肾部分切除术后迟发性出血原因分析及防治

目的 探讨肾部分切除术后迟发性出血原因及其防治方法.方法 1998-2007年行肾部分切除术382例,发生迟发性出血5例(1.3%).男4例,女1例.平均年龄51(42～63)岁.原发病均为肾癌,肿瘤平均直径2.8(2.3～4.2)cm.2例肿瘤直径＞3.0 cm者手术时阻断肾蒂,3例肿瘤直径＜3.0 cm者游离肾脏后以手握控制肾脏出血;切除范围距离肿瘤边缘0.5～1.0 cm正常肾实质,肾创面"8"字或"U"形对合缝合.5例术后出血时间为6 d～3个月;出血量平均2300(1000～4500)ml.患者均表现为反复肉眼血尿伴患侧腰背部胀痛不适,伴休克表现3例,接受输血治疗3例.5例患者肾动脉造影发现出血原因均为创面肾动脉分支残端形成假性动脉瘤.其中3级肾动脉分支出血4例,4级肾动脉分支出血1例.结果 1例再次手术行患肾切除术,4例行经皮选择性肾动脉栓塞治疗.5例术后出血皆停止.未发生高血压、尿瘘等并发症.4例随访2～9年,肿瘤无复发,未再出血.结果 肾部分切除术后迟发性出血原因包括切面肾动脉小分支未结扎或部分结扎,缝合肾脏创面时缝针贯穿肾实质内动脉等.一旦出现此并发症,需要及时治疗,经皮选择性肾动脉栓塞是有效的治疗方法.     

肾部分切除术后肾动脉假性动脉瘤一例并文献复习

目的 探讨肾部分切除术后少见但危重的肾动脉假性动脉瘤(RAP)的临床表现、诊断与处理方法。方法 报告2019年8月我科诊疗的1例腹腔镜左肾部分切除术后出现RAP患者的临床资料,并复习相关文献对RAP的临床特征、诊断与治疗进行分析总结。结果 患者男,77岁,因“发现左肾占位1个月”入院,术前诊断为“左肾占位:肾癌可能性大”。行腹腔镜下左肾部分切除术,术后病理结果示左肾透明细胞癌,包膜完整。术后第8天出现无痛性肉眼血尿,超声造影提示左肾RAP,介入下肾动脉造影再次确诊并同时行超选择性肾动脉栓塞,成功栓塞动脉后患者无再发血尿,顺利出院。结论 RAP是肾部分切除术后少见但严重的并发症,可疑患者应尽早行超声造影检查,超选择性肾动脉栓塞治疗安全有效。     

后腹腔镜肾部分切除术治疗肾肿瘤7例报告

目的探讨后腹腔镜肾部分切除术治疗。肾肿瘤的手术方法及临床疗效。方法选择7例肾肿瘤患者行后腹腔镜肾部分切除术。其中T1期肾癌6例,肾错构瘤1例。术中阻断肾动脉主干4例,选择性阻断肾段动脉3例。距肿瘤约1．0cm处,整块剪除肿瘤和部分肾实质及其表面的脂肪组织,分层缝合集合系统和肾实质后,解除阻断。观察手术时间、肾动脉或肾段动脉阻断时间、术中出血量及围术期并发症。结果7例手术均成功完成,肿瘤包膜完整,术后切缘阴性。手术时间110～220min,平均155min;术中出血40-250mL,平均120mL。肾动脉阻断时间22～50min,平均35min,肾段动脉阻断时间16～28min,平均23min。术后随访1～9月,无继发出血,无漏尿,无肿瘤局部复发,总肾功能及分肾功能无异常。结论后腹腔镜肾脏部分切除术微创安全可行,控瘤效果好,保留的肾单位功能恢复好;选择性段动脉阻断的肾部分切除术,可期望得到最大限度的。肾功能保留。     

