后腹腔镜下肾部分切除治疗早期肾癌不同术式的比较

目的 探讨后腹腔镜下肾部分切除术（RLPN）的不同术式治疗早期肾癌的有效性及安全性。方法 回顾性分析2006年2月至2012年12月我院收治的肿瘤最大径＜4cm，并行RLPN的肾癌患者127例。分为4组，传统组（n=44）以传统肾肿瘤剜除术治疗，假包膜组（n=35）为单纯沿肿瘤假包膜切除肿瘤，免打结组（n=39）为沿肿瘤假包膜切除肿瘤并采用免打结缝合修补肾脏组织缺损，选择性阻断组（n=9）在免打结技术的基础上对肾动脉选择性阻断并切断肿瘤血供。比较前3组肾蒂血管阻断时间、手术时间、术中出血量、术后住院天数、术中输血率及术后尿漏发生率。结果 3组的肾蒂血管阻断时间分别为（32.07±5.59）min、（30.20±5.84）min、（27.31±6.17）min， 差异有统计学意义（P=0.002）；3组的手术时间分别为（109.68±20.07）min、（106.20±16.32）min、（97.00±17.65）min，差异有统计学意义（P=0.007）；3组的术中出血量分别为（106.93±72.26）ml、（80.26±49.57）ml、（54.23±36.32）ml， 差异有统计学意义（P=0.000）；3组的术后住院天数分别为（7.82±1.42）d、（6.31±1.69）d、（5.97±1.51）d，差异有统计学意义（P=0.000）；3组术中输血率分别为2.3％（1／44）、0（0／35）及0（0／39），差异无统计学意义（P＞0.05）；3组术后尿漏发生率分别为0（0／44）、2.9％（1／35）及2.6％（1／39），差异无统计学意义（P＞0.05）。术后随访14～60个月，127例患者均无复发或转移。结论 对于较小的肾癌，沿包膜剜除肾肿瘤及术中免打结技术的应用明显缩短了肾动脉的阻断时间及术中出血量。同时，选择性肾动脉阻断技术的应用将有望摆脱肾蒂阻断时间及热缺血时间的限制，值得进一步研究。

Comparison of different surgical treatment of retroperitoneal laparoscopic partial nephrectomy for patients with localized renal cell carcinoma

Objective To investigate the efficacy and safety of different surgical treatment of retroperitoneal laparoscopic partial ne-phrectomy for patients with localized renal cell carcinoma. Methods 127 patients with tumor size＆lt;4cm underwent RLPN from February 2006 to December 2012 in our hospital. According to the course of the new surgical techniques adopted, they were divided into 4 groups：conven-tional group（n=44）, simple enucleation group（n=35）, knot-free suture group（n=39）and selective artery clamping group（n=9）. The data of operative time, renal artery clamping time, blood loss during operation, postoperative hospital stay, intraoperative transfusion rate and the incidence of urinary leakage postoperation were collected, and those data of the former three groups were statistical analyzed. Results The mean time of renal artery clamping in the former three groups was（32？07＆#177;5？59）min,（30？20＆#177;5？84）min,（27？31＆#177;6？17）min,respectively. The mean operative time were（109？68＆#177;20？07）min,（106？20＆#177;16？32）min,（97？00＆#177;17？65）min,respectively. The mean blood loss during operation was（106？93＆#177;72？26）ml,（80？26＆#177;49？57）ml,（54？23＆#177;36？32）ml,respectively. The mean time of postoperative hospital stay was（7？82＆#177;1？42）d, （6？31＆#177;1？69）d,（5？97＆#177;1？51）d, respectively. There were statistically differences between the three groups on the time of renal artery clam-ping, the operative time, the blood loss and the time of postoperative hospital stay（P＆lt;0？05）. The rate of transfusion during operation was 2？3%（1/44）, 0（0/35）, 0（0/39）, respectively. The incidence of urinary leakage after operation was 0（0/44）, 2？9%（1/35）, 2？6%（1/39）. The above clinical parameters had no significant differences among the three groups（P＆gt;0？05）. All the patients were followed up for 14-60 months, and no recurrence and metastasis was found. Conclusion For small renal cell cancer, the techniques of simple enucleation and knot free suture can significantly reduce renal artery clamping time and blood loss during operation. The techniques of selective artery clamping will prolong the operation time and almost have no warm ischemia time and it can deserve further research.