根治性肾切除术联合Mayo 0-Ⅱ级静脉癌栓取出术的临床麻醉管理

目的:探讨根治性肾切除术联合Mayo 0-Ⅱ级静脉癌栓取出术临床麻醉管理的安全性和可行性.方法:回顾性分析2015年2月至2017年1月北京大学第三医院泌尿外科单中心收治的40例肾癌合并Mayo 0-Ⅱ级静脉癌栓患者的临床资料.其中男性35例,女性5例.年龄25~84岁,平均(60.1±11.5)岁.本组40例肾癌患者中,合并Mayo 0级癌栓者13例,MayoⅠ级癌栓者10例,MayoⅡ级者17例.ASA I级者4例,Ⅱ级者32例,Ⅲ级者4例.分析40例患者麻醉时间、术中出入量、术中血流动力学变化、术后转归情况等.结果:本组40例Mayo 0-Ⅱ级肾癌伴静脉癌栓患者手术均顺利完成.行开放手术10例,行完全腹腔镜手术30例.1例患者先在后腹腔途径腹腔镜下行右肾根治性切除术,后中转开放取栓手术.40例患者手术平均时间(305.7±114.1) min,麻醉平均时间(368.3±115.1) min.术中出血量为(823.3±930.2) ml,术中输注悬浮红细胞平均(546.9±687.3) ml.27例MayoⅠ-Ⅱ级癌栓(下腔静脉癌栓)患者行术中下腔静脉阻断,下腔静脉阻断时间为10~60 min,平均(24.2±12.4) min.与阻断前即刻比较,下腔静脉阻断后10 min心率显著增快(P<0.05).下腔静脉阻断后5 min呼气末二氧化碳分压(end tidal carbon dioxide partial pressure,PETCO2 )较阻断前显著降低,阻断开放后5 min、10 min,PETCO2较阻断前显著升高(P<0.05).其他血流动力学指标稳定,较阻断前指标变化无统计学差异(P>0.05).所有病例术中、术后无肺栓塞等严重并发症发生,无疾病进展及死亡病例.结论:根治性肾切除术联合Mayo 0-Ⅱ级静脉癌栓取出术麻醉管理安全可行,手术中行下腔静脉阻断和开放期间循环相对稳定.     

肾癌伴下腔静脉癌栓的外科治疗

目的:探讨肾癌伴下腔静脉癌栓的外科治疗.方法:回顾分析2004年5月-2008年10月16例经手术及病理证实的肾癌伴下腔静脉癌栓患者的资料,行肾癌根治术及静脉癌栓取出术,其中男性11例、女性5例,下腔静脉癌栓I级(肝下水平)11例、Ⅱ级(肝后水平)3例、Ⅲ级(肝上水平)1例、Ⅳ级(右心房水平)1例.结果:13例患者得到随访,平均随访(19±4.3)个月(6-48个月),2例失访,1例死亡.结论:肾癌根治性切除加癌栓取出术是治疗肾癌伴下腔静脉癌栓的有效方法.     

肾癌下腔静脉癌栓的诊断和手术方法的探讨--附6例临床分析并文献复习

背景与目的:肾癌下腔静脉癌栓临床处理困难,肾癌根治性切除的同时再切除肾静脉癌栓和取出下腔静脉癌栓,预后仍然良好。术前明确诊断,特别是对癌栓延伸范围的判断,对手术方式的选择十分重要。本研究结合我们的经验,进一步探讨肾癌下腔静脉癌栓的诊断和手术治疗。方法:回顾性分析我院2000～2004年收治的6例肾癌并发下腔静脉癌栓患者的临床资料,包括诊断方法、手术治疗和预后。结果:6例患者术前均经B超、CT和MRI明确诊断,肾静脉型1例,肝下型3例,肝内型2例;1例肝内型患者术中死亡,余5例均手术成功。术后随访3～30个月,1例肝下型和1例肝内型患者分别于术后9个月、3个月死于远处转移,其余3例仍存活。结论:CT、MRI是目前无创诊断肾癌伴下腔静脉癌栓的最佳方法;对无淋巴结和远处转移的患者,应积极手术治疗;手术方式的选择取决于癌栓的延伸范围以及是否侵犯下腔静脉壁。     