Hem-o-lok结扎夹在腹腔镜肾部分切除术中的应用

目的：探讨腹腔镜肾部分切除术中减少打结的方法。方法：2005年3月～2008年3月，对22例肾肿瘤患者行腹腔镜肾部分切除术。其中肾细胞癌15洌．为临床分期T。期；良性肿瘤7例。术前放置F5输尿管导管．阻断肾蒂或肾动脉，锐性切除肿瘤，用线尾带Hem-o-lok结扎央的20可吸收线缝合肾实质及集合系统，术后注射美蓝检查是否漏尿。结果：本组患者肿瘤平均大小为3．2（1．4～4．6）cm，平均手术时间为110（85～270）min，平均热缺血时间为33．2（111～55）min，估计出血量平均为197（30～1000）ml。1例中转开放手术，行肾切除术。无术后出血及漏尿发生。结论：腹腔镜肾部分切除术中应用Hem-o-lok结扎夹简化了缝合过程，是一种安全、有效的打结替代方法。     

肾错构瘤的诊断和治疗(附22例报告)

目的：探讨提高肾错构瘤的诊断和治疗水平。方法：回顾性分析22例肾错构瘤的诊断和治疗结果：男10例，女12例，年龄16～67岁。肿瘤位于右侧9例，左侧13例；肿瘤大小0．4cm×0．6cm×0．7cm～13．5cm×14．3cm×15．2cm。主要临床症状为腰部不适、胀痛、包块、出血性休克等。结果：B超诊断准确率为86．4％（19／22），CT诊断准确率为90．9％（20／22），肿瘤小于4cm而无症状的7例采用B超、CT定期随访。手术15例，其中肿瘤直径小于4cm伴患侧腰痛或肉眼血尿的7例行肿瘤剜除术；直径大于4cm者8例，行肾部分切除术4例，肾切除术2例，因误诊为肾癌而行肾根治性切除术2例。结论：B超、CT、MRI等影像学检查对肾错构瘤的诊断准确率较高，必要时可作针刺活检及术中冷冻病理检查，关键是治疗方法的选择，即如何尽最大可能选择保留肾单位手术，其中选择性肾动脉栓塞术、肿瘤剜除术、肾部分切除术应作为首选。     

肾动脉CT成像在肾段动脉阻断肾部分切除术中的应用研究

目的为临床开展肾段动脉阻断的肾部分切除术提供影像解剖学指导。方法对390侧肾动脉CT成像（CTA）资料进行研究,分析肾动脉一级和二级分支处与肾门上下缘连线（A线）的关系,观察副肾动脉及支配情况。结果390侧肾动脉CTA资料研究结果显示：肾动脉第一级分支处在A线之内者为122例,占31．28％（122／390）,在A线外侧者268例,占68．72％（268／390）。二级分支处在A线之外者187例,占47．95％（187／390）。副肾动脉共出现120侧128支,占30．77％（120／390）,其中支配肾上极的副肾动脉共95支,占74．22％（95／128）,支配肾下极者33支,占25．78％（33／128）。结论①肾动脉是呈节段性分布的,肾段动脉与肾门之间存在一定的空间,为肾段动脉阻断的肾部分切除术提供了安全保障;②副肾动脉出现机率较高,大部分支配肾上极,术中需注意保护副肾动脉,避免不必要的肾单位损伤;③CTA能够提供肾段动脉和副肾动脉的分布特点和个体变异情况,是选择性肾段动脉阻断。肾部分切除术前手术评估的重要手段。     

孤立肾肾肿瘤外科保肾治疗策略的选择及初步探讨

目的:探讨孤立肾肾肿瘤保肾治疗策略的选择。方法:回顾本中心2017年2月—2022年3月收治孤立肾肾肿瘤患者41例,男28例,女13例,年龄59(27～79)岁。其中38例为体检或术后复查中发现,2例患者因血尿就诊,1例患者因腰腹部肿块就诊。肿瘤位于左肾14例,右肾27例,其中肾门部肿瘤2例,肿瘤直径24(8～75) mm。所有患者均在气管插管全麻下进行,其中4例行开放肾部分切除术,19例行腹腔镜肾部分切除术,11例行机器人辅助腹腔镜肾部分切除术,3例行小切口辅助腹腔镜肾部分切除术,4例行腹腔镜肾肿瘤微波消融术。记录手术时间、出血量、肾动脉阻断方式、肾动脉阻断时间、术中及术后并发症、术前及出院前血肌酐值、住院时间。结果:所有手术均安全顺利完成,无术中并发症发生,2例腹腔镜肾部分切除术采用分支动脉阻断,其余肾部分切除术均采用肾动脉主干阻断,腹腔镜肾肿瘤微波消融术均无阻断。2例患者出现术后并发症。开放肾部分切除术组、腹腔镜肾部分切除术组、机器人肾部分切除术组、小切口辅助腹腔镜肾部分切除术组及腹腔镜微波消融组中位手术时间(173 min vs 135 min vs 120 min vs 26...     

