MSCTA在诊断肾静脉变异中的价值

分析多层螺旋CT血管造影（MSCTA）对肾静脉（RV）变异的诊断价值。方法回顾性分析352例行腹部MSCTA检查患者,采用容积再现（VR）“血管生长”技术进行RV重建。结果352例共检出RV变异36例,检出率10.2%。双侧RV变异2例;右肾RV变异11例;左侧肾RV变异23例,包括主动脉周围型RV变异12例（3.4%）,完全性主动脉后位型RV变异6例（1.7%）;其他5例（1.4%）。结论MSCTA能清楚显示肾静脉变异,为临床提供解剖学资料。     

小肾癌选择性保肾手术治疗体会

目的探讨小肾癌选择性保肾手术的临床价值。方法回顾性分析1999年12月～2001年12月采用局部低温、保留肾单位手术治疗小肾癌16例。所有病例对侧肾功能正常，肿瘤直径平均2．4(1．5～3．0)cm，均为RobsonⅠ期。结果16例手术均获成功，平均手术时间1．2(1．0～1．5)h，平均输血400(100～800)ml。术中损伤肾盏6例，以4-0的Dexon线修补，无术后出血、肾功能衰竭、感染、尿瘘等并发症。术后平均随访26(3～57)个月，未见并发症及肿瘤局部复发及转移。结论保留肾单位手术治疗小肾癌安全有效，对肿瘤体积小、位置适宜、年轻患者可考虑行保留肾单位手术。     

CT血管成像技术在腹腔镜下肾肿瘤保留肾单位手术中的应用价值

目的 探讨CT血管成像(CTA)技术对肾血管解剖形态的评估,以及在腹腔镜下肾肿瘤保留肾单位手术(LNSS)中对肾动脉的控制指导价值. 方法 肾肿瘤患者87例,均行LNSS.CTA组40例,术前行CTA检查,采用容积再现(VR)、最大密度投影(MIP)等重建技术评估肾动脉血管解剖形态;未行CTA检查47例作为对照组.比较2组手术时间,术中热缺血时间、出血量、中转开放手术率,住院时间,术后并发症发生率及疗效. 结果 CTA组和对照组手术时间分别为94(76～118)和115(90～190)min,术中热缺血时间分别为23(12～39)和29(18～40)min,2组间比较差异均有统计学意义(P<0.05);术中出血量分别为90(20～160)和130(90～600)ml,2组间比较差异有统计学意义(P<0.01);中转开放手术分别为0例和1例,中转原因为术中分离肾动脉时出血严重,影响视野;术后住院时间分别为4.1(3～5)和5.5(3～9)d,2组间比较差异均有统计学意义(P<0.05).2组肾癌患者病理检查切缘均为阴性.术后随访4～32个月,平均16个月,2组患者均无肾功能损害和肿瘤复发或转移,2组各有1例尿瘘. 结论 CTA作为LNSS术前了解肾动脉的有效方法,能指导操作者术中更快速、准确地处理肾动脉,缩短手术时间和热缺血时间,减少术中出血量及术后并发症的发生,同时并不增加患者经济负担.     

CT的肾血流重建3D影像在内生型肾癌保留肾单位手术中的应用

目的 探讨CT的肾血流重建3D影像在内生型肾癌保留肾单位手术(LNSS)中的应用.方法 术前通过肾肿瘤血流在CT增强中的“快进快退”表现,对患肾进行CT肾血流重建,旋转3D重建影像见肿瘤区域缺损.术中同轴旋转影像及肾脏,根据缺损部位定位肿瘤,并进行LNSS.结果 4例患者均完成LNSS,剥离出肿瘤均见包膜完整,肿瘤直径(2.2±0.5)cm.术中热缺血时间17～27min,平均21.7min.出血20 ～ 55mL,平均32mL.病理回示均为透明细胞癌.术后随访7个月～5年,患者血肌酐、尿素氮及碱性磷酸酶无明显变化,肾小球滤过率测定患肾功能无明显下降,CT均未见局部肿瘤复发.结论 采用CT的肾血流重建3D影像帮助内生型T1a期肾癌的LNSS进行精准定位,该技术是安全、有效的,并且方法简便易行,利于推广.     

