Surgical treatment options and techniques for central and hilar renal tumours in the robotic era
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摘要: 目的 分析并总结机器人肾部分切除术治疗中央型及肾门型肾肿瘤以及北大泌尿(Institute of Urology，Peking University，IUPU)脂肪囊法冷却技术在术中缓解热缺血损伤的安全性、有效性及其技术要点。方法 回顾性收集2019年4月—2023年4月于北京大学第一医院泌尿外科接受机器人辅助肾部分切除术22例的中央型及肾门型肾肿瘤患者，并根据术中是否接受IUPU脂肪囊法冷却技术将患者分为技术组(8例)和对照组(14例)，收集患者的随访资料，对比2组手术参数、肾功能改变、围手术期并发症和随访结果。结果 本研究纳入的22例患者手术均顺利完成，术后无并发症患者18例(81.8%)，经过中位随访时长17个月的观察尚未有患者出现复发、进展、肾萎缩及死亡。术中接受IUPU脂肪囊法冷却技术的患者相较于对照组患者在年龄、性别比、体重指数(body mass index，BMI)、手术时间、术中出血等方面均差异无统计学意义，但中位术中热缺血时间显著延长(48.0 min vs 25.5 min，P＜0.001)，2组患者术中尿量、术后血肌酐及肾小球滤过率(glomerular filtration rate，eGFR)变化值及并发症发生率比较均差异无统计学意义。结论 机器人肾部分切除术可以安全有效地处理术前充分评估并选择良好的中央型及肾门型肾肿瘤。IUPU脂肪囊法冷却技术可以在术中有效缓解较长热缺血时间带来的继发性肾功能损伤。
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关键词:
- 机器人肾部分切除术 /
- 中央型及肾门型肾肿瘤 /
- IUPU脂肪囊法冷却技术 /
- 术中B超 /
- 缝合技术 /
- 有效性及安全性评价
Abstract: Objective To analyse and summarise the safety and efficacy of robotic partial nephrectomy for the treatment of central and hilar renal tumours as well as the IUPU(Institute of Urology, Peking University) perirenal adipose sac cooling technology for intraoperative relief of thermal ischaemic injury and its technical points.Methods Twenty-two patients with central and hilar renal tumours who underwent robot-assisted partial nephrectomy in the Department of Urology, First Hospital of Peking University from April 2019 to April 2023 were retrospectively collected, and the patients were divided into a technical group(8 patients) and a control group(14 patients) according to whether or not they received intraoperative IUPU perirenal adipose sac cooling technology. The follow-up data of the patients were collected, and the two groups were compared with respect to their surgical parameters, renal function changes, perioperative complications and follow-up results.Results Surgery was successfully completed in all 22 patients included in this study, and 18(81.8%) were free of postoperative complications, with no patients experiencing recurrence, progression, renal atrophy, or death after median follow-up time of 17 months. There were no significant differences in age, sex ratio, body mass index(BMI), operative time or intraoperative bleeding between the two groups, but the median intraoperative ischaemic time of the technical group significantly prolonged compared with the control group(48.0 minutes vs 25.5 minutes, P < 0.001). No significant differences were observed in the intraoperative urinary output, the changes in postoperative blood creatinine or glomerular filtration rate(eGFR), or the complication rate between two groups.Conclusion Robotic partial nephrectomy can safely and effectively manage central and hilar renal tumours that have been adequately assessed and well-selected preoperatively. The IUPU perirenal adipose sac cooling technology can be effective in intraoperatively mitigating renal impairment secondary to long thermal ischaemia time. -
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表 1 22例入组患者的围术期、病理相关信息及预后情况
例(%)，M(P25，P75) 项目 数值 ASA评分 Ⅰ 4(18.2) Ⅱ 14(63.6) Ⅲ 4(18.2) 肿瘤类型 完全内生性 19(86.4) 肾门肿瘤 3(13.6) 肿瘤部位 上极 8(36.4) 中部 13(59.1) 下极 1(4.5) 手术入路 经腹 17(77.3) 经腹膜后 5(22.7) 动脉根数 1 18(81.8) ≥2 4(18.2) 局部复发二次手术或腹腔手术史 2(9.1) 术中采用IUPU脂肪囊法冷却技术 8(36.4) 手术时间/min 125.0(106.3，150.3) 热缺血时间/min 32.5(23.5，43.0) 预估出血量/mL 100.0(50.0，150.0) 术中尿量/mL 150.0(37.5，300.0) 术后并发症 肠梗阻 2(9.1) 血尿肾周尿外渗 2(9.1) 肿瘤类型 透明细胞癌 21(95.5) 错构瘤 1(4.5) 肿瘤分期 T1a 18(81.8) T1b 2(9.1) T3a 1(4.5) 病理分级 G1 15(68.2) G2 5(22.7) G3 1(4.5) 切缘阳性 1(4.5) 肿瘤最大径/cm 2.5(1.7，3.2) 随访时长/月 17(13.3，30.3) 死亡 0(0) 复发或进展 0(0) 肾萎缩或肾功能衰竭 0(0) 注：美国麻醉医师协会(American Society of Anesthesiologists，ASA)。纳入22例患者中包含1例肾错构瘤无对应分期分级标准。 
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表 2 2组患者围术期及肾功能变化比较
例(%)，M(P25，P75) 项目 对照组(14例) 技术组(8例) P值 年龄/岁 48.0(42.0，62.0) 55(51.3，63.3) 0.306 性别 0.602 男 12(85.7) 6(75.0) 女 2(14.3) 2(25.0) BMI/(kg/m2) 26.6(24.6，28.8) 27.1(22.5，28.7) 0.785 手术时间/min 116.6(98.0，152.2) 134.0(111.3，150.0) 0.785 热缺血时间/min 25.5(20.0，35.0) 48.0(39.3，76.3) ＜0.001 预估出血量/mL 75.0(45.0，112.5) 100.0(50.0，187.5) 0.463 术中尿量/mL 125.0(0，300.0) 200.0(100.0，337.5) 0.370 术后并发症 2(14.3) 2(25.0) 0.602 术后肌酐升高/(μmol/L) 22.0(8.2，34.8) 14.6(4.1，28.6) 0.682 术后eGRF减低/(mL/min/1.73 m2) 19.2(9.3，29.9) 8.6(5.6，21.7) 0.195
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