经动脉栓塞治疗肾内动静脉畸形后血管再通的治疗

目的探讨经动脉栓塞治疗肾内动静脉畸形后畸形血管再通的原因和治疗。方法回顾性分析4例肾内动静脉畸形经动脉栓塞治疗,术后畸形血管发生血管再通患者的临床资料。本组共4例,男1例,女3例,年龄19~70岁。左肾2例,右肾2例;1支肾动脉2例,2支肾动脉2例。经动脉造影明确诊断,并应用明胶海绵栓塞治疗,术中见栓塞确实,出血停止。术后1~24 h再次出现血尿,发生畸形血管再通。结果行二次动脉造影证实原动静脉畸形处血管再通,应用弹簧圈超选择性栓塞治愈。随诊未发现畸形血管再通。结论经动脉栓塞治疗先天性肾内动静脉畸形应采用超选择性动脉栓塞技术,用明胶海绵栓塞易发生血管再通。应用合适大小的弹簧圈超选择性肾动脉栓塞治疗肾内动静脉畸形可以取得确实疗效。     

肾动静脉瘘的诊断与治疗（附6例报告）

目的探讨肾动静脉瘘的诊断和治疗方法。方法1996年至2006年经超选择性肾动脉造影确诊的6例肾动静脉瘘患者,原发性动静脉瘘5例,获得性动静脉瘘1例;临床表现严重血尿5例,高血压1例。4例行经皮超选择性肾动脉栓塞治疗,2例行肾切除术。结果4例栓塞后血尿得到控制,随访5个月-8年,均无复发;2例肾切除者血尿消失,血压下降。结论影像学是诊断肾动静脉瘘的主要手段,超选择性肾动脉造影是确诊的首选方法;动脉栓塞是最佳治疗方法,创伤小、疗效确切,还可最大限度保留患侧肾功能;肾功能丧失者可考虑肾切除。     

基于全息影像技术肾肿瘤手术难度评分系统的应用价值

目的基于全息影像技术建立肾肿瘤手术难度评分系统, 探讨其在肾部分切除术中的应用价值。方法回顾性分析2019年10月至2022年1月厦门大学附属第一医院收治的184例临床分期为cT1～T2期肾肿瘤患者的资料。男110例, 女74例;年龄中位值55(47, 62)岁;体质指数23.7(21.8, 26.4)kg/m2;肿瘤最大径3.9(2.9, 5.2)cm;伴高血压病60例, 糖尿病24例, 高尿酸血症7例;中位R.E.N.A.L.评分8(6, 9)分, 中位PADUA评分9(8, 10)分;中位术前估算肾小球滤过率(eGFR)99.7(83.4, 114.2) ml/(min·1.73m2);cT1期153例, cT2期31例。184例行机器人辅助肾部分切除术或根治性肾切除术。根据患者术前CT或MRI检查进行全息影像重建, 综合考虑肿瘤最大径(D), 肿瘤压迫肾分支血管程度(C), 肿瘤占肾窦体积的比率(O), 肿瘤外生率(M), 我们提出了基于全息影像技术的肾部分切除手术难度评分系统(DCOM评分系统)。根据DCOM总评分将肿瘤手术复杂程度分为低度复杂(4～6分)、中度复杂(7～8分...     

