下腔静脉整段切除术治疗肾肿瘤伴下腔静脉癌栓完全性梗阻

目的提高肾肿瘤根治术的治疗效果。方法报告应用下腔静脉整段切除术和右肾癌根治性切除术,治疗４例右肾肿瘤并下腔静脉癌栓完全性梗阻病人。４例下腔静脉癌栓均位于肝静脉平面以下。结果所有病人术后血尿素氮、肌酐水平无明显上升。１例因肿瘤肺转移于术后１年零３个月死亡,１例随访３年后失访,２例健在（分别为术后１年及１０个月）。结论无远处重要器官转移的伴有下腔静脉癌栓完全梗阻的肾肿瘤病人仍是积极手术治疗的指征。整段切除癌栓完全梗阻的下腔静脉,因包括左肾在内的血液回流已建立了良好的侧支循环,因而无需再行血管重建手术。     

双侧肾细胞癌21例报告

目的 探讨双侧肾细胞癌手术治疗的疗效。方法 1990年1月至2005年1月收治双侧肾细胞癌患者21例。其中同时性10例，异时性11例。肿瘤位于肾上极15枚，中极19枚，下极20枚；左肾28枚，右肾26枚。肿瘤直径0．5～16．0cm，平均4．5cm。2例伴下腔静脉癌栓。17例经手术治疗。6例同时性肾癌中，5例行双侧一期手术，1例行分期手术。其中1例行双肾部分切除术；1例行双肾部分切除及左肾上腺切除术；3例行一侧肾癌根治术及对侧肾部分切除术；1例行一侧肾癌根治术，对侧肾部分切除术及下腔静脉切开取癌栓术。11例异时性肾癌均分期手术。其中3例行双肾部分切除术；1例行一侧肾癌根治术，对侧肾肿瘤剜出术；1例行一侧肾癌根治术，对侧肾部分切除术加下腔静脉切开取癌栓术；6例行一侧肾癌根治术，对侧肾部分切除术。未行手术治疗4例．其中行介入治疗1例，生物学治疗1例，保守治疗2例。结果 21例随访3个月～24年，平均3．4年。17例手术治疗者中，13例未见肿瘤复发和转移，术后肾功能均可；1例术后10个月出现左上肺转移，已带瘤存活9个月；1例术后1年出现残肾肿瘤复发，经生物学和中药治疗，已带瘤存活5个月；2例死于肿瘤转移。4例未手术者中，1例10个月后死于胰腺转移，1例4个月后死于肾衰竭，1例6个月后死于脑血管意外，1例伴腹膜后淋巴结转移者经化疗和生物学治疗，病情稳定，已带瘤存活7个月。异时性肾癌者的先发一侧行肾癌根治术，对侧肾出现肿瘤的时间为7个月～18年。结论 双侧肾癌并非手术禁忌，如果采取积极的治疗措施，仍可获得满意的手术效果。保肾手术是目前较为理想的治疗方法，如果保留足够的肾实质，患者仍可获得良好的生存状态。     

肾癌并肾静脉、下腔静脉、右心房癌栓的外科治疗(附3例报告)

目的评价肾肿瘤并肾静脉、下腔静脉、右心房癌栓患者行根治性肾切除术及取栓术后的早期和远期疗效。方法对本院2011年3月至2013年5月手术治疗的3例肾肿瘤并肾静脉、下腔静脉、右心房癌栓的患者进行回顾性分析。本单位泌尿外科团队联合心外科团队对这3例患者施行了根治性肾切除术及低温体外循环下右心房和腔静脉癌栓取栓术,手术过程顺利。术后规律随访,第1年患者每3个月复查评估1次,第2年及第3年每6个月1次,此后1年1次。结果所有患者术中无栓塞,无院内死亡。1例患者术后6个月发生肺转移,2年后死亡。另外2例患者健在(分别随访90个月、64个月),在未给予其他的辅助治疗情况下没有发现肿瘤复发或转移。结论肾肿瘤并肾静脉、下腔静脉、右心房癌栓患者手术治疗需要多学科参与。根治性肾切除术及低温体外循环下能安全有效地进行右心房和腔静脉癌栓取栓术,并发症发生率低。准确的诊断及合理的治疗措施能减少相关的并发率和死亡率。长期随访结果是可喜的。但需要更多更大样本量的研究结果来进一步验证。     