肾癌伴腔静脉癌栓的手术治疗

目的:探讨手术治疗肾癌合并腔静脉癌栓患者的预后。方法:回顾分析2003年12月～2009年12月我院12例经手术及病理证实的肾癌合并腔静脉癌栓患者的资料,其中男性10例,女性2 例,中位年龄62（42～76）岁。肾静脉癌栓6 例,左侧2 例,右侧4 例; 下腔静脉癌栓Ⅱ级（肝下型）3 例,Ⅲ级（肝内型）3 例。12例患者术前均经CT或MRI 检查明确诊断肾癌合并腔静脉癌栓。结果:12例患者接受肾癌根治术的同时行静脉癌栓切除,术后9 例患者得到随访,随访时间6～72个月,无瘤生存1～3 年4例,生存5 年以上的4 例,1 例术后6 个月死于肿瘤复发。结论:CT和MRI 对肾癌伴下腔静脉癌栓诊断率较高,可准确判断癌栓位置,对无淋巴结和远处转移者,在行肾癌根治术的同时行下腔静脉癌栓取出术是治疗肾癌合并静脉瘤栓积极有效的治疗方法。      

肾癌伴下腔静脉癌栓的外科治疗

目的：探讨肾癌伴下腔静脉癌栓的外科治疗。方法：回顾分析2004年5月-2008年10月16例经手术及病理证实的肾癌伴下腔静脉癌栓患者的资料,行肾癌根治术及静脉癌栓取出术,其中男性11例、女性5例,下腔静脉癌栓I级（肝下水平）11例、Ⅱ级（肝后水平）3例、Ⅲ级（肝上水平）1例、Ⅳ级（右心房水平）1例。结果：13例患者得到随访,平均随访（19±4．3）个月（6—48个月）,2例失访,1例死亡。结论：肾癌根治性切除加癌栓取出术是治疗肾癌伴下腔静脉癌栓的有效方法。     

Ⅳ型下腔静脉肾癌癌栓的诊治体会(附2例报告并文献复习)

肾癌在泌尿系肿瘤中较为常见,肾癌细胞侵入血管后向肾静脉及下腔静脉延伸成为癌栓,肾癌发生腔静脉转移者占肾癌患者的7%～10%[1],以往认为合并腔静脉瘤栓的肾癌预后极差,近年认为如未发现局部或远处转移,肾痛根治性切除的同时冉切除肾静脉癌柃和取出卜腔静脉癌栓,预后仍然良好.其5年生存率可达53%～72.7%[2].相反,如不积极手术治疗,患者会很快死亡或发牛肿瘤全身转移.目前外科手术是治疗肾癌并腔静脉癌栓的最佳方法[3],随着外科和麻醉技术的进步以及体外循环的广泛应用,此类疾病患者的治愈有了显著提高.     

肾癌腔静脉癌栓的诊断与治疗

背景与目的：肾癌可侵犯肾静脉,形成癌栓延伸至腔静脉,甚至右心房。肾癌腔静脉癌栓临床处理困难,但是在根治性肾切除时取尽癌栓,患者可获得长期生存。本文报告我们处理肾癌腔静脉癌栓的体会。方法：回顾性分析1995年5月～2003年10月经手术治疗的14例肾癌腔静脉癌栓患者的临床资料,包括术前诊断、手术方法和患者的预后。结果：B超发现腔静脉癌栓9例,漏诊5例;CT诊断癌栓12例,漏诊2例;8例MR1检查均发现腔静脉癌栓并对癌栓范围显示清楚。14例中肝下腔静脉癌栓12例、肝内膈下和膈上腔静脉癌栓各1例,术后随访时间6～37个月,13例无瘤生存,1例(ⅢC患者)于术后23个月因癌死亡。结论：B超和CT是诊断肾癌腔静脉癌栓常用方法,MR1判断癌栓范围较B超和CT准确。对没有淋巴和远处转移的肾癌腔静脉癌栓患者外科治疗能获良好的远期效果。     

体外循环下肾癌伴下腔静脉癌栓的处理（附3例报告）

目的 探讨肾癌下腔静脉癌栓的诊断和手术治疗.方法 回顾性分析我院2007年5月至2008年10月3例肾癌伴下腔静脉癌栓的临床资料,包括术前诊断,手术方法和患者的预后.结果 3例术中均完整取出下腔静脉癌栓,术后随访1～15个月,3例均健在,未见肿瘤转移征象.结论 对于无淋巴结和远处转移的肾癌下腔静脉癌栓患者,手术治疗能获得良好的远期效果.     