螺旋CT三维成像技术在后腹腔镜下保留肾单位手术前的应用价值

漏尿发生. 结论 螺旋CT三维成像技术能清晰重建肾脏解剖构像,为选择后腹腔镜下NSS治疗肾肿瘤提供可靠依据.     

术前CTA评估大体积肾癌肾动静脉解剖及癌栓

目的观察术前CTA评估大体积肾癌肾动静脉解剖及癌栓的应用价值。方法回顾性分析56例经术后病理证实肾癌患者术前256层螺旋CT肾动脉+肾静脉CTA,并进行图像重建,观察肾动脉及肾静脉解剖、癌栓位置及分型,并与术中所见对比。结果 56例肿瘤均单发,左肾26例、右肾30例,最大径71～144 mm,平均(84.33±20.59)mm。健侧与患侧肾动脉、肾静脉变异率差异均无统计学意义(P均0.05)。CTA显示117支肿瘤供血动脉,术中发现118支,符合率99.15%(117/118);CTA示引流静脉69支,术中发现69支,符合率100%(69/69)。CTA示14例存在癌栓,5例(5/56,8.93%)肾静脉浸润,9例(9/56,16.07%)肾静脉+下腔静脉浸润,Mayo癌栓分型为0型5例,Ⅰ型3例,Ⅱ型4例,Ⅲ型2例;42例(42/56,75.00%)未见静脉癌栓。结论术前肾动脉+肾静脉CTA可较准确评价大体积肾癌肾动静脉解剖、癌栓位置及分型。     

螺旋CT扫描在肾癌术前分期中的应用价值

目的探讨螺旋CT检查在肾癌术前临床分期中的应用价值。方法回顾性分析经手术病理证实的93例肾癌患者资料。男63例，女30例。年龄15～78岁，平均55岁。术前均采用螺旋CT平扫加多期增强扫描。将CT分期与病理分期结果进行比较分析。结果93例患者CT分期Ⅰ期55例、Ⅱ期17例、Ⅲ期6例、Ⅳ期15例；手术病理分期Ⅰ期44例、Ⅱ期28例、Ⅲ期8例、Ⅳ期13例。线性趋势检验结果提示2种分期方法密切相关（P〈0．01），Pearson积矩相关系数rp=0．91，呈正相关关系，但这种关联不是简单的直线关系。螺旋CT对肾癌术前分期的敏感性、特异性和准确性分别为77．4％、92．5％和88．7％。结论螺旋CT能很好地显示肾癌的影像学特征，并进行准确的临床分期，应列为肾癌术前的常规检查项目。     

超声造影与增强CT在诊断小于3cm肾肿瘤中的对比研究

目的 对比超声造影(CEUS)与增强CT(CECT)在诊断小于3cm肾实性肿瘤的应用价值.方法 选取本院2010年1月至2013年1月期间收治的小于3cm肾占位患者54例作为研究对象,分别进行CEUS及CECT检查,观察两种方法的增强强度、增强均匀、假包膜征、增强消退时间,比较其诊断准确率,CEUS利用时间-强度曲线分析软件,对比肾脏占位性病变与病变周围正常肾组织在峰值强度、达峰时间、曲线尖度及曲线下面积的差异.结果 CEUS明显增强42例,肿瘤可见假包膜征31例,呈快进慢出39例,与CECT相比差异有统计学意义(P＜0.05),CEUS准确度92.59％,显著高于CECT(77.78％),差异有统计学意义.结论 CEUS对于小于3cm肾实性肿瘤在增强强度、增强均匀度、假包膜征、增强消退时间与CECT有不同的影像学表现,CEUS诊断小于3cm肾实性肿瘤的敏感度与准确度显著高于CECT.     