Pelvic angiomyolipoma

A case of renal artery pseudoaneurysm (RAP) after partial nephrectomy for an 11-cm renal tumor is reviewed. Symptoms, computed tomography (CT) scan images and angiography are all displayed. A 57-year-old woman was readmitted 4 months after she underwent a retroperitoneal laparoscopic partial nephrectomy for an 11-cm right renal tumor. Contrast CT revealed a 10.3-cm mass recurrence in the same position as her former tumor. Renal arteriography confirmed active bleeding from the anterior upper pole segmental branch into a 3 × 3 × 7-cm pseudoaneurysm. Percutaneous selective coil angioembolization was successfully performed. The remaining kidney parenchyma was fully preserved.     

Laparoscopic partial nephrectomy for hilar tumors: technique and results

BACKGROUND: Laparoscopic partial nephrectomy for hilar tumors is a cutting edge procedure for which little data is available in the current literature. OBJECTIVE: To describe our technique and results of laparoscopic partial nephrectomy for renal hilar tumors. DESIGN, SETTING, AND PARTICIPANTS: Between April 2000 and September 2006, 94 partial laparoscopic nephrectomies were performed at our institution. A total of 18 (19.1%) patients had hilar tumors. A hilar tumor was defined as a lesion suspicious for renal cell carcinoma in contact with a major renal vessel on preoperative cross-sectional imaging. In 3 (16.7%) of the patients, the indication for nephron-sparing surgery was imperative. Mean tumor size was 3cm (range, 2-4.5). Eight (44.4%) surgeries were performed with renal artery perfusion for cold ischemia; the remaining surgeries were performed under warm ischemia. INTERVENTION(S): After occluding the renal artery and controlling the renal vein by using separate rubber band tourniquets, we excised the tumor mass including delicate mobilization away from the blood vessels. Although we used to insert a ureteral stent at the beginning of our experience with laparoscopic partial nephrectomies, we no longer do so. All surgeries were performed by a single urologist (G.J.). MEASUREMENTS: Operative time, ischemia time, blood loss, renal function using the Cockroft formula as well as renal scans, operative and post-operative complications, pathology parameters. RESULTS AND LIMITATIONS: All surgeries were completed laparoscopically. Mean surgical time was 238min (range, 150-420). Mean ischemia times were 42.5min (range, 27-63) and 34.1min (range, 24-56) for the cold and warm ischemia groups, respectively. Estimated intraoperative blood loss was 165ml (range, 50-500). There were two (11%) entries into major vessels during tumor excision, namely a segmental renal artery in one patient and a segmental renal vein in another. Both of these occurrences were managed laparoscopically. One patient necessitated laparoscopic reexploration for urine extravasation in the immediate postoperative period. All postoperative nuclear scans (available in 12 of 18 patients) showed functional kidney moiety. Mean split renal function was 38.6% (range, 24-50) on the operated side. Histopathological examination confirmed renal cell carcinoma in 14 (77.8%) of the patients. One (7.1%) patient had a positive surgical margin on the surface that was adjacent to the renal artery. In a median follow-up of 26 mo (range, 1-59), no local recurrence or systemic progression occurred. CONCLUSION: Laparoscopic partial nephrectomy for hilar tumors is a feasible and safe procedure in the hands of experienced laparoscopic surgeons. Oncological results seem excellent, but further follow-up is needed for accurate long-term assessment of this surgical approach.     

