摘要
目的 探讨“球冠状”肾部分切除术治疗早期肾癌在肿瘤根治性、肾功能保护和手术安全性方面的效果. 方法 2011年3月至2013年12月采用开放或腹腔镜下“球冠状”肾部分切除术治疗早期肾癌患者210例.男145例,女65例.年龄25 - 78岁,平均（56±12）岁.术前影像学检查显示肿瘤最大径≤4.0 cm 143例（68.1％）,4.1-7.0 cm 49例（23.3％）,＞7.0cm 18例（8.6％）.肿瘤术前PADUA评分显示低危组（6-7分）90例（42.9％）,中危组（8-9分）86例（40.9％）,高危组（≥10分）34例（16.2％）.患者术前肾小球滤过率估计值（estimated glomerular filtration rate,eGFR） 40.6-152.8 ml/（min·1.73 m^2）,平均（120.6±48.2）ml/（min· 1.73 m^2）.全麻下行“球冠状”肾部分切除术,该术式的技术要点：阻断肾动脉后沿距离肾实质-肿瘤交界3-5 mm处锐性切开肾包膜,楔形切入肾实质,探及肾肿瘤假包膜与肾实质间的“过渡带”,在“过渡带”平面采用钝性剥离为主的手法将肾肿瘤与肾实质分开,至肿瘤基底部进入肾窦后,沿假包膜完整切除肿瘤.记录手术切缘阳性率、热缺血时间、并发症发生率以及术后eGFR变化,根据Trifecta标准评价该术式治疗早期肾癌的效果.结果 本组210例中,行开放“球冠状”肾部分切除术92例,手术时间（120±45） min,热缺血时间（15±5） min,术中出血量（246±188） ml,术中22例（23.9％）行集合系统修补.行腹腔镜下“球冠状”肾部分切除术118例,手术时间（145±50） min,热缺血时间（23±7）min,术中出血量（185±120） ml,术中30例（25.4％）行集合系统修补.病理检查提示切缘阳性2例.术后30 d内出现并发症42例（20.0％）,其中Clavien Ⅰ -Ⅱ级并发症36例,ClavienⅢ-Ⅳ级并发症6例.泌尿系统并发症包括出血6例,漏尿4例.围手术期无死亡病例.随访10-38个月,中位随访时间18个月.术后6个月eGFR 32.8-150.2 ml/（min·1.73 m^2）,平均（109.0±52.4） ml/（min· 1.73 m^2）,eGFR下降幅度为（9.8±20.4）ml/（min· 1.73 m^2）,术后eGFR下降超过预计水平10％者62例（29.5％）.随访中未发现局部复发及远处转移.85例手术符合Trifecta标准,达标率为40.5％. 结论 “球冠状”肾部分切除术在保证肿瘤完整切除的同时,最大程度地保留了肾实质,并且减少了对血管和集合系统的损伤,在肿瘤学、功能学和手术安全性上具有优越性,今后可开展前瞻性临床对照研究进一步验证.
Objective To present a novel ＂Hat-Spherical Model＂ for partial nephrectomy and evaluate its oncological,functional outcomes and complication risks in the application for localized kidney cancer treatment.Methods Two hundred and ten patients with localized kidney cancer underwent open or laparoscopic ＂Hat-Spherical＂ partial nephrectomy from Mar.2011 to Dec.2013,and were included for this retrospective analysis.Of the 210 patients,145 were males and 65 were females.The age ranged from 25 to 78 （56±12） years.The tumor greatest dimension was ≤4.0 cm in 143 cases （68.1%）,4.1-7.0 cm in 49 cases （23.3%） and 〉7.0 cm in 18 patients （8.6%）.According to PADUA （Preoperative Aspects and Dimensions Used for an Anatomical） classification,90,86 and 34 patients were respectively stratified as low（42.9%）,intermediate-（40.9%） and high-risk （16.1%） groups.In contrast to traditional technique,the key points of ＂Hat-Spherical＂ partial nephrectomy were as follows：after clamping,the renal capsule was incised sharply 3-5 mm away from the tumor edge,and the incision plane was wedge-shaped and towards the tumor pseudocapsule.The ＂transition zone＂ between pseudocapsule and normal renal parenchyma was the ideal surgical plane.When reached,the tumor was bluntly separated from the surrounding parenchyma following the natural plane.When close the bottom or approaching the renal sinus,the tumor was enucleated along the pseudocapsule.The positive surgical margin rate,warm ischemic time,complication rate and the postoperative eGFR decline were evaluated.The ＂Trifecta＂ criteria,in which the 3 key outcomes of negative cancer margin,minimal renal functional decrease and no urological complications,were applied to evaluate the ＂ Hat-Spherical＂ partial nephrectomy technique.Results Ninety-two patients underwent open ＂Hat-Spherical＂ partial nephrectomy.The mean operation time was 120±45 min,the mean warm ischemic time was 15± 5 min.The estimated blood loss was 246± 188 ml.Twenty-two patients （23.9%） needed renal calyceal repairing.One hundred and eighteen patients underwent laparoscopic ＂Hat-Spherical＂ partial nephrectomy.The mean operation time and warm ischemic time were 145±50 min and 23±7 min,respectively.The mean estimated blood loss was 185± 120 ml and 30 patients （25.4%） needed renal calyceal repairing.The rate of positive surgical margin was 0.95% （2/210）.A total of 42 patients （20.0%） experienced complications during 30 days postoperatively,including 36 Clavien Ⅰ-Ⅱ minor complications and 6 cases of Clavien Ⅲ-Ⅳ major complications.There were 6 postoperative bleeding events （2.9%） and 4 urine leakages （1.9%）.There was no perioperative death.The median （range） follow-up was 18 （10-38） mon.The mean decrease in postoperative eGFR was 9.8±20.4 ml/（min · 1.73 m^2）,and 62 patients had a greater than 10% reduction in the actual vs volume predicted postoperative eGFR.Until the last follow-up,there was no local recurrence and distant metastasis.Trifecta outcome was achieved in 85 patients （40.5%）.Conclusions The ＂Hat-Spherical＂ partial nephrectomy has three main technical advantages,including safely keeping negative surgical margin,maximal preservation of renal parenchyma and reducing the risk of vessel and renal calyceal injury.The superiority of ＂Hat-Spherical＂ technique over traditional partial nephrectomy needs further validation by prospective comparative clinical trials.
出处
《中华泌尿外科杂志》
CAS
CSCD
北大核心
2015年第3期166-171,共6页
Chinese Journal of Urology
基金
国家自然科学基金（81272841）
上海卫生系统先进适宜技术推广项目（2013SY027）
上海市自然科学基金（13ZR1425100）
关键词
肾癌
“球冠状”肾部分切除术
过渡带
Kidney cancer
＂Hat-Spherical＂ partial nephrectomy
Transition zone
