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肾癌是泌尿系统常见的恶性肿瘤之一,占成人恶性肿瘤的2%~3%[1-2]。腹腔镜下肾部分切除术(laparoscopy partial nephrectomy, LPN)因具有创伤小且保留肾单位的优势,已被推荐为T1期肾癌的主要治疗方式[3]。目前,大部分医院仍在肾脏血流阻断的前提下完成肿瘤切除与残肾处理,包括创面缝合止血、集合系统修补和残余肾成形等。由于热缺血时间(warm ischemia time, WIT)是影响术后残肾功能的关键因素,因此,如何缩短WIT从而保护LPN术后残肾功能是泌尿外科医生关注的问题之一。本研究通过探讨半程肾动脉阻断技术在LPN中的安全性及术后肾功能的改变,从手术技巧层面为减少WIT和保护肾功能提供新的思路和方法。
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94例病人手术均获成功,A组病人解除肾动脉阻断后无再次或反复阻断情况发生。所有肉眼血尿均在术后24~72 h内消失,无严重经尿道不可控活动性出血。A组和B组、A1和B1组、A2和B2组病人相比,性别、年龄、BMI、肿瘤大小、分期、位置以及R.E.N.A.L.评分等一般资料差异均无统计学意义(P>0.05)(见表 1)。
分组 n 男 女 年龄
(x±s)/岁BMI(x±s)/
(kg/m2)肿瘤大小
(x±s)/cm肿瘤分期 肿瘤位置 R.E.N.A.L.
评分(x±s)/分T1a T1b 上极 中极 下极 A组 32 20(62.5) 12(37.5) 52.44±4.62 22.84±3.53 3.53±1.51 21(65.6) 11(34.4) 8(25) 14(43.8) 10(31.2) 6.28±0.46 B组 62 38(61.3) 24(38.7) 52.44±4.67 23.02±3.30 3.55±1.59 43(69.4) 19(30.6) 17(27.4) 26(41.9) 19(30.7) 6.30±0.50 t — 0.01* 0.01 0.57 0.14 0.14* 0.06* 0.24 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 A1组 21 12(57.1) 9(42.9) 52.24±4.44 23.33±2.48 3.33±1.48 21(100.00) 0(0.00) 7(33.3) 5(23.8) 9(42.9) 6.43±0.51 B1组 43 30(69.8) 13(30.2) 52.51±4.74 23.28±2.45 3.46±1.5 43(100.00) 0(0.00) 12(27.9) 16(44.2) 15(34.9) 6.56±0.5 t — 0.10* 1.57 0.44 0.99 — 1.15* 0.97 P — >0.05 >0.05 >0.05 >0.05 — >0.05 >0.05 A2组 11 8(72.7) 3(27.3) 52.45±4.52 22.36±2.5 3.45±1.52 0(0.00) 11(100.00) 1(9.1) 9(81.8) 1(9.1) 6.45±0.52 B2组 19 8(42.1) 11(57.9) 52.63±4.50 22.53±2.51 3.68±1.67 0(0.00) 19(100.00) 5(26.3) 10(52.6) 4(21.1) 6.37±0.5 t — 2.63* 0.92 0.84 0.97 — 2.57* 0.45 P — >0.05 >0.05 >0.05 >0.05 — >0.05 >0.05 *示χ2值 表 1 不同阻断时程和肿瘤分期病人的一般资料比较[n; 百分率(%)]
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A组病人WIT短于B组病人,eGFR下降值低于B组(P < 0.01)。但病人手术时间、术中出血量、术后住院时间等围手术期指标在2组差异无统计学意义(P>0.05)(见表 2)。
分组 n 手术时间/min WIT/min 术中
出血量/mL术后住院
时间/d血尿
[n; 百分率(%)]漏尿
[n; 百分率(%)]eGFR下降/
(mL/min)肾萎缩
[n; 百分率(%)]A组 32 77.25±4.47 16±3.01 54±4.5 6.2±1.7 4(12.5) 1(3.13) 6.66±2.85 4(12.50) B组 62 76.16±4.80 22±3.40 53±4.2 6.5±1.5 6(9.68) 3(4.84) 11.75±2.95 7(11.30) t — 1.05 29.44 0.15 2.24 0.18* 0.15* 8.02 0.00* P — >0.05 < 0.01 >0.05 >0.05 >0.05 >0.05 < 0.01 >0.05 *示χ2值 表 2 2种阻断方式病人围手术期及远期并发症指标比较(x±s)
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为了证实2种阻断方式在不同分期病人中的应用价值,分别将A组和B组病人根据分期不同分为A1和A2,B1和B2组。病人WIT A1组短于B1组、A2组短于B2组(P < 0.01)。但在手术时间、术中出血量、血尿、漏尿、肾萎缩等指标差异无统计学意义(P>0.05)(见表 3)。
分组 n 手术
时间/minWIT/min 术中
出血量/mL术后住院
时间/d血尿
[n; 百分率(%)]漏尿
[n; 百分率(%)]eGFR下降/
(mL/min)肾萎缩
[n; 百分率(%)]A1组 21 74.57±5.66 15±2.80 52.7±4.8 5.8±1.9 1(4.76) 0(0.00) 8.67±5.42 2(9.50) B1组 43 74.14±5.37 20±3.28 53.1±4.2 5.9±1.7 1(2.33) 1(2.33) 6.29±3.96 2(4.70) t — 1.10 24.65 0.13 0.49 — — 0.88 0.43△ P — >0.05 < 0.01 >0.05 >0.05 >0.05* >0.05* >0.05 >0.05 A2组 11 79.09±4.94 17.21±2.98 58.2±5.1 6.5±1.5 3(27.3) 1(9.09) 7.79±2.85 2(18.20) B2组 19 79.89±5.20 23.00±2.89 55.9±4.8 6.4±1.6 5(26.3) 2(10.53) 8.82±2.75 2(26.3) t — 1.90 21.69 1.24 0.09 0.00△ 0.02△ 0.98 0.04△ P — >0.05 < 0.01 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 *示Fisher′s确切概率法;△示χ2值 表 3 2种阻断方式在T1a病人中的应用比较(x±s)
