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目的分析后腹腔镜辅助小切口完成R.E.N.A.L.评分≥7肾肿瘤肾部分切除术的安全性和可行性,评价手术疗效,探讨临床应用价值。方法 2011年1月至2012年11月R.E.N.A.L.评分≥7肾肿瘤后腹腔镜辅助小切口肾部分切除术的患者19例,其中男性10例、女性9例,年龄(48.5±14.0)岁,体质指数(24.0±2.6)kg/m2,ASA评分(1.9±0.4),Charlson全身合并症指数(age-weighted)0.6±0.2,肿瘤侧别(左/右)11/8,肿瘤最大径(3.3±1.2)cm,肾肿瘤R.E.N.A.L.评分(8.6±0.9),术前估算肾小球滤过率(eGFR)(104.8±24.0)mL/(min.1.73m2)。后腹腔镜下分离保留肾动静脉、肾周及肾脏肿瘤后,沿肋缘下两穿刺口连线作切口,阻断肾蒂,冰屑降温,切除肿瘤,缝合重建,完成手术。观察术中、术后情况并进行随访,评价手术疗效。结果 19例患者手术均顺利完成,无任何术中并发症,无术中输血,手术时间(220.2±57.5)min,术中出血(252.6±182.9)mL,肾脏冷缺血时间(25.2±6.6)min,手术切缘均为阴性。患者恢复顺利,术后住院时间(11.4±3.4)d。病理学检查提示:肾癌15例,血管平滑肌脂肪瘤2例,其他2例。术后随访(13.1±6.7)个月,19例患者均存活,无一例出现局部肿瘤复发或远处转移,eGFR(90.4±17.0)mL/(min.1.73m2),与术前相比差异有统计学意义(Z=-3.099,P=0.002)。结论对于复杂程度较高的局限性肾肿瘤,后腹腔镜辅助分离小切口肾部分切除术安全、可行、有效,结合了开放手术和传统腹腔镜手术的优势,扩大了保留肾单位手术的临床适应证,操作简便、费用低,值得进一步推广运用。
Objective To analyze the safety and feasibility of retroperitoneoscopically assisted small incisions in the partial nephrectomy with R.E.N.A.L. score ≥7, evaluate the efficacy of surgery, and explore the clinical application value. Methods From January 2011 to November 2012, RENAL score ≥ 7 patients undergoing laparoscopically assisted small incision partial nephrectomy were performed in 19 patients, including 10 males and 9 females, aged (48.5±14.0) years, body mass index. (24.0 ± 2.6) kg/m2, ASA score (1.9 ± 0.4), Charlson age-weighted 0.6 ± 0.2, tumor side (left/right) 11/8, tumor maximum diameter (3.3 ± 1.2) )cm, Renal tumor RENAL score (8.6 ± 0.9), estimated preoperative glomerular filtration rate (eGFR) (104.8 ± 24.0) mL / (min.1.73m2). After laparoscopic separation and preservation of renal arteriovenous, perirenal, and renal tumors, along the costal margin of the two puncture lines for the incision, blocking the renal pedicle, ice cooling, resection of the tumor, suture reconstruction, to complete the operation. The intraoperative and postoperative conditions were followed and follow-ups were performed to evaluate the efficacy of the surgery. Results All the 19 cases were performed successfully, without any intraoperative complications, no intraoperative blood transfusion, operation time (220.2±57.5) min, intraoperative blood loss (252.6±182.9) mL, and cold ischemia time (25.2±6.6) Min, surgical margins were negative. The patient recovered smoothly and postoperative hospital stay was (11.4±3.4) days. Pathological examination suggested that there were 15 cases of renal cell carcinoma, 2 cases of angiomyolipoma, and 2 other cases. At the time of follow-up (13.1 ± 6.7) months, 19 patients were alive and none of the patients had local tumor recurrence or distant metastasis. The eGFR was (90.4±17.0) mL/(min.1.73m2), which was different from that before surgery. Statistical significance (Z=-3.099, P=0.002). Conclusions For the more complicated localized neoplasms, retroperitoneoscopically assisted small incision partial nephrectomy is safe, feasible, and effective. It combines the advantages of open surgery and traditional laparoscopic surgery and expands the clinical adaptation of nephrostomy surgery. The certificate is easy to operate, low in cost and worthy of further promotion.