肾癌射频消融治疗后的影像学评价

射频消融（RFA）已用于肾癌的临床治疗,具有微创、可重复操作、并发症少、有利于保留患者的肾功能等优点。通过影像学检查,可以准确评价肾癌RFA疗效,早期检测是否存在肿瘤残留及复发。本文对CT、MRI及超声在肾癌RFA治疗后疗效评价中的应用进行综述。     

MSCTA观察肾动脉起源、形态及变异

目的采用MSCTA观察肾动脉起源、形态及变异情况。方法回顾性分析MSCTA检查未见异常的308例患者的影像学资料,观察肾动脉开口位置、两侧肾动脉开口高度差、肾动脉开口距腹主动脉分叉的距离、肾动脉与腹主动脉夹角(α夹角)、肾动脉形态及肾动脉变异情况。结果 97.73%(301/308)肾动脉开口位于L1椎体上1/3至L2椎体下1/3;48.70%(150/308)右肾动脉开口高于左肾动脉,42.53%(131/308)右肾动脉开口与左肾动脉开口持平,8.77%(27/308)右肾动脉开口低于左肾动脉开口。左侧肾动脉开口与腹主动脉分叉的距离[(9.79±1.11)cm]小于右侧[(10.23±1.09)cm,P0.001]。左侧α夹角[(63.74±13.24)°]大于右侧α夹角[(52.54±13.82)°,P0.001]。肾动脉形态以下斜型最常见,左、右侧分别占35.71%(110/308)和52.60%(162/308)。以研究对象为单位,肾副动脉及过早分支发生率分别为36.04%(111/308)和34.42%(106/308);以肾脏为单位则分别为20.78%(128/616)和20.29%(125/616)。结论肾动脉起源及走行具有一定规律;MSCTA可为肾脏相关手术,尤其是肾动脉介入治疗提供解剖学参考。     

Mayo Clinic Scottsdale experience with laparoscopic nephron sparing surgery for renal tumors

PURPOSE: Nephron sparing surgery is an accepted treatment for small renal masses, of which many have been detected incidentally due to the widespread use of advanced imaging techniques. We report our experience with laparoscopic nephron sparing surgery. MATERIALS AND METHODS: From May 2000 to May 2002 a total of 20 laparoscopic partial nephrectomies were performed in 19 patients. The kidney was mobilized to allow adequate dissection, hemostasis and inspection of the kidney. Cautery, a harmonic scalpel and a TissueLink (TissueLink Medical, Inc., Dover, New Hampshire) device were variably used for dissection and hemostasis. Further hemostasis was then achieved using an argon beam laser with Fibrillar (Fibrillar Ethicon, Somerville, New Jersey), fibrin glue or the TissueLink device. Intact removal and biopsy of the lesion base were done to assess margin status. RESULTS: Mean patient age was 66 years (range 41 to 80). Mean tumor size was 2.1 cm. (range 1 to 7) and average operative time was 130 minutes (range 60 to 210). Mean hospital stay was 2.2 days. Mean estimated blood loss was 120 ml. (range 20 to 400) and no blood transfusions or conversions to an open procedure were required. Complications included intraoperative fragmentation of a tumor in 1 case, postoperative dyspnea, postoperative bleeding and pneumonia in 1. CONCLUSIONS: Laparoscopic partial nephrectomy for small renal tumors was performed safely and effectively. Technique depended on the size and location of the mass. Long-term followup is required to compare cancer control with that of open nephron sparing surgery.     

Exploration for hemorrhage following laparoscopic renal surgery: intraoperative findings

PURPOSE: Bleeding after surgery is a rare but potentially life threatening complication. We reviewed operative and postoperative clinical features in patients who required surgical exploration secondary to hemorrhage following laparoscopic renal procedures. MATERIALS AND METHODS: We retrospectively reviewed the records of patients undergoing laparoscopic renal surgery between January 1996 and September 2004. Nine of 1,123 patients (0.8%) underwent early exploration for bleeding within 5 days of surgery. RESULTS: Two groups were identified. Group 1 consisted of 4 patients who underwent early exploration at less than 10 hours after surgery and had arterial bleeding. Group 2 consisted of 5 patients who underwent exploration a mean 38 hours after surgery and in whom no bleeding source was identified. Group 1 patients had pronounced hypotension with systolic blood pressure 70 to 79 mmHg and hematocrit decreases (mean 10.5%) in a short time course before repeat exploration (mean 4.5 hours). Arterial bleeding was identified in the hilum and adrenal bed. Group 2 patients demonstrated a decrease in hematocrit from an initial mean of 28.3% to 22.5% with tachycardia and mild hypotension (systolic blood pressure 90 to 99 mmHg). On exploration group 2 patients had diffuse oozing. Mean hospital stay in group 1 was 8 days (range 4 to 9) vs 12 (range 6 to 24) in group 2. CONCLUSIONS: Early hemodynamic instability after laparoscopic renal surgery is likely to indicate a discrete arterial bleeding source from the hilum or adrenal bed, requiring surgical control. In patients who underwent exploration after a delayed bleeding presentation no discrete source was found intraoperatively. Therefore, it is unclear whether these patients benefited from surgical exploration.     