腹腔镜治疗肾错构瘤并肾静脉及下腔静脉瘤栓1例并文献复习

目的：探讨全腹腔镜治疗肾错构瘤并肾静脉及下腔静脉瘤栓的可行性分析。方法：回顾性分析1例腹腔镜治疗肾错构瘤并肾静脉及下腔静脉瘤栓患者的临床资料。患者,女,26岁,体检时发现右肾占位,B超示右肾窦内可见5．1cm×2．7cm高回声占位,边界欠规则,内见血流。CT示右肾盂旁可见一不规则团块状混杂密度影,大小为4．5cm×2．9cm×1．9cm,可见脂肪成分,最低密度-40HU;病变软组织部分明显强化,增强前后CT值分别为31HU和97HU,病变主要位于肾窦,部分延伸至肾静脉及腔静脉内。检索Pubmed和CBM数据库相关文献进行复习。结果：患者在全麻下行腹腔镜右肾切除及肾静脉、下腔静脉取栓术,瘤栓进入下腔静脉0．6cm。病理诊断右肾错构瘤。术后随访6个月无肿瘤复发和转移。结论：肾错构瘤并。肾静脉及下腔静脉瘤栓临床罕见,对选择性病例行腹腔镜肾切除并行肾静脉及下腔静脉取栓术安全可行。     

改良机器人辅助腹腔镜下右肾癌根治术联合下腔静脉Ⅰ级癌栓切除术一例报道（英文）

下腔静脉癌栓切除术是泌尿系统最复杂和最具挑战性的手术之一。本文报道1例改良的机器人辅助腹腔镜下右肾癌根治术联合下腔静脉I级癌栓切除术。相比常规下腔静脉癌栓切除术,改良的机器人辅助腹腔镜下腔静脉癌栓切除术不需要完全分离下腔静脉,无需结扎腰静脉、肾上腺静脉,不用阻断下腔静脉、左肾静脉,也不需要切开下腔静脉和重建下腔静脉。本例手术先完全分离右肾,然后向侧面抬起右肾,使下腔静脉内的瘤栓降至肾静脉入下腔静脉处,然后用机械臂将瘤栓完全推进右肾静脉内,在不阻断下腔静脉的情况下完整切除瘤栓。此改良手术成功完成,无任何并发症,未进行输血。患者随访4年后无任何复发迹象。这表明此改良手术简单、安全、可行、值得推广,尤其适用于初学者。     

双侧同时性肾癌治疗方式的选择

目的 探讨双侧同时性肾癌患者有效治疗方式的选择. 方法双侧同时性肾癌14例.男12例,女2例.平均年龄45岁.临床表现腰部酸痛感4例、血尿2例、体检偶然发现8例.14例术前影像学检查均明确为双侧肾脏占位性病变.其中发现腔静脉癌栓1例,肾门或腹膜后淋巴结肿大2例.14全均未发现远处转移.Robson分期Ⅱ期11例,Ⅲ期3例.肿瘤直径1.0～8.5 cm.行一期双侧手术6例,其中行双侧肾部分切除4例,一侧根治性肾切除、对侧肾部分切除2例.行二期手术8例,先行一侧部分切除术,1个月后行对侧根治性肾切除术3例;先行一侧根治性肾切除术,1个月后行对侧部分切除术2例;先行一侧部分肾切除术,1个月后行对侧肾部分切除术2例;1例伴有腔静脉癌栓患者一期于下腔静脉肝下水平放置静脉内支架加滤网防止癌栓脱落,再行根治性肾切除,1个月后再行对侧肾部分切除.结果 14例共行22例次手术,均获成功.一期双侧手术者平均手术时间(263±52)min;二期手术者平均手术时间(155±46)min.病理报告:29个肿瘤中,透明细胞癌23个,未分化肿瘤4个,嫌色细胞癌2个.10例患者获随访,随防时间6～41个月.3例行一侧肾部分切除加对侧根治性肾切除患者SCr升高,但无需血液透析;1例术后14个月后双侧肺转移,25个月后死亡;1例术后21个月左侧肾窝肿瘤复发,经放疗及化疗,38个月后死亡,1例术后6个月死于脑血管意外;6例无瘤存活,1例腔静脉癌栓未切除者随访32个月存活.结论 双侧肾肿瘤的处理原则为兼顾肾功能保留和肾肿瘤治疗,治疗方案应根据患者全身情况及肿瘤大小、部位进行详细评估,尽可能保留足够的肾功能.     

