to 70 years old）.The average tumor size was 2.8 cm （rang from 2.0 to 4.0 cm）.Preoperative CT scan or MRI scan showed the renal tumors were completely endophytic and 3 of them were solitary kidney.The mean R.E.N.A.L score was 9.8 （rang from 9 to 10）.A double lumen balloon-tipped angio-catheter was passed into the renal artery through a femoral puncture preoperatively.The renal artery was occluded by an intraluminal balloon and the renal vein was clipped by Bulldog.Ringer lactate at 4℃ was perfused into kidney drained through the gonadal vein on the left side and through incision of renal vein on the right side,which established a cold ischemia.Intraoperative ultrasound was used to guide tumor enbloc resection with negative margin.Two layers renorrhaphy were performed using 1-0 Quill string and he vessels or collecting system need to be repaired if open.Results All the operations were successfully performed,with a mean operation time of 152 min（rang from 78 to 184 min） and a mean cold ischemia time of 61 min （ranging from 35 to 102 min）.The mean estimated blood loss was 265 ml （rang from 100 to 500 ml）.The mean postoperative hospital stay was 8.6 days （rang from 4 to 14 days）.No positive margin was found.Hematuria occurred in one patient and disappeared three days later.Urinary leakage occurred in one patient and relieved in one week.The pathological diagnosis confirmed 9 clear cell renal cell carcinoma and 1 angioleiomyolipoma.The mean preoperative GFR of the affected kidney was 53.9 （rang from 42.3 to 61.9 ml/min）.The mean post

关 键 词：肾肿瘤 内生型肿瘤 保留肾单位手术 肾动脉低温灌注 机器人腹腔镜技术 

分 类 号：R737.11[医药卫生—肿瘤]