Robotic partial nephrectomy for complex renal tumors: surgical technique

OBJECTIVES: Laparoscopic partial nephrectomy requires advanced training to accomplish tumor resection and renal reconstruction while minimizing warm ischemia times. Complex renal tumors add an additional challenge to a minimally invasive approach to nephron-sparing surgery. We describe our technique, illustrated with video, of robotic partial nephrectomy for complex renal tumors, including hilar, endophytic, and multiple tumors. METHODS: Robotic assistance was used to resect 14 tumors in eight patients (mean age: 50.3 yr; range: 30-68 yr). Three patients had hereditary kidney cancer. All patients had complex tumor features, including hilar tumors (n=5), endophytic tumors (n=4), and/or multiple tumors (n=3). RESULTS: Robotic partial nephrectomy procedures were performed successfully without complications. Hilar clamping was used with a mean warm ischemia time of 31 min (range: 24-45 min). Mean blood loss was 230 ml (range: 100-450 ml). Histopathology confirmed clear-cell renal cell carcinoma (n=3), hybrid oncocytic tumor (n=2), chromophobe renal cell carcinoma (n=2), and oncocytoma (n=1). All patients had negative surgical margins. Mean index tumor size was 3.6 cm (range: 2.6-6.4 cm). Mean hospital stay was 2.6 d. At 3-mo follow-up, no patients experienced a statistically significant change in serum creatinine or estimated glomerular filtration rate and there was no evidence of tumor recurrence. CONCLUSIONS: Robotic partial nephrectomy is safe and feasible for select patients with complex renal tumors, including hilar, endophytic, and multiple tumors. Robotic assistance may facilitate a minimally invasive, nephron-sparing approach for select patients with complex renal tumors who might otherwise require open surgery or total nephrectomy.     

腹膜后入路腹腔镜肾段动脉阻断肾部分切除术治疗早期肾癌(附39例报道)

【摘要】〓目的〓评估腹膜后入路腹腔镜肾段动脉阻断肾部分切除术治疗早期肾癌的疗效、安全性。方法〓选择39例肾肿瘤患者,其中男28例,女11例,年龄39~86岁,平均58±3岁。其中左肾肿瘤20例,右肾肿瘤19例;所有均为单发。肾上极肿瘤 18例,下极肿瘤 12例,中部肿瘤9例。肿瘤最大径2.0~5.0 cm,平均3.5±0.6 cm。所有病例在临时阻断肾段动脉后,行腹膜后入路腹腔镜下肾部分切除术。统计手术时间、术中出血量、肾段动脉阻断时间及围术期并发症。结果〓39例手术均于后腹腔镜下顺利完成,手术时间65~110 min,平均85±16 min;肾段动脉阻断时间20~42 min,平均26±5 min;出血量10~50 mL,平均25 mL。无术后继发出血、尿外渗、种植;肾功能无显著变化。结论〓腹膜后入路腹腔镜肾段动脉阻断肾部分切除术治疗早期肾癌安全、效果确切;最大限度保护了肾功能,具有术野清晰、创伤小的优势。     

“Ride the Green Light”: Indocyanine Green–marked Off-clamp Robotic Partial Nephrectomy for Totally Endophytic Renal Masses

BackgroundComplexity of robot-assisted partial nephrectomy (RAPN) mostly depends on tumor size and location. Totally endophytic renal masses represent a surgical challenge in terms of both intraoperative identification and anatomical dissection.ObjectiveTo detail a novel technique for marking preoperatively endophytic renal tumors with transarterial superselective intrarenal mass delivery of indocyanine green (ICG)-lipiodol mixture, in order to enhance surgical margins control during purely off-clamp (OC) RAPN with the use of near-infrared fluorescence imaging.Design, setting, and participantsBetween June and July 2017, 10 consecutive patients with totally endophytic renal masses underwent preoperative ICG tumor marking immediately followed by RAPN.Surgical procedurePreoperative superselective transarterial delivery of a lipiodol-ICG mixture (1:2 volume ratio) into tertiary-order arterial branches feeding the renal mass prior to transperitoneal OC-RAPN.MeasurementsClinical data were prospectively collected in our institutional RAPN dataset. Perioperative, pathological, and functional outcomes of RAPN were assessed.Results and limitationsMedian tumor size was 3 cm (interquartile range 2.3–3.8). The median PADUA score was 10 (9–11). Angiographic procedure was successful in all patients. Median operative time was 75 min (65–85); median estimated blood loss was 250 ml (200–350). No conversion to on-clamp PN or radical nephrectomy was needed. All patients had uneventful perioperative course; median hospital stay was 3 d (2–3). At discharge, median hemoglobin (Hgb) and percent estimated glomerular filtration rate (eGFR) drop were 3.3 g/dl (2.1–3.3) and 11% (10–20%), respectively. Surgical margins were negative in all cases. One-year median ipsilateral renal volume and 1-yr eGFR percent decreases were 11.7% (6–20.9%) and 12.2% (5.3–13.7%), respectively.ConclusionsWe described a novel technique to simplify challenging RAPN based on ICG superselective transarterial tumor marking. Key benefits include quick intraoperative identification of the mass with improved visualization and real-time control of resection margins.Patient summaryRobot-assisted partial nephrectomy (RAPN) for totally endophytic renal masses is a technically demanding surgical procedure, sometimes requiring radical nephrectomy. This novel technique significantly simplified surgical complexity in our Institution. Further studies with larger cohorts are warranted to confirm whether this technique provides relevant intraoperative and functional advantages.     

