机器人辅助腹腔镜肾部分切除术治疗高复杂性肾肿瘤（R．E．N．A．L．评分≥10分）经验总结

摘要

目的：：探讨 R．E．N．A．L．评分≥10分的高复杂性肾肿瘤行机器人辅助腹腔镜肾部分切除术的安全性、可行性及疗效.方法：回顾性分析2012年5月~2016年2月由同一术者完成的38例患者的临床资料,患者均为 R．E．N．A．L．评分≥10分的高复杂性肾肿瘤,均行机器人辅助腹腔镜肾部分切除术,其中男26例,女12例,年龄19~72岁,平均(51.0±11.9)岁.体质指数为19.6~35.2 kg/m2,平均(25.2±3.4)kg/m2.麻醉评分为1~2分,平均(1.91±1.03)分.肿瘤均为单发,左侧16例,右侧22例,最大径2~16 cm,平均(4.27±2.27)cm.R．E．N．A．L．评分为10分31例,11分7例.术前肾小球滤过率估计值(eGFR)69.8~131.4 ml•min－1•1.73 m－2,平均(97.9±24.3)ml•min－1•1.73 m－2.探讨手术技巧,分析围手术期数据,评估手术效果.结果：除1例因术中出血中转开放肾部分切除术,其余手术均顺利完成.手术时间105~308 min,平均(208.8±46.5)min；肾脏缺血时间14~49 min,平均(26.6±7.4)min；术中出血10~600 ml,平均(150.3±115.5)ml；术后住院9~25 d,平均(14.4±3.6)d；总体输血率5.3％(2/38),手术总体并发症发生率7.9％(3/38)；术后病理提示：手术切缘均阴性,肾透明细胞癌32例、嫌色细胞癌1例、TFE-3基因融合相关性肾癌1例、血管平滑肌脂肪瘤4例；术后3个月eGFR平均下降7.1％,术前后eGFR变化值有统计学差异意义(P＜0.004).术后随访9~51个月,平均(27.8±9.7)个月,38例均未见肿瘤转移和复发.结论：对于 R．E．N．A．L．评分≥10分的高复杂性肾肿瘤,机器人辅助腹腔镜肾部分切除术安全可行,围手术期疗效确切,但远期效果仍需进一步随访观察.%Objective:To evaluate the safety,feasibility and efficacy of robot-assisted laparoscopic partial ne-phrectomy (RAPN)in treating renal tumors with R.E.N.A.L.score ≥10.Methods:All patients receiving RAPN by the same surgeon during May 2012 and Feb 2016 were reviewed.Among them,38 patients with high complex renal tumors (R.E.N.A.L.score ≥10)were enrolled in this study.The male/female ratio was 26/12 with a mean age of 51.0±11.9 (19-72)years.The mean body mass index was 25.2±3.4 (19.6-35.2)kg/m2 ,and the mean ASA score was 1.91±1.03 (1 to 2). All tumors were solitary including 16 on the left and 22 on the right.The mean diameter was 4.27±2.27 (2-16)cm.There were 31 cases and 7 cases with R.E.N.A.L.score 10 points and 11 points respectively.The mean preoperative estimated glomerular filtration rate was 97.9±24.3 (69.8-131.4) mL•min-1•1.73 m-2 .Results:All procedures were completed successfully except one conversion to open sur-gery for intraoperative bleeding.The mean operation time was 208.8±46.5 (105-308)min,ischemia time was 26.6±7.4 (14-49)min,and estimated blood loss was 150.3±115.5 (10-600)mL.The mean postoperative hos-pital stay was 14.4±3.6 (9-25)days.The overall rate of blood transfusion was 5.3% (2/38)and the complica-tion rate was 7.9% (3/38).No positive surgical margin was observed.Postoperative pathology results revealed 32 renal clear cell carcinomas,1 chromophobe renal cell carcinoma,1 TFE-3 fusion gene related renal cell carcinoma renal cell carcinoma and 4 angiomyolipomas.The meane eGFR decreased by 7.1% three months after operation with a significant difference compared to preoperativee eGFR (P<0.004).All patients had no local recurrence or distant metastasis during a mean follow-up period of 27.8±9.7 (9-51)months.Conclusions:Robot-assisted lapa-roscopic partial nephrectomy is safe and effective for high-complexity renal tumors with R.E.N.A.L.≥10.