基于三维影像重建的肾窦内肿瘤手术难度评分系统  

A novel operation difficulty scoring system for renal carcinoma in renal sinus based on three-dimensional image reconstruction

作　　者：彭程[1] 黄庆波[1] 朱捷[1] 顾良友 杜松良 史涛坪[1] 沈诞[1] 陈健文[1] 李世超[1] 张旭[1] 马鑫[1] PENG Cheng;HUANG Qingbo;ZHU Jie;GU Liangyou;DU Songliang;SHI Taoping;SHEN Dan;CHEN Jianwen;LI Shichao;ZHANG Xu;MA Xin(Department of Urology,Chinese PLA General Hospital,State Key Laboratory of Kidney Diseases,Beijing 100853,China)

机构地区：[1]解放军总医院泌尿外科学部·解放军总医院肾脏疾病国家重点实验室,北京100853

出　　处：《机器人外科学杂志（中英文）》2020年第5期345-354,共10页Chinese Journal of Robotic Surgery

基　　金：北京市自然科学基金青年项目(7194319)。

摘　　要：目的:根据术前三维影像重建建立肾窦内肿瘤手术难度评分系统,并评价其对手术策略的指导价值。方法:纳入2015年7月~2017年4月于解放军总医院泌尿外科就诊的55例肾癌患者,其中男性37例,女性18例,中位年龄54(32~67)岁。肿瘤位于左侧肾脏20例,位于右侧肾脏35例,肿瘤直径1.6~6.8cm,平均(3.9±1.3)cm。根据患者术前CT或MRI检查并行三维重建,综合考虑肾窦内肿瘤占肾窦体积的比率(Ratio),肾门血管及集合系统受肿瘤压迫程度(Oppress),肿瘤与血管和肾盂的位置关系(Association)、肿瘤直径(Diameter)及是否为孤立肾肿瘤(Solitary kidney),提出了肾窦内肿瘤手术难度评分系统(ROADS评分系统)。ROADS评分系统将肾窦内肿瘤手术复杂程度分为轻度(4~6分)、中度(7~9分)、高度(≥10分),根据该评分系统对以上55例患者进行评分,分析评分对手术时间、出血量、肾脏缺血时间及手术策略的影响。结果:所有手术均顺利完成,其中15例行根治性肾切除术,40例行保留肾单位手术。根治性肾切除组中ROADS评分中位分值10(8~15)分,保留肾单位组的手术方式分为常规术式和低温灌注冷缺血术式,其中常温组23例,ROADS评分中位分值5(4~8)分;低温组17例,ROADS评分中位分值7(5~9)分。手术难度为高度复杂组的患者均采用了根治性肾切除术。轻度复杂和中度复杂组中有40例(85%)患者采用了保留肾单位手术,其中轻度复杂组中位手术时间120(55~230)min,中位出血量150(20~300)ml,中位缺血时间22(10~60)min,术后中位肌酐变化率7%(-7%~21%),术后中位eGFR变化率-6%(-17%~6%);中度复杂组中位手术时间157(105~225)min,中位出血量200(40~400)ml,中位缺血时间50(13~118)min,术后中位肌酐变化率22%(-18%~208%),术后中位eGFR变化率-20%(-73%~19%)。中度复杂组中14例考虑肾缺血时间较长,均采用肾动脉低温灌注技术,中位缺血时间为54(33~118)min,术后eGFR平均降低12%(-25%~19%),术后肾Objective:To develop an operation difficulty scoring system for renal tumors located on the renal sinus by making three-dimensional reconstruction before surgery.Then the guiding value of the novel scoring system on surgical decision making was investigated.Methods:55 patients with renal carcinoma in our hospital from July 2015 to April 2017 were analyzed,including 37 males and 18 females with a median age of 54(32 to 67)years old.The tumors were located on the left kidney in 20 cases and 35 cases on the right side.The average diameter of tumors was(3.9±1.3)(1.6 to 6.8)cm.Threedimensional reconstruction was made based on the computed tomography or MRI before surgery,the Ratio of tumor volume to the volume of renal sinus(R),the Oppression on vessels of renal hilus or collection system caused by the tumor(O),the Anteroposterior relation of tumor,vessels and pelvis(A),the tumor Diameter(D)and whether the tumor affects a Solitary kidney(S)(ROADS)were comprehensively considered and the ROADS scoring system was proposed.According to the ROADS scoring system,the operative complexity of the renal tumor was divided into low(4 to 6),moderate(7 to 9)and high level(≥10).The 55 patients were scored with the ROADS scoring system,the association of scores with operation approaches,operation complexity and intraoperative outcome was evaluated.Results:All the operations were performed successfully.40 cases underwent nephron sparing surgery(NSS group)and 15 cases underwent radical nephrectomy(RN group).The median score of RN group was 10(8 to 15),the NSS group were divided into routine group and hypothermia perfusion group.The median score of the routine and hypothermia perfusion group were 5(4 to 8)and 7(5 to 9)respectively.All patients in the high complexity group underwent radical nephrectomy.Most patients in low-and moderate-complex groups received nephron sparing surgery.The median operation time was 120(50 to 230)min,the median estimated blood loss was 150(20 to 300)ml and the median ischemia time was 22(10 to 60)min in l

关 键 词：肾肿瘤 内生性肿瘤 肾窦 保留肾单位手术 肾动脉低温灌注 三维重建 

分 类 号：R737.11[医药卫生—肿瘤]