基于肾单位精细解剖的后腹腔镜肾部分切除术方法改进与应用

郭刚; 蔡伟; 韩宇; 祝强; 张旭

基于肾单位精细解剖的后腹腔镜肾部分切除术方法改进与应用

- 解放军总医院泌尿外科(北京, 100853)

详细信息

通讯作者: 蔡伟,E-mail:caiw139@139.com

中图分类号: R737.11

收稿日期: 2013-02-03

Application and improvement of laparoscopic nephron sparing surgery for renal cell carcinoma based on nephron anatomy

- Department of Urology Surgery, General Hospital of PLA, Beijing, 100853, China

More Information

Corresponding author: CAI Wei, E-mail: caiw139@139.com

Received Date: 03 February 2013

摘要

摘要: 目的：探索基于肾单位精细解剖的后腹腔镜保留肾单位肾部分切除的手术方法和技巧，借助解剖方法减少出血和尿瘘的可能性。方法：我院2012年1~12月期间住院的肾脏肿瘤患者31例，男19例，女12例，年龄28~68岁，平均（56.1±13.8）岁。肿瘤直径1.2~6.0 cm，平均（3.4±0.7） cm。术中阻断肾动脉后，距肿瘤边缘3~5 mm剪开肾包膜及肾皮质，在肾实质的切口内，沿肾锥体髓放线钝性加锐性向深处和基底分离，使包裹一层肾髓质的瘤体与保留的肾脏髓质分开，显露出的基底部的血管应用双极电凝后剪断。仔细剥离肾小盏，以可吸收线两层缝合，关闭肾脏创面。记录动脉阻断时间、手术时间、术中出血量、术后引流量、病理结果和手术并发症。结果：本组31例患者采用切开包膜实质剥离髓质方法均获成功。其中19例可见基底部1支血管，8例可见2支血管，19例可见肾盏。平均手术时间（95.5±27.1） min；平均术中动脉阻断时间（21.2±7.2） min；平均术中出血量（55.7±18.9） ml；平均术后引流量（92.3±28.9） ml，平均术后住院时间（6.1±0.6） d；术后无继发出血、漏尿等并发症发生。所有标本呈完整楔形块状，切缘均为阴性。术后病理证实：肾透明细胞癌27例、嗜酸细胞腺瘤1例、肾小球旁细胞瘤1例、嫌色细胞癌2例。TNM分期：T_1a期28例，T_1b期3例。结论：采用切开包膜和实质剥离肾髓质改良的后腹腔镜保留肾单位肾部分切除术，切除瘤体部所附着肾组织确切完整，有利于切缘阴性。基底部止血确实，处理累及的肾盏确切，可以减少术后继发出血及漏尿的发生。
- 肾脏肿瘤 /
- 腹腔镜 /
- 肾部分切除术
Abstract: Objective: To evaluate the application and Improvement of laparoscopic nephron sparing surgery for renal cell carcinoma based on nephron anatomy. Decrease the incidence of hemorrhage and urinary fistula postoperative.Method: Data were collated for all 31 patients with a mean age of 28-68 (56.1±13.8) years who underwent nephron sparing surgery at our department for one 12 to 60 (3.4±0.7) cm renal cell carcinomas between Jan. 2012 and Dec. After block the renal artery, circularly cut the renal capsule and cortex from the tumor edge 3 to 5 mm. Separate the renal medulla by medullary ray, so the parceled tumor and normal renal medullary is separated. Carefully coagulate the vessel and peel off the renal lights. Close the kidneys wound by two layers suture. Record the artery occlusion time, operative time, blood loss volume, postoperative drainage, pathological findings and surgical complications.Result: All patients received successful operation by the new way. Estimated average intraoperative blood loss was (55.7±18.9) ml, average operation time was (95.5±27.1) minutes, vascular pedicle clamping for (21.2±7.2) minutes, average postoperative drainage volume was (92.3±28.9) ml and the average postoperative length of stay was (6.1±0.6) d. There was not hemorrhage and urinary fistula postoperative. All specimens were wedge mass and margins were all negative. 27 cases were renal cell carcinoma, two were chromophobe carcinoma, one was Oxyphilic adenoma and one was juxtaglomerular cell tumor. 28 cases were T_1a stage and other three were T_1b.Conclusion: Laparoscopic nephron sparing surgery based on nephron anatomy is effective and feasible. It is good for tumor cutting completely and margin negative. It also can decrease the incidence of hemorrhage and urinary fistula postoperative.
- kidney tumor /
- laparoscopy /
- partial nephrectomy

HTML全文

参考文献(15)

[1]	Margreiter M, Marberger M. Current status of open partial nephrectomy[J]. Curr Opin Urol, 2010, 20:361-364.
[2]	Schwaibold H E, Stolzenburg J U. Laparoscopic partial nephrectomy[J]. Arch Ital Urol Androl, 2009, 81:72-75.
[3]	Pietzak E J, Guzzo T J. Advancements in laparoscopic partial nephrectomy:expanding the feasibility of nephron-sparing[J]. Adv Urol, 2012:148952.
[4]	Aron M, Turna B. Laparoscopic partial nephrectomy:Newer trends[J]. Indian J Urol, 2009, 25:516-522.
[5]	Wen J, Li H Z, Ji Z G, et al. Evaluation of retroperitoneoscopic partial nephrectomy with in situ hypothermic perfusion[J]. Clin Transl Oncol, 2012, 14:382-385[ZK)].
[6]	Nozaki T, Iida H, Morii A, et al. Selective renal parenchymal clamping in retroperitoneal partial nephrectomy[J]. J Laparoendosc Adv Surg Tech A, 2012, 22:168-172.
[7]	Gill I S, Ramani A P, Spaliviero M, et al. Improved hemostasis during laparoscopic partial nephrectomy using gelatin matrix thrombin sealant[J]. Urology, 2005, 65:463-466.
[8]	Zorn K C, Gong E M, Orvieto M A, et al. Impact of collecting-system repair during laparoscopic partial nephrectomy[J]. J Endourol, 2007, 21:315-320.
[9]	Kong W, Zhang J, Dong B, et al. Application of a standardized anatomical classification in a Chinese partial nephrectomy series[J]. Int J Urol, 2012, 19:551-558.
[10]	Springer C, Hoda M R, Fajkovic H, et al. Laparoscopic vs open partial nephrectomy for T1 renal tumours:evaluation of long-term oncological and functional outcomes in 340 patients[J]. BJU Int, 2013, 111:281-288.
[11]	Breda A, Stepanian S V, Liao J, et al. Positive margins in laparoscopic partial nephrectomy in 855 cases:a multi-institutional survey from the United States and Europe[J]. J Urol, 2007, 178:47-50; discussion 50.
[12]	Wang P, Xia D, Wang S. Multiple factor analysis of urine leaks after retroperitoneal laparoscopic partial nephrectomy[J]. Urol Int, 2011, 87:411-415.
[13]	Sampaio F J. Renal anatomy. Endourologic considerations[J]. Urol Clin North Am, 2000, 27:585-607, vii.
[14]	Okhunov Z, Shapiro E Y, Moreira D M, et al. R.E.N.A.L. nephrometry score accurately predicts complications following laparoscopic renal cryoablation[J]. J Urol, 2012, 188:1796-1800.
[15]	Stroup S P, Palazzi K, Kopp R P, et al. RENAL nephrometry score is associated with operative approach for partial nephrectomy and urine leak[J]. Urology, 2012, 80:151-156.