肾脏恶性肿瘤并静脉转移的外科治疗

目的：探讨肾脏恶性肿瘤并发静脉内转移的外科治疗方法及预后。方法：报告10例肾脏恶性肿瘤，其中肾细胞癌6例，肾母细胞瘤2例，肾盂癌1例，肾平滑肌肉瘤1例。肾静脉内转移4例，肝下型腔静脉转移5例，肝后和肝上的腔静脉内转移1例。在根治性切除患肾的同时阻断瘤栓上下的腔静脉和对侧肾静脉，完整取除瘤栓，腔静脉壁受累者同时切除腔静脉壁，术后辅以免疫治疗和放射治疗。结果：随访7年，平均5年生存率40％，肾母细胞瘤生存期小于3年，腔静脉壁受累者生存期小于1年，并发区域淋巴结转移者5年生存率33％。结论：手术切除静脉内转移癌是提高患者生存期的惟一手段，其预后取决于原发癌肿的性质和癌栓是否完全切除，而与癌栓的位置无直接相关。静脉内肿瘤转移同时并发腔静脉壁受累或区域淋巴结阳性的患者预后较差。     

腹腔镜下根治性肾切除并肾静脉及腔静脉取栓术

目的 探讨腹腔镜下根治性肾切除并肾静脉及腔静脉取栓术的可行性. 方法 右肾占位病变患者2例.增强CT显示1例肿物部分延伸至肾静脉及腔静脉内,1例右肾静脉内可见充盈缺损并突入腔静脉内.均在全麻下行经后腹腔镜下根治性右肾切除及肾静脉、腔静脉取栓术.术中放置4个穿刺套管针,切断肾动脉后游离腔静脉及肾静脉,腔镜血管阻断钳部分阻断腔静脉,切开腔静脉取出瘤栓,缝合腔静脉,完整切除肾脏及瘤栓. 结果 2例患者的腔静脉瘤栓长度分别为0.3和1.0 cm,均安全取出,术后恢复良好,5 d出院.病理诊断分别为上皮样肾血管平滑肌脂肪瘤和肾透明细胞癌1～2级.术后随访5个月未见肿瘤复发和转移. 结论 对选择性肾肿瘤并肾静脉及腔静脉瘤栓患者行腹腔镜下根治性肾切除并肾静脉及腔静脉取栓术安全可行.     

重复肾并肾肿瘤3例报告并文献复习

目的探讨重复肾合并肾肿瘤的诊断和治疗,提高对重复肾并肾肿瘤的认识并提供临床正确诊治此类疾病的参考。方法回顾分析3例重复肾并发肾肿瘤患者的临床资料,其中男性2例,女性1例,年龄52～62岁。并发肾盂癌1例,肾乳头状细胞癌1例,肾肉瘤样癌并腔静脉瘤栓1例。结果 1例行经腹腔镜肾部分切除术,随访2年1个月未见复发;1例行手助腹腔镜肾输尿管全长及膀胱袖状切除术,随访10个月未见复发;1例行肾癌根治术及下腔静脉取栓术,随访10个月未见复发。结论 B超可作为重复肾并肾肿瘤的早期筛查方法;CTU可用于了解泌尿系统的立体结构,大概明确肿瘤性质和肿瘤位置;逆行尿路造影可检查是否合并膀胱病变和进一步确定肿瘤位置。该类患者多需要通过手术治疗,根据肿瘤大小、位置和是否合并瘤栓选择术式,术后化疗则根据病理结果。     

肾癌并肝下型下腔静脉癌栓的手术治疗并文献复习

目的 探讨肾细胞癌并下腔静脉癌栓的手术治疗方法.方法 回顾性分析6例经手术及病理证实的肾细胞癌并肝下型下腔静脉癌栓患者的临床资料,所有病例均行根治性肾切除并癌栓切除术,分别采用下腔静脉切开、下腔静脉部分切除和节段性下腔静脉切除三种方法 取出癌栓.结果 6例手术均获成功,无大出血、肺梗塞等并发症,术后患者恢复良好.其中2例分别于术后38个月和76个月死亡,3例仍健在,平均存活时间为54个月,1例术后18个月后失访.结论 右肾癌并下腔静脉癌栓患者下腔静脉节段性切除能够安全地进行,根治性肾切除并癌栓切除术能够使患者获得长期存活.     

Renal pelvic cancer with tumor thrombus in the vena cava inferior: a case report

We report a case of right renal pelvic cancer with tumor thrombus in the inferior vena cava. A 65-year-old man with right flank abdominal pain and high fever was reffered to our hospital. Computed tomography showed right renal mass. Magnetic resonance imaging revealed tumor thrombus extending into the renal vein and the inferior vena cava. Preoperative diagnosis was renal cell carcinoma with vena caval thrombus. Radical nephrectomy with thrombectomy and lymphodenectomy was performed. Pathologic evaluation revealed transitional cell carcinoma with tumor thrombus into the vena cava. One course of M-VAC chemotherapy was added and he has been alive for 56 months without recurrence. A literature review of 15 cases of renal pelvic cancer with tumor thrombus in the vena cava in Japan revealed that 7 cases were diagnosed as renal cell carcinoma preoperatively.     