肾细胞癌伴下腔静脉瘤栓的外科治疗

肾细胞癌(简称肾癌)(renal cell carcinoma,RCC)是泌尿系统常见肿瘤之一。肾癌有4%~10%的可能性向静脉内延伸形成瘤栓并可能进一步延伸进入下腔静脉甚至右心房。近年来得益于外科技术的进步与诊断技术的发展,人们认为在肾癌未发现局部或远处转移的情况下,肾癌根治性切除术加肾静脉瘤栓取出术可使肾癌伴腔静脉瘤栓的患者获得良好预后,但由于该术式难度较大,风险较高,术前需精确评估肿瘤与瘤栓部位,侵犯程度等,对于手术适应证应慎重把控与选择。     

保留肾单位手术治疗双肾细胞癌十例临床分析

目的:观察保留肾单位手术治疗双侧肾细胞癌的疗效.方法:回顾性分析10例双侧肾细胞癌患者的临床资料.7例同时性肾癌中,1例行双侧Ⅰ期手术,6例行分期手术.其中3例行双肾肿瘤剜除术,1例行双肾部分切除及右肾上腺切除术,2例行一侧肾癌根治性切除术及对侧肾肿瘤剜除术,1例行一侧肾癌根治性切除术、下腔静脉切开取癌栓术及对侧肾肿瘤剜除术.3例异时性肾癌均分期手术,其中2例行双肾肿瘤剜除术,1例行一侧肾癌根治性切除术,对侧肾肿瘤剜除术.所有患者术后均行生物学治疗3个月.10例获随访3个月～8年,平均19个月.结果:7例未见肿瘤复发和转移.1例术后6个月出现肺转移,已带瘤生存3个月;1例术后1年出现残肾肿瘤复发,经生物学治疗,已带瘤生存3个月;1例术后3个月后死于肾衰竭.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分别为9个月、2年和6年.结论:保留肾单位的肾切除术是目前双侧肾癌较为理想的治疗方法,它对肾功能的影响较少.双侧肾癌的预后和单侧肾癌一样,与肿瘤的分期和分级有关,而与肿瘤是否多发无关.     

Radical nephrectomy using a chevron incision to treat complicated renal carcinoma: a report of 15 cases

OBJECTIVE To investigate the outcome and indications for radical nephrectomy with a Chevron incision to treat complicated renal carcinoma.METHODS Large renal carcinomas were found in 15 patients during a preoperative CT and/or MRI examination. A tumor thrombus in the renal vein or inferior vena cava was found in 5 cases, and a complication of metastasis in the contralateral adrenalgl and was found in 2 patients. All of the 15 patients underwent a radical nephrectomy by a chevron incision and the postoperative pathological results noted.RESULTS Of the 15 patients who underwent a radical nephrectomy and lymphadenectomy, 5 also received a thrombectomy, and 2 a contralateral adrenalectomy. All surgical operations were safe and successful. The mean operation time was (4.45±0.83) h, and the intraoperative blood loss was (785±910) ml. All patients recovered well after the surgery. Multimodal therapy was conducted in these cases, with rigorous follow-up.CONCLUSION In determining the type of incision for surgery of renal carcinoma, a chevron incision is suitable for cases with a large tumor, local nodal metastasis, thrombus of the renal vein or inferior vena cava and complicated metastasis to the contralateral adrenal gland. The incision produces a clear operating field with less intra- and post-operative complications.     

术中介入超声在肾癌合并静脉瘤栓手术中的应用

目的探讨术中介入超声处理肾细胞癌静脉瘤栓的临床意义。方法2004年8月至2008年7月,对18例巨大肾癌患者术前进行超声、CT和（或）MRI检查,充分收集影像学资料明确肿瘤生长情况并详细了解血管的侵犯情况,根据术中超声结果阻断血管取出瘤栓并检查有无瘤栓残留。结果18例手术均成功实施,手术操作平均（3.69±0.82）h,术中出血平均（463±342）ml,术中直视下应用介入超声检查有无瘤栓及瘤栓侵犯情况,对术前瘤栓分期进行修正,明确血管阻断范围,其中9例实施静脉取瘤栓手术,取栓后检查有无瘤栓残留,18例手术过程中未发生瘤栓脱落及残留,术后恢复顺利。结论术中血管超声检查能够在手术中提供瘤栓的实时准确信息,避免瘤栓脱落和残留,与以往的检查方法相比具有明显的优势,对成功实施手术具有重要意义。     