三维可视化技术结合术中超声在可切除肝癌腹腔镜手术的应用

目的探讨术前应用三维可视化技术结合术中超声实时引导在可切除原发性肝癌腹腔镜手术中应用的近期效果及价值。 方法回顾性分析蚌埠医学院第一附属医院2021年1月至2022年3月行腹腔镜肝切除术的68例原发性肝癌患者资料,根据术前是否行肝脏三维重建及术中超声引导,将患者分为对照组和观察组,各34例。对照组术前增强CT检查后行手术规划,观察组术前在增强CT的基础上采用三维可视化技术进行肝脏三维重建,拟定手术方案,术中行超声实时引导。对比两组患者的手术方式、术中出血量、术中输血比例、肝门阻断时间、手术时间、术后并发症发生率及术后住院时间。 结果与对照组相比,观察组患者术中出血量更少,术中输血比例更低,术中肝门阻断时间、手术时间及术后住院时间更短（均P<0.05）。对照组6例患者中转开腹,两组手术方式比较差异有统计学意义（χ²=4.570,P=0.033）。观察组术后总并发症发生率显著低于对照组（11.8% vs 35.3%,χ²=5.231,P=0.022）。 结论术前三维可视化技术结合术中超声引导在可切除原发性肝癌腹腔镜手术中的应用,有助于制定个体化手术策略,提升临床治疗效果,减少术中出血和肝门阻断时间,降低术后并发症的发生率,对腹腔镜肝切除手术的发展有重要指导意义。     

机器人辅助腹腔镜与腹腔镜保留肾单位手术治疗肾门唇部肿瘤的临床对比分析

目的:探讨机器人辅助腹腔镜与传统腹腔镜对肾门唇部肿瘤行保留肾单位手术的临床疗效对比及手术经验。方法:回顾性分析2016年1月～2018年8月我院行保留肾单位微创手术治疗的68例肾门唇部肿瘤患者的临床资料,其中前唇肿瘤45例,后唇肿瘤23例。肿瘤直径1.5～8.0cm,平均4.2cm。行机器人手术38例(机器人组),腹腔镜手术30例(腹腔镜组)。结果:68例手术均顺利进行,平均手术时间93min(60～180min,不包含机器人装机时间),平均肾动脉阻断时间21.6(7～44)min,平均术中出血量156(20～600)ml,平均术后引流管拔除时间4(3～6)d,平均术后住院5.3(4～9)d,未出现明显术后并发症。中位随访13.5(3～32)个月,无复发、转移、死亡病例。与腹腔镜相比,机器人手术可明显减少手术时间(P<0.001)和术中出血量(P=0.011);机器人组与腹腔镜组肾动脉阻断时间分别为(19.0±6.5)min和(25.0±7.4)min(P=0.001),住院费用分别为(5.2±0.4)万元和(3.7±0.4)万元(P<0.001)。结论:肾门肿瘤采用微创保留肾单位手术进行治疗是安全可行的。与传统腹腔镜相比,机器人手术的住院费用增加,但对于治疗肾门肿瘤优势明显,可以显著缩短热缺血时间,减少术中出血量,使患者得到最大程度的获益。     

Cost trends for oncological renal surgery: support for a laparoscopic standard of care

