Dilemma and strategy of minimally invasive nephron-sparing surgery for cystic renal cell carcinoma
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摘要: 囊性肾癌是一类低度恶性潜能的复杂性肾肿瘤，约占肾脏肿瘤的4%。囊性肾癌的保肾手术挑战大，其囊壁薄，术中易破溃导致肿瘤细胞外溢可能，很难达到保肾手术的无瘤原则。本中心通过结合术前智能三维重建、解剖程序化操作、早期开放缝合技术等多种创新技术及方案，提高了囊性肾癌保肾手术的安全性和可行性。本文将从囊性肾癌的微创保肾手术角度，阐述囊性肾癌的术前评估、术中难点、术中技巧等方面，结合国内外文献及本中心诊疗经验进行深入探讨。Abstract: Cystic renal cell carcinoma is a complex renal tumor with a low-grade malignancy potential, accounting for approximately 4% in all kidney tumors. Nephron-sparing surgery for cystic renal cell carcinoma is challenging. It is easy to rupture during surgery, leading to the possibility of tumor cell extravasation, because the cyst wall is thin. It is difficult to achieve the tumor-free principle of nephron-sparing surgery. Our center has improved the safety and feasibility of nephron-sparing surgery for cystic renal cell carcinoma by combining various innovative technologies and solutions such as preoperative intelligent 3D reconstruction, anatomical procedure surgery, and early unclamping technology. From the perspective of minimally invasive nephron-sparing surgery for cystic renal cell carcinoma, this article describes the preoperative evaluation, intraoperative difficulties, and intraoperative skills of cystic renal cell carcinoma, and conducts in-depth discussions based on literature and our center's experience.
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Key words:
- cystic renal cell carcinoma /
- nephron-sparing surgery /
- surgical strategy
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表 1 Bosniak分级的2005版与2019版
级别 2005版Bosniak分级 2019版Bosniak分级 Ⅰ 发丝样薄壁；均匀水样密度，囊内无分隔、钙化、实性成分；无强化(单纯囊肿)。 边界清晰，壁薄(≤2 mm)且光滑；均匀单纯液体密度(-9~20 HU)；无分隔、钙化；囊壁可强化。 Ⅱ 2种类型：①囊性病变伴少(1~3个)且薄的分隔，囊壁及分隔可强化，可被感知的强化；囊壁或分隔可伴细小钙化；②≤3 cm的均匀高密度病变，边缘光滑，无强化。 边界清晰，壁薄(≤2 mm)且光滑，分为6种类型：①囊内分隔少、薄，囊壁或分隔可出现可伴任意类型的钙化；②CT平扫上呈均匀高密度(≥70 HU)；③病变均匀无强化，CT值>20 HU，可伴任意类型的钙化；④未行增强CT检查时，病变密度均匀，CT值-9~20 HU；⑤增强扫描实质期CT值为21~30 HU的均匀密度病变；⑥太小而无法定性的均匀低密度病变。 ⅡF 2种类型：①囊壁或分隔轻度增厚，囊内多发薄分隔伴或不伴可察觉但不可测量的强化，可有粗大或结节样钙化；②边界清晰的>3 cm的肾脏高密度病变，无强化。 囊壁光滑、略增厚(3 mm)且强化，或略增厚的1个或多个强化分隔又或多个(≥4个)强化的光滑、薄壁(≤2 mm)分隔。 Ⅲ 囊壁或分隔增厚或不规则，伴可测量的强化。 至少1个强化的厚壁(≥4 mm)或分隔，或者壁或分隔强化且不规则(出现≤3 mm与囊壁或分隔呈钝角的突起)。 Ⅳ 出现软组织成分，伴可测量的强化。 至少1个强化结节(≥4 mm与囊壁或分割呈钝角的突起，或者任意大小与囊壁或分隔呈锐角的强化突起)。 
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