Renal cell carcinoma extending to the renal vein and inferior vena cava: Results of surgical treatment and prognostic factors

Forty-seven patients with renal cell carcinoma with tumor thrombus extension to the renal vein or inferior vena cava (IVC) were treated surgically over a 10-year period. There were 41 males and 6 females with a mean age of 45.7 years. Thirty-three patients had right-sided and 14 had left-sided tumors. Patients with renal vein or infrahepatic IVC thrombus were treated with radical nephrectomy with tumor thrombus excision after achieving conventional vascular control over the IVC and the opposite renal vein. Four patients with retrohepatic IVC thrombus were treated with venacavotomy and thrombectomy after achieving vascular control above the thrombus but below the hepatic veins while two other patients with retrohepatic and one with suprahepatic thrombus required a bifemoroatrial partial venous bypass prior to tumor thrombectomy. There was one postoperative death due to pulmonary embolism. The actuarial 5-year survival for all patients with venous extention was 50% and the median survival was 4.35 years. Perinephric spread and lymph node metastases were significant prognostic factors affecting survival. This suggests that it is the locoregional spread of renal cell carcinoma rather than the level of the thrombus which governs the prognosis of patients with tumor thrombus extension to the renal vein or IVC.     

Surgical treatment of renal cell carcinoma with tumor thrombi in the inferior vena cava

Background We evaluated the results of surgical treatment for renal cell carcinoma with tumor thrombi in the inferior vena cava. Methods Between March 1984 and July 1996, 25 patients were surgically treated for renal cell carcinoma with extension to the inferior vena cava. Inferior vena caval thrombosis was classified as supradiaphragmatic in 3 patients and infradiaphragmatic in 14 patients. Thrombi were also detected around the renal vein in 8 patients. Twenty-three patients underwent transperitoneal radical nephrectomy, and thrombectomy. One patient with bilateral renal cancer underwent right nephrectomy, left partial nephrectomy, and thrombectomy. The remaining patient underwent nephrectomy and an incomplete thrombectomy due to massive hemorrhage during surgery. In 10 patients with an inferior vena caval diameter of >40 mm, a partial cardiopulmonary bypass was used during surgery. After removal of tumor thrombi, simple closure of the caval wall was performed in 14 patients, Gore-Tex^™ (W.L. Gore & Associates, Elkton, MD, USA) patch grafting, in 10 patients, and inferior vena caval replacement with Gore-Tex, in 1 patient. Results The 1-, 3- and 5-year cause-specific survival in all patients was (72%, 50%, and 23%), respectively. The mortality rate was (8%). There was no significant difference in cause-specific survival according to tumor thrombi level. However, the cause-specific survival of patients with metastasis to either regional lymph node or distant organs, or both (n=10), was significantly lower compared to that of patients without metastasis (n=15); the 3-year cause-specific survival was (17%) and (59%) in the metastasis group and the non-metastatic group, respectively (P=0.042).) Conclusion These results indicate that removal of tumor thrombi in the inferior vena cava is a safe and useful treatment for renal cell carcinoma with no metastasis.     

肾癌下腔静脉癌栓的诊断及治疗(附6例报告并文献复习)

提高对肾癌下腔静脉癌栓的认识。方法：结合文献复习对６例下腔静脉癌栓的诊断及治疗,进行讨。结果：６例经磁共振成像均确定癌栓范围,其中４例膈下型,２例为膈上。全部手术取出癌栓,１例术后１２天死于急性肾功能衰竭,１例术后１６个月死于肝转移,其余４例目前健在,最长者已生存４３个月。     

Improving surgical outcomes in renal cell carcinoma involving the inferior vena cava

Radical nephrectomy with tumor thrombectomy remains the mainstay of treatment in renal cell carcinoma with inferior vena cava extension. Despite the rapid improvements experienced in perioperative care in recent years, this intervention still often results in significant morbidity and mortality. A deeper understanding of salient features of this complex operation provides a valuable insight into the clinical mechanisms underlying the variations observed in surgical outcomes. The ‘operation profile’ serves not only as a basis for making an adequate prognostic assessment, but also creates a platform from which ‘innovative’ strategies for improving quality and safety can be made. The present review aims to set a ‘profile’ for radical nephrectomy and tumor thrombectomy, and to propose a number of strategies that may reduce the complication rates of this intervention.