半程肾动脉阻断在腹腔镜肾部分切除术中的应用
Appliance value of half-course renal artery blocking in laparoscopy partial nephrectomy
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摘要:
目的探讨半程肾动脉阻断技术在腹腔镜肾部分切除术(laparoscopy partial nephrectomy,LPN)中的安全性及对残肾功能的保护作用。 方法回顾性分析行LPN的T1期肾脏肿瘤病人共94例。根据肾动脉阻断时程不同分为半程肾动脉阻断组(A组)32例和全程肾动脉阻断组(B组)62例。根据肿瘤分期不同,A组分为T1a期病人(A1组)21例和T1b期病人(A2)11例;B组分为T1a期病人(B1组)43例和T1b期病人(B2组)19例。分析病人手术时间、出血量、热缺血时间(warm ischemia time,WIT)、血尿、漏尿等围手术期指标和肾萎缩、肾功能下降等远期并发症等指标。 结果94例病人均手术顺利。A组病人WIT明显短于B组病人,eGFR下降值低于B组(P < 0.01);病人WIT A1组短于B1组、A2组短于B2组(P < 0.01)。但在手术时间、术中出血量、血尿、漏尿、肾萎缩等指标差异无统计学意义(P>0.05)。 结论半程肾动脉阻断技术可减少T1期肿瘤LPN中肾脏WIT,减少肾功能下降,尤其对T1b期肿瘤优势更为显著。该技术具有良好的安全性与实用性,值得临床推广。 Abstract:ObjectiveTo investigate the safety and protective effect on renal function of half-course renal artery blocking in laparoscopy partial nephrectomy(LPN). MethodsThe clinical data of 94 stage T1 renal cancer patients treated with LPN were retrospectively analyzed.The patients were divided into the half-course renal artery blocking group(group A, 32 cases))and whole-course renal artery blocking group(group B, 62 cases)according to the blocking course of renal artery.According to the tumor staging, the group A was subdivided into the stage T1a group(group A1, 21 cases)and stage T1b group(group A2, 11 cases), and the group B was subdivided into the stage T1a group(group B1, 43 cases)and stage T1b group(group B2, 19 cases).The operation time(OT), bleeding volume(BV), warm ischemia time(WIT), hematuria and urine leakage of perioperative indicators, and renal atrophy and renal function loss of long-term complications parameters in group A and group B were analyzed. ResultsThe operations in all patients were successfully completed.The WIT in group A was significant shorter that in group B, and the decreasing value of eGFR in group A was significant lower that in group B(P < 0.01).The WIT in group A1 and group A2 were shorter those in group B1 and group B2, respectively(P < 0.01).However, there was no statistical significance in OT, BV, hematuria, urine leakage, renal function decline and renal atrophy between group A and group B(P>0.05). ConclusionsThe half-course renal artery blocking can shorten renal WIT and reduce incidence of postoperative renal atrophy, especially for patients with stage T1b renal tumor.It has good safety and practicability, and is worthy of clinical application and promotion. -
表 1 不同阻断时程和肿瘤分期病人的一般资料比较[n; 百分率(%)]
分组 n 男 女 年龄
(x±s)/岁BMI(x±s)/
(kg/m2)肿瘤大小
(x±s)/cm肿瘤分期 肿瘤位置 R.E.N.A.L.
