临床T1b期肾癌选择性保留肾单位手术分析

摘要

Objective To investigate the safety and feasibility of elective nephron sparing surgery (NSS) in clinical T1b (4-7 cm) renal cell carcinoma (RCC).Methods From January 2005 to Decem-ber 2008,elective NSS was carried out in 30 (19 males,11 females,mean age 56 years,from 39 years to 74 years) asymptomatic,single sited,peripheral,and organ confined RCCs,and the mean tumor size was 5.4 cm (4.2-7.0 cm).Intraoperative frozen section analysis was routinely used in suspect areas.A single urologist carried out the major surgical procedure.Peritumoral margin was 0.5 cm for the cortex and 0.2 cm for the deep part.Maximal diameter of the tumor divided by the maximal diameter of affected kidney (9.6-12.6 cm,mean 11.4 cm) in thin-layer CT scan or MRI was calculated as the relative tumor size (0.38-0.47,mean 0.43).Surgical parameters,pathological characters and clinical outcomes were documented and analyzed.Results Only 1 case was converted to radical nephrectomy due to uncontrollable bleeding during operation.For the rest 29 successful NSSs,median warm ischemia was 17 min (14-30 min) ; median blood lose was 40 ml (20-100 ml),no transfusion needed.All the 30 patients,including 26 clear cells,2 papillary and 2 chromophobe carcinomas,were pathologically confirmed to be T1b.The serum creatinine levels 3 months after operation were similar with those before operation.After a median follow-up of 56 months (36-72 months),all the 30 patients survived without recurrence.Conclusions Elective NSS in clinical T1b renal cell could be effective and safe.Location and relative tumor size should also be taken into account in addition to other ordinary indications.%目的 探讨临床T1b期肾癌选择性保留肾单位手术(nephron sparing surgery,NSS)的安全性和可行性. 方法 2005年1月至2008年12月行NSS治疗T1b期肾癌30例,男19例,女11例；年龄39 ～ 74岁,平均56岁；CT或MRI测量肿瘤最大径4.2～7.0 cm,平均5.4 cm；患侧肾脏最长径9.6～12.6 cm,平均11.4 cm.相对肿瘤大小定义为薄层CT或MRI上肿瘤最大径与患肾最长径的比值；相对肿瘤大小为0.38 ～0.47,平均0.43.术中可疑区域行冰冻活检控制阳性切缘,安全切缘为肾表面距肿瘤0.5 cm,基底距肿瘤0.2 cm.评估术中血管阻断时间、出血量、切缘阳性等技术参数和术后患者肾功能变化及肿瘤控制情况. 结果 1例因术中切穿肾盂,开放血流后出血不能控制,中转开放性肾切除术；29例成功完成NSS,动脉阻断时间14 ～ 30 min,中位17 min；术中出血量20～100 ml,中位40 ml,无输血.术后3个月肾功能无变化.随访36 ～72个月,中位56个月,患者均存活,肿瘤无复发. 结论 临床T1b期肾癌选择性NSS治疗安全、有效,肿瘤位置及相对肿瘤大小是NSS手术的重要影响因素.