摘要
目的探讨机器人患肾切取、工作台手术联合机器人自体肾移植术治疗复杂肾肿瘤的安全性和可行性。方法回顾性分析2018年1—7月收治的5例肾肿瘤患者的病例资料。男4例,女1例。中位年龄49岁(32~66岁)。中位体质指数25.6 kg/m2(21.1~27.8 kg/m2)。工作台手术前的血肌酐水平为87.2 μmol/L(78.0~88.9 μmol/L)。5例均为双肾多发肿瘤,且对侧肾脏已行腹腔镜或机器人肾部分切除术。拟行工作台手术的患肾为左侧4例,右侧1例;患肾肿瘤均≥2枚;患肾同时合并完全内生型肿瘤、直径>7 cm肿瘤或肾门肿瘤。5例均全麻下行机器人患肾切取、离体工作台肾部分切除联合机器人自体肾移植术。患者先取健侧斜卧位,行机器人患肾切取术,经6 cm绕脐正中切口取出肾脏。肾脏取出后行低温工作台肾肿瘤切除及肾脏重建,然后将肾脏装入塑料袋内并填塞冰屑,塑料袋相应部位剪口显露肾动静脉。最后患者取截石位、头低足高约20°。将塑料袋包裹的自体肾经绕脐切口置入腹腔行机器人自体肾移植术,将肾动静脉分别与右侧髂外动静脉端侧吻合,输尿管与膀胱吻合。4例自体肾置于腹腔,1例自体肾置于右侧髂窝并行腹膜外化。术中移植肾血供恢复前其表面的冰屑均未完全融化,血供恢复后自体肾均即刻泌尿。结果 5例手术均顺利完成,无中转开放病例。手术总时间460 min(415~645 min),机器人肾脏切取时间120 min(74~300 min),机器人自体肾移植时间135 min(103~163 min),肾脏热缺血时间3 min(1.5~6.0 min),冷缺血时间182 min(135~210 min),复温时间50 min(45~55 min),术中估计出血量100 ml(50~300 ml),术后住院时间6 d(5~9 d)。切除肿瘤数量4枚(2~6枚)。术后病理诊断为透明细胞癌3例,嫌色细胞癌2例,切缘均为阴性。术后第7、30天血肌酐水平分别为111.1 μmol/L(87~217.6 μmol/L)和106.1 μmol/L(87.1~172 μmol/L)。术后1个月CT检查均提示自体移植肾功能、形态良好。5例中位随访时间7个月(5.4~11.7个月),均无肿瘤复发和转移情况。结论对于无法在体内原位行肾部分切除术的复杂肾肿瘤患者,机器人患肾切取、工作台手术联合机器人自体肾移植术能完整切除肿瘤、最大限度保留肾功能以及尽可能地减少患者创伤,使复杂肾肿瘤患者的终极保肾手段变得更加微创和安全。
Objective To investigate the safety and feasibility of robotic nephrectomy, work bench surgery with robotic kidney autotransplantation in the treatment of complex renal tumors. Methods The clinical data of 5 patients with renal tumors admitted from January 2018 to July 2018 were analyzed retrospectively. There were 4 males and 1 females. The median age was 49 years old, ranging 32-66 years. The median body mass index was 25.6 kg/m2, ranging 21.1-27.8 kg/m2. Serum creatinine level was 87.2 μmol/L, ranging 78.0-88.9μmol/L before bench surgery. 5 patients had multiple bilateral renal tumors and had undergone laparoscopic or robotic partial nephrectomy on the contralateral kidney. For bench surgery kidney, 4 cases were on the left side and 1 case was on the right side. Each kidney has more than 2 separate tumors, combined with complete endophytic tumors, tumors larger than 7 cm in diameter or hilar tumors. 5 patients were all performed robotic nephrectomy, work bench partial nephrectomy with robotic kidney autotransplantation under general anesthesia. The patient was first in a lateral decubitus position for robotic nephrectomy, and the kidney was removed through a median 6 cm periumbilical incision. After kidney removal, kidney tumors were resected and kidney was reconstructed on a hypothermic working table. Then the kidney was packed in a plastic bag, filling with ice slush. The corresponding parts of the plastic bag were cut to expose the renal artery and vein. Finally, the patient was moved to lithotomy position with Trendelenburg tilt of 20°, and the autologous kidney wrapped in the plastic bag was placed through the previous periumbilical incision into the abdominal cavity for robotic kidney autotransplantation. The renal artery and vein were anastomosed end-to-side with the right external iliac artery and vein. The ureter and bladder were anastomosed. Autologous kidneys were placed in abdominal cavity in 4 cases, and placed in right iliac fossa with retroperitonealization in 1 case. Ice slush on the surface of the autologous kidney did not completely melt before the blood supply was restored during the operation, and the autologous kidney immediately urinated after the blood supply was restored.Results All surgeries were performed successfully without conversion to open surgeries. The total operation time was 460 min, ranging(415-645 min), the time of robotic nephrectomy was 120 min, ranging(74-300 min), the time of robotic kidney autotransplantation was 135 min, ranging(103-163 min), the warm ischemia time was 3 min, ranging(1.5-6.0 min), the cold ischemia time was 182 min, ranging(135-210 min), the rewarming time was 50 min, ranging(45-55 min), the estimated blood loss during operation was 100 ml, ranging(50-300 ml), and the hospital stay was 6 d, ranging(5-9 d). The number of resected tumors was 4, ranging(2-6). The pathology reveals clear cell carcinoma in 3 cases and chromophobe cell carcinoma in 2 cases. The surgical margins were all negative. The serum creatinine levels were 111.1 μmol/L (87-217.6 μmol/L) and 106.1 μmol/L (87.1-172 μmol/L) on the 7th and 30th day after operation, respectively. One month after operation, CT showed that the function and morphology of the autologous kidneys were fine. No recurrence or metastasis was found in 5 patients during a median follow-up of 7 months, ranging (5.4-11.7 mon). Conclusions For patients with complex renal tumors who cannot undergo in situ partial nephrectomy, robotic nephrectomy, work bench surgery with robotic kidney autotransplantation can completely remove the tumors, maximize the preservation of renal function and minimize the trauma of patients, making the ultimate means of nephron-sparing surgery for patients with complex renal tumors more minimally invasive and safe.
作者
范阳
董隽
祖强
马鑫
李宏召
祝强
段珥耀
王昕凝
王保军
彭程
张旭
Fan Yang;Dong Jun;Zu Qiang;Ma Xin;Li Hongzhao;Zhu Qiang;Duan Junyao;Wang Xinning;Wang Baojun;Peng Cheng;Zhang Xu(Department of Urology, PLA General Hospital, Beijing 100853, China)
出处
《中华泌尿外科杂志》
CAS
CSCD
北大核心
2019年第5期340-345,共6页
Chinese Journal of Urology
基金
国家自然科学基金(81702492).
关键词
复杂肾肿瘤
工作台手术
机器人自体肾移植
Complex renal tumors
Work bench surgery
Robotic kidney autotransplantation