PURPOSE: There may be inherent costs associated with the cultivation of laparoscopic expertise. We compared the cost trends for laparoscopy during the development of our program with that of open surgery for renal neoplasms. MATERIALS AND METHODS: We retrospectively reviewed the records of 381 patients treated surgically for renal cortical neoplasms from 1998 to 2003. Demographic information and cancer specific data were recorded on each subject. Direct variable costs, which are directly traceable to the patient care service provided and vary with patient volume, were used to analyze cost. Temporal trends were assessed using multivariate models developed to determine smoothed mean costs by year. RESULTS: Although it was initially more expensive, by 2003 mean costs were lower for laparoscopic than for open radical nephrectomy ($5,157 vs $5,808). This reflected a significantly lower annual increase in direct variable costs for laparoscopy vs open surgery even after adjustment for patient age, sex, race and clinical stage (p = 0.013). Although a similar trend was observed when comparing nephron sparing procedures vs open surgery, this did not attain statistical significance. In addition to surgical technique, only higher clinical stage was independently associated with increased direct variable costs after adjustment for operative year (p <0.0001). CONCLUSIONS: Relative to their open counterparts the costs of laparoscopic treatment of renal cortical neoplasms have increased at a lower rate in the last 6 years. When considered in the context of the well established benefits of laparoscopy, our findings lend additional support in favor of laparoscopy as the standard of care.     

腔镜甲状腺手术联合术中超声检查治疗结节性甲状腺肿25例报告

目的 探讨腔镜甲状腺手术联合术中超声检查治疗结节性甲状腺肿的应用价值.方法 我科2008年1月至2010年1月采用腔镜甲状腺手术联合术中超声检查治疗结节性甲状腺肿患者25例,对其临床资料进行总结.结果 25例手术均获成功,无中转开放手术,手术时间（130.2±38.3）min.术后病理证实均为结节性甲状腺肿,随访（6.3±3.2）个月无复发患者.结论 腔镜甲状腺手术联合术中超声检查可以安全准确地切除可疑结节,防止出血和副损伤.     

后腹腔镜保留肾单位手术治疗T1b期肾癌的疗效观察

目的：探讨后腹腔镜保留肾单位手术（NSS）治疗Tlb期肾癌（RCC）的手术方法及临床疗效。方法：2009年2月-2012年2月,对5例临床分期为T1b期RCC患者行后腹腔镜NSS,其中男3例,女2例,平均年龄（55．4±9．6）岁,左侧3例,右侧2例。肿瘤平均直径（5．7±1．3）cm。结果：所有手术均顺利完成,无中转开放,围手术期无严重并发症。平均手术时间（110．0±29．5）min,术中平均热缺血时间（24．2±5．1）min,术中平均出血量（42．2±13．1）ml,术后尿漏1例;术后平均住院时间（5．9±2．1）d,术后平均随访（25．3±11．1）个月,全部患者。肾功能正常且未见肿瘤局部复发及远处转移。结论：后腹腔镜NSS治疗Tlb期RCC创伤小、出血少、并发症少且近期疗效满意;但其远期疗效还需大样本对照研究和长期随访观察。     

Fibrin glue-oxidized cellulose sandwich for laparoscopic wedge resection of small renal lesions

Purpose:We present our experience with standard laparoscopic wedge resection of small renal tumors using a fibrin glue-oxidized cellulose sandwich for hemostasis.Materials and Methods:From May 2002 to December 2003, 15 patients underwent laparoscopic wedge resection for a total of 15 nonhilar renal masses. Renal hilar clamping was performed in 1 patient and no sutures were placed. We used ultrasonic shears and an argon beam coagulator to resect and then coagulate the tumor bed. Tisseel (Baxter Corp., Deerfield, Illinois) was applied to the resection bed, followed by a layer of oxidized, regenerated cellulose (Surgicel, Ethicon, Somerville, New Jersey) and a final layer of Tisseel.Results:Mean preoperative tumor size was 2.2 × 2.2 × 2.1 cm. Lesions were subdivided based on the percent of the lesion that extended beyond the renal parenchymal border on computerized tomography as exophytic—greater than 60% in 6 cases, endophytic—less than 40% in 4 and mesophytic—40% to 60% in 5. Mean operative time was 3.8 hours (range 3 to 5). Mean blood loss was 108 ml (range 20 to 300). No patient required blood transfusion. There was no significant difference in blood loss or change in creatinine among the endophytic, exophytic and mesophytic groups (150, 121 and 93 ml, and 0.03, 0.07 and 0.04 mg/dl, respectively). Margin status was negative in all cases (mean thickness 3.2 mm). Average hospital stay and time to the resumption of oral intake were 2.7 and 1.4 days, respectively.Conclusions:Small exophytic or mesophytic renal lesions can be safely excised laparoscopically without vessel clamping. Excellent hemostasis was achieved in each case with the newer hemostatic agents.