Laparoscopic radical nephrectomy for cancer with level I renal vein involvement

PURPOSE: Venous involvement develops in 5% to 10% of patients with renal cell carcinoma and is generally considered a relative contraindication to laparoscopic radical nephrectomy. To our knowledge we report the initial clinical series of laparoscopic radical nephrectomy for renal cell carcinoma associated with level I renal vein thrombus. MATERIALS AND METHODS: At our 2 institutions 8 patients each underwent laparoscopic radical nephrectomy for level I microscopic renal vein thrombus (group 1) and level I gross thrombus (group 2). In all 8 group 2 patients the level I thrombus was preoperatively diagnosed by computerized tomography. Mean renal tumor size in groups 1 and 2 was 7.8 and 12.4 cm., respectively. After controlling the renal artery the renal vein was secured by firing an endoscopic gastrointestinal anastomosis stapler on its collapsed, uninvolved proximal part adjacent to the vena cava. Intraoperative, postoperative and pathological parameters were assessed in the 2 groups. RESULTS: In group 1 laparoscopic radical nephrectomy was technically successful in all 8 patients. Mean operative time was 3.1 hours, mean estimated blood loss was 382 cc and mean hospital stay was 1.9 days. In 1 patient each a soft tissue and a vascular margin was positive for cancer. At a mean follow up of 19.5 months (range 2 to 36) metastatic disease occurred in 3 cases (38%). In group 2 laparoscopic radical nephrectomy was technically successful in 7 cases with open conversion in 1. Mean operative time was 3.3 hours, mean estimated blood loss was 354 cc and mean hospital stay was 2.3 days. Surgical soft tissue and the renal vein vascular margin of the transected vein were negative for cancer in all 8 cases. At a mean followup of 9.4 months (range 5 to 16) pulmonary metastasis developed in 1 patient (13%). CONCLUSIONS: Although it is an advanced procedure, laparoscopic radical nephrectomy in patients with level I renal vein thrombus is feasible, safe and follows established oncological principles.     

腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓

目的探讨腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓的临床经验和文献分析。 方法女性患者,61岁,临床诊断：右肾癌合并高位肝后下腔静脉癌栓。术前全面评估手术风险,组织多学科会诊为患者制定详尽的围手术期治疗与护理方案,拟行腹腔镜下右侧肾癌根治性切除+高位肝后下腔静脉癌栓取出+腹膜后淋巴结清扫术。术后医护密切配合严密观察患者病情变化,进行围手术期观察处理与护理。 结果手术顺利完成,手术时间390 min,无中转开放手术。术中完全游离右侧和左侧肾静脉、肝后下腔静脉直达第二肝门水平远端,近右肾静脉处下腔静脉内侧壁剪开静脉壁,癌栓下部小灶性侵犯静脉壁,切除部分腔静脉壁完整取出癌栓,恢复左侧肾静脉、腔静脉血流回流无障碍。术后病理提示符合透明细胞癌,癌组织侵犯肾窦脂肪,腹膜后淋巴结（-）。术后随访6个月未见肿瘤复发。 结论腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓安全可行,多学科协助模式为疑难复杂病例提供了一种新的选择,值得临床进一步推广。     

肾癌伴静脉癌栓外科治疗的疗效观察

目的探讨外科治疗肾癌伴静脉癌栓患者的预后。方法自1994年8月至2004年7月共33例患者行肾癌根治术及静脉癌栓取出术,其中男性26例、女性7例,中位年龄60岁(20~82岁)。肾静脉癌栓15例,下腔静脉癌栓Ⅰ级(肝下水平)9例、Ⅱ级(肝后水平)5例、Ⅲ级(肝上水平)1例、Ⅳ级(右心房水平)3例。采用Kaplan-Meier方法进行生存分析。结果29例患者得到随访,14例死亡,平均生存(16·4±2·9)个月(1~42个月),15例存活,平均随访(17·3±4·6)个月(3~67个月)。1例患者术后第2天死亡,3例失访。5年生存率为16%。肾静脉癌栓患者平均生存(49·9±9·8)个月,明显高于Ⅰ级下腔静脉癌栓患者的(16·7±1·9)个月(P<0·05)。结论肾癌根治性切除加癌栓取出术是治疗肾癌伴静脉癌栓的有效方法,肾静脉癌栓患者的预后好于腔静脉癌栓患者。     

