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目的:探讨后腹腔镜联合经腰小切口“杂交”手术在复杂肾肿瘤保留肾单位手术中的临床疗效和安全性。方法:回顾性分析2015年4月至2016年12月在北京大学人民医院泌尿外科进行“杂交”保留肾单位手术的复杂肾肿瘤患者的临床资料,其中男性10例,女性6例,年龄(50.2±10.7)岁,肿瘤位于左侧9例,右侧7例,肿瘤直径(6.1±1.0)cm,R.E.N.A.L.评分平均(9.3±1.3)分。患者均采用后腹腔镜联合经腰小切口的“杂交”手术方式进行保留肾单位手术,即在后腹腔镜下完全游离肾和肾蒂血管,预置肾动脉,然后取12肋下长约10~12 cm的切口进行开放手术,阻断肾动脉,直视下切除肿瘤、缝合创面。记录手术时间、肾缺血时间、术中出血量、术后并发症等围手术期资料以及术后肾功能随访情况。结果:16例均全部成功完成手术。手术时间(164.9±23.6)min,肾缺血时间(32.4±6.2)min,术中出血量(204.0±125.1)m L,引流管拔除时间(4.1±1.0)d,术后平均住院时间(6.9±1.5)d。术后发生ClavienⅢ级以上并发症2例:1例集合系统损伤;1例患者因术后出血,再次急诊手术探查止血。术后第1天平均血肌酐水平为(126.3±26.4)μmol/L,与术前(74.3±16.9)μmol/L比较,差异有统计学意义(P<0.05)。术后1个月平均血肌酐水平为(92.6±18.2)μmol/L、术后3个月平均血肌酐水平为(80.8±18.4)μmol/L,与术前比较差异无统计学意义(P>0.05)。随访3~20个月,均未见肿瘤复发和转移。结论:后腹腔镜联合经腰小切口“杂交”保留肾单位手术能够降低手术难度,提高手术安全性,适用于部分经过选择的复杂肾肿瘤患者,有一定的临床推广价值。
Objective: To investigate the clinical effect and safety of retroperitoneal laparoscopic combined with transcervical incision “hybridization” in the surgery of nephron in patients with complicated renal tumors. Methods: The clinical data of patients with complicated renal neoplasm who underwent “hybridization” and retained nephron surgery at Department of Urology, Peking University People’s Hospital from April 2015 to December 2016 were retrospectively analyzed. There were 10 males and 6 females, aged (50.2 ± 10.7) years old. The tumors were located on the left side in 9 cases and on the right side in 7 cases. The diameter of the tumor was 6.1 ± 1.0 cm and the mean RENAL score was 9.3 ± 1.3. All patients underwent retroperitoneal laparoscopy combined with transcervical incision “suture” operation to retain the nephron operation, that is, the complete renal and renal pedicle blood vessels were retroperitoneally laparoscopic, and the renal artery was preset. About 10 ~ 12 cm incision for open surgery, blocking the renal artery, resection of the tumor under direct vision, suture wounds. Record the operation time, renal ischemia time, intraoperative blood loss, postoperative complications such as perioperative data and postoperative renal function follow-up. Results: All the 16 cases completed the operation successfully. The operative time (164.9 ± 23.6) min, renal ischemia time (32.4 ± 6.2) min, intraoperative blood loss (204.0 ± 125.1) m L, drainage tube removal time (4.1 ± 1.0) d and postoperative average hospital stay time ± 1.5) d. Postoperative Clavien grade Ⅲ or more complications in 2 cases: 1 case of collection system injury; 1 patient due to postoperative bleeding, again emergency surgery to stop bleeding. The average serum creatinine level on the first postoperative day was (126.3 ± 26.4) μmol / L, which was significantly lower than that before operation (74.3 ± 16.9) μmol / L (P <0.05). The average level of serum creatinine at one month after operation was (92.6 ± 18.2) μmol / L and the average serum creatinine level at 3 months after operation was (80.8 ± 18.4) μmol / L, with no significant difference compared with that before operation (P> 0.05). All the patients were followed up for 3 to 20 months, no tumor recurrence and metastasis. Conclusions: Retroperitoneal laparoscopic combined with small incision “hybridization ” to retain nephron surgery can reduce the difficulty of operation and improve the safety of operation. It is suitable for some selected patients with complex renal tumors and has certain clinical value.