评分(x±s)/分T1a T1b 上极 中极 下极 A组 32 20(62.5) 12(37.5) 52.44±4.62 22.84±3.53 3.53±1.51 21(65.6) 11(34.4) 8(25) 14(43.8) 10(31.2) 6.28±0.46 B组 62 38(61.3) 24(38.7) 52.44±4.67 23.02±3.30 3.55±1.59 43(69.4) 19(30.6) 17(27.4) 26(41.9) 19(30.7) 6.30±0.50 t — 0.01* 0.01 0.57 0.14 0.14* 0.06* 0.24 P — >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 A1组 21 12(57.1) 9(42.9) 52.24±4.44 23.33±2.48 3.33±1.48 21(100.00) 0(0.00) 7(33.3) 5(23.8) 9(42.9) 6.43±0.51 B1组 43 30(69.8) 13(30.2) 52.51±4.74 23.28±2.45 3.46±1.5 43(100.00) 0(0.00) 12(27.9) 16(44.2) 15(34.9) 6.56±0.5 t — 0.10* 1.57 0.44 0.99 — 1.15* 0.97 P — >0.05 >0.05 >0.05 >0.05 — >0.05 >0.05 A2组 11 8(72.7) 3(27.3) 52.45±4.52 22.36±2.5 3.45±1.52 0(0.00) 11(100.00) 1(9.1) 9(81.8) 1(9.1) 6.45±0.52 B2组 19 8(42.1) 11(57.9) 52.63±4.50 22.53±2.51 3.68±1.67 0(0.00) 19(100.00) 5(26.3) 10(52.6) 4(21.1) 6.37±0.5 t — 2.63* 0.92 0.84 0.97 — 2.57* 0.45 P — >0.05 >0.05 >0.05 >0.05 — >0.05 >0.05 *示χ2值 表 2 2种阻断方式病人围手术期及远期并发症指标比较(x±s)
分组 n 手术时间/min WIT/min 术中
出血量/mL术后住院
时间/d血尿
[n; 百分率(%)]漏尿
[n; 百分率(%)]eGFR下降/
(mL/min)肾萎缩
[n; 百分率(%)]A组 32 77.25±4.47 16±3.01 54±4.5 6.2±1.7 4(12.5) 1(3.13) 6.66±2.85 4(12.50) B组 62 76.16±4.80 22±3.40 53±4.2 6.5±1.5 6(9.68) 3(4.84) 11.75±2.95 7(11.30) t — 1.05 29.44 0.15 2.24 0.18* 0.15* 8.02 0.00* P — >0.05 < 0.01 >0.05 >0.05 >0.05 >0.05 < 0.01 >0.05 *示χ2值 表 3 2种阻断方式在T1a病人中的应用比较(x±s)
分组 n 手术
时间/minWIT/min 术中
出血量/mL术后住院
时间/d血尿
[n; 百分率(%)]漏尿
[n; 百分率(%)]eGFR下降/
(mL/min)肾萎缩
[n; 百分率(%)]A1组 21 74.57±5.66 15±2.80 52.7±4.8 5.8±1.9 1(4.76) 0(0.00) 8.67±5.42 2(9.50) B1组 43 74.14±5.37 20±3.28 53.1±4.2 5.9±1.7 1(2.33) 1(2.33) 6.29±3.96 2(4.70) t — 1.10 24.65 0.13 0.49 — — 0.88 0.43△ P — >0.05 < 0.01 >0.05 >0.05 >0.05* >0.05* >0.05 >0.05 A2组 11 79.09±4.94 17.21±2.98 58.2±5.1 6.5±1.5 3(27.3) 1(9.09) 7.79±2.85 2(18.20) B2组 19 79.89±5.20 23.00±2.89 55.9±4.8 6.4±1.6 5(26.3) 2(10.53) 8.82±2.75 2(26.3) t — 1.90 21.69 1.24 0.09 0.00△ 0.02△ 0.98 0.04△ P — >0.05 < 0.01 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 *示Fisher′s确切概率法;△示χ2值 -
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