Laparoscopic radical nephrectomy with level II vena caval thrombectomy: survival porcine study

PURPOSE: Inferior vena caval tumor thrombus due to renal cell carcinoma generally precludes laparoscopic techniques for radical nephrectomy. We developed the technique of laparoscopic infrahepatic (level II) inferior vena caval thrombectomy in a survival porcine model. MATERIALS AND METHODS: Of the 7 female pigs used in the study 2 were acute and 5 were chronic animals which were allowed to survive for 6 weeks postoperatively. Laparoscopic right radical nephrectomy and inferior vena caval thrombectomy were performed in accordance with established open surgical principles, including vascular control and intracorporeal reconstruction of the vena cava and left renal vein. RESULTS: Complete removal of the simulated caval thrombus was successful in each case without intraoperative or postoperative complications. Average operative time was 160 minutes. Postoperatively inferior venacavography showed a patent vena cava and left renal vein in all animals. CONCLUSIONS: Laparoscopic radical nephrectomy was successful in an animal model simulating renal cell carcinoma with infrahepatic vena caval tumor thrombus. Clinical application of this technique appears possible.     

伴有肾静脉瘤栓的左肾癌全腹腔镜根治术

目的：探讨左肾癌并肾静脉瘤栓患者行经后腹腔途径全腹腔镜左肾痛根治术的可行性。方法：3例左肾癌伴左。肾静脉瘤栓患者均在全麻下行经后腹腔全腹腔镜左肾癌根治术：术中放置4个穿刺套管针,游离腹主动脉和肾动脉后,用Hem—o-lok结扎切断肾动脉,于肾静脉近下腔静脉处用Hem-o-lok结扎切断肾静脉,完整切除。肾脏及瘤栓。结果：3例手术均获得成功,术后恢复良好,5灭出院。病理检查分别诊断为肾透明细胞癌2例,嫌色细胞癌1例。术后随访1～3个月,未见肿瘤复发和转移。结论：对选择性左肾癌并肾静脉瘤栓患者行经后腹腔全腹腔镜左。肾癌根治术完全可行。     

Management of contralateral adrenal metastasis from renal cell carcinoma: possibility of inferior vena cava tumour thrombus

OBJECTIVE: The contralateral adrenal gland is a rare metastatic site in renal cell carcinoma (RCC). We describe our experiences with this metastasis in a cohort of 610 radical nephrectomy patients analysed. To our knowledge this study is the first to demonstrate an inferior vena cava tumour thrombus from metachronous contralateral adrenal metastasis. PATIENTS AND METHODS: After radical nephrectomy for RCC, 610 patients treated at our institution from 1985-99 were retrospectively investigated for the incidence of contralateral adrenal metastasis, additional clinical findings, treatment modalities and survival after treatment for contralateral adrenal gland metastasis. RESULTS: The incidence of contralateral adrenal metastasis was 1.1% (7/610 patients), while the incidence of ipsilateral metastasis was 3.4% (21/610). In 3 of 7 cases the contralateral adrenal metastasis occurred simultaneously with primary RCC in the kidney. The contralateral adrenal gland was affected by distant tumour spread metachronously in 4 of 7 cases (3/4 bilateral adrenal involvement, 1/4 unilateral disease). In 1 case a metachronous contralateral adrenal metastasis caused vena cava tumour thrombus by propagation via the suprarenal venous route. After a mean follow-up of 20 months (range 1-54 months), 4 of 6 patients showed no evidence of disease after contralateral adrenalectomy. CONCLUSIONS: The probability of contralateral adrenal metastasis from RCC is 1.1%. Adrenalectomy in these cases offers a good chance of cure. In 71% of cases contralateral adrenal metastasis occurs in conjunction with ipsilateral disease, which provides a strong argument for routine ipsilateral adrenalectomy during radical nephrectomy. Care must be taken in preoperative diagnostics, as metachronous adrenal metastasis is capable of causing vena cava tumour thrombus.     

肾癌并发下腔静脉癌栓的诊断与治疗

目的：提高对肾癌并发下腔静脉癌栓的诊断及治疗经验。方法：分析8例肾癌并发下腔静脉癌栓的诊断方法及治疗措施。结果：术前已明确诊断6例,8例均经手术治疗,1例术中死亡,余7例手术成功。结论：手术切除肾癌并取出癌栓是目前有望治愈的方法之一,手术方式的选择取决于癌栓的大小及部位。手术风险大、难度大,必须警惕癌栓的脱落。