单侧肾上腺切除术治疗原发性双侧大结节性肾上腺皮质疾病的疗效和围手术期处理(附手术视频)  

Effectiveness and perioperative managements of unilateral adrenalectomy as surgical treatment in curing primary bilateral macronodular adrenal hyperplasia

作　　者：方晨[1] 戴军[1] 何威[1] 黄欣[1] 徐丹枫[1] 苏颋为[2] 宁光[2] 王卫庆[2] 孙福康[1] Fang Chen;Dai Jun;He Wei;Huang Xin;Xu Danfeng;Su Tingwei;Ning Guang;Wang Weiqing;Sun Fukang(Department of Urology,Shanghai Rujin Hospital affiliated to School of Medicine,Shanghai Jiaotong University,Shanghai 200025,China;Department of Endocrinology,Shanghai Ruijin Hospital affiliated to School of Medicine,Shanghai Jiaotong University,Shanghai 200025,China)

机构地区：[1]上海交通大学医学院附属瑞金医院泌尿外科,上海200025 [2]上海交通大学医学院附属瑞金医院内分泌科,上海200025

出　　处：《中华泌尿外科杂志》2024年第4期271-275,共5页Chinese Journal of Urology

摘　　要：目的探讨单侧肾上腺切除术治疗原发性双侧大结节性肾上腺皮质疾病(PBMAH)的疗效和围手术期处理。方法云回顾性分析2008年5月至2023年3月上海瑞金医院收治的54例PBMAH患者的病例资料,男24例,女30例。年龄(55.1±7.9)岁。体质量指数(24.9±2.9)kg/m^(2)。库欣综合征特征性临床表现分别为满月脸32例,水牛背24例,紫纹9例,痤疮6例,多血质面容30例,多毛质10例。51例(94.4%)伴高血压,收缩压(159.1±15.8)mmHg(1mmHg=0.133kPa),舒张压(99.2±11.0)mmHg。所有患者术前CT影像均显示双侧肾上腺明显增大伴多发大小不等结节,呈融合团块样特征性改变。结节最大径(10.3±3.5)cm。术前8:00时血皮质醇(21.5±7.7)μg dl,24h尿游离皮质醇(442.6±300.4)μg/24h,8:00时血浆促肾上腺皮质激素(ACTH)(6.4±2.3)pg/ml。所有患者术前行2mg地塞米松抑制试验,结果均为不被抑制。48例术前行8mg地塞米松抑制试验,结果均为不被抑制。根据患者术前临床表现和实验室检查结果,分为亚临床型8例、临床型37例、危重型9例。本组54例,均选择影像学检查显示肿瘤较大侧肾上腺,行单侧肾上腺切除术,均为首次行肾上腺切除术,传统开放手术13例,普通腹腔镜手术27例,机器人辅助腹腔镜手术14例。比较不同术式的手术时间、术中出血量、住院时间。比较各型患者手术前后临床症状、血尿皮质醇浓度、ACTH变化,记录术后生化复发率。比较复发患者术前一般资料与总体患者的差异。结果与普通腹腔镜手术相比,机器人辅助腹腔镜手术的手术时间更短[(115.4±22.1)min与(95.0±19.8)min,P=0.045],术中出血量[(118.2±57.0)ml与(125.6±45.3)ml,P=0.441]和住院时间[(5.2±0.9)d与(6.4±1.2)d,P=0.279]差异无统计学意义。与微创手术相比,开放手术的手术时间更长[(134.0±34.5)min与(104.3±20.1)min,P=0.035],术中出血量更多[(305.5±85.2)ml与(122.5±44.3)ml,P=0.012],住院时间更长[(10.4±3.2)d与(5.7±1.0Objective To evaluate the efficacy and safety of unilateral adrenalectomy for treating primary bilateral macronodular adrenal hyperplasia(PBMAH)of different clinical types.Methods The clinical and biochemical data of 54 patients with PBMAH who underwent unilateral adrenalectomy from May 2008 to March 2023 were retrospectively collected.Preoperative CT images of all patients showed enlarged bilateral adrenal glands with multiple nodules of"fused masses".Mean preoperative blood cortisol concentration at 8am was(21.5±7.7)μg/dl,urinary free cortisol concentration was(442.6±300.4)μg/24h,and mean 8am ACTH concentration was(6.4±2.3)pg/ml.Postoperative symptoms,BMI,blood pressure,mass diameter,cortisol and ACTH concentration were recorded and analyzed.Results Compared with ordinary laparoscopic surgery,robot-assisted surgery showed shorter operation time[(115.4±22.1)min vs.(95.0±19.8)min,P=0.045];less blood loss[(118.2±57.0)ml vs.(125.6±45.3)ml,P=0.441] and shorter hospitalization time[(5.2±0.9)day vs.(6.4±1.2)day,P=0.279].Compared with laparoscopic surgery,open surgery showed longer operation time[(13434.5)min vs.(104.3±20.1)min,P=0.035];more blood loss[(305.5±85.2)ml vs.(122.5±44.3)ml,P=0.012]and longer hospitalization time[(10.4±3.2)day vs.(5.7±1.0)day,P=0.020].The average follow-up time was(23.7±11.7)months.Sixteen cases biochemically relapsed,and the average relapse-free time was(25.4±13.4)month.Mean postoperative systolic blood pressure was(131.1±16.8)mmHg(P=0.001)while diastolic blood pressure decreased to(82.2±11.1)mmHg(P=0.002).Postsurgical average blood cortisol concentration decreased to(10.2±4.0)μg/dl(P<0.01),while urine cortisol concentration decreased to(106.6±43.4)μg/24h(P<0.01).Average ACTH concentration increased to(12.6±4.1)pg/ml(P=0.005).Recurrent patients had higher preoperative blood and urine cortisol concentration(24.7±8.2)μg/dl(P=0.046),(522.8±234.2)μg/24h(P=0.028),and all of them underwent contralateral adrenalectomy.Conclusions Unilateral adrenalectomy is safe and ef

关 键 词：肾上腺切除术 肾上腺大结节样增生 库欣综合征 亚临床 复发率 

分 类 号：R736.6[医药卫生—肿瘤]