肾癌肾部分切除术的临床价值及合适的手术切缘的探讨

目的：探讨肾癌肾部分切除术(保留肾单位手术)的临床价值及合适的手术切缘。方法：回顾性分析15例行肾部分切除术的肾癌患者临床资料．其中双侧异时性肾癌且一侧为多发肿瘤2例，单发肿瘤13例。肿瘤直径2～6cm．均为T1期(1997年TNM分期标准)。对15例肾癌患者行肾部分切除术．手术切缘位于肿瘤外1cm。另取肾癌根治性手术标本21例．于体外沿假包膜行肾肿瘤剜除术．并随机切取肿瘤边缘0．3cm、0．5cm及1cm处肾实质及肾蒂处淋巴脂肪组织行病理检查。结果：15冽患者随访12～72个月．平均41个月．未见并发症及残肾内肿瘤复发。21例标本于体外行肿瘤剜除后肉眼下均无肿瘤组织残留，送检组织均无肿瘤细胞浸润。结论：肾部分切除术能安全有效地治疗局限的早期肾癌患者．而手术切缘为肿瘤边缘1cm处较为合适。     

后腹腔镜肾部分切除术在治疗肾肿瘤的临床应用

目的探讨后腹腔镜保留肾单位的肾部分切除术治疗肾肿瘤的临床应用价值。方法 11例患者施行后腹腔镜保留肾单位的肾部分切除术的临床资料,其中男8例,女3例,年龄平均51.2岁,肿瘤直径3～4cm回顾性分析。结果所有手术均获成功,手术时间70～120min,血管阻断时间20～40min,术中失血100～300ml,术后无出血、尿漏等并发症。术后病理9例肾脏透明细胞癌(T1N0M0),2例肾血管平滑肌脂肪瘤,随访3～15个月无局部复发。结论后腹腔镜下保留肾单位的肾部分切除术治疗早期肾脏肿瘤,安全、有效,兼有创伤小,康复快等优点,近期疗效满意,远期疗效有待进一步观察。     

原位肾低温灌注腹腔镜下肾部分切除术

目的 探讨一种改进的原位肾低温灌注方法在腹腔镜下肾部分切除术中的临床价值.方法 2009年3-5月,对5例解剖性或功能性孤立肾患者行原位肾低温灌注腹腔镜下肾部分切除术.男3例,女2例;平均年龄49(39～63)岁;肿瘤位于左侧2例,右侧3侧;肿瘤直径平均5.6(3.8～7.0)cm.慢性肾功能不全2例,孤立肾1例,对侧肾萎缩1例,较大良性肿瘤1例.术前经皮穿刺经股动脉介入方法在患侧肾动脉留置带球囊契压导管1根,术中契压导管的球囊注水以阻断患侧肾动脉,并通过契压导管在加压泵下持续向肾动脉内灌注4℃冰盐水约200 ml,以实现患侧肾脏低温原位灌注,同时行腹腔镜下肾部分切除术,术后抽出球囊水以解除肾动脉阻断.结果 5例均成功施行原位肾低温灌注腹腔镜下肾部分切除术,手术时间平均102(80～120)min,肾动脉阻断时间平均35(29～39)min,术中出血量平均190(50～300)ml.低温灌注后皮肤温度平均降低0.6℃,肾脏表面温度降低10.0℃,肿瘤表面温度平均降低9.8℃.术前、术后第1、3、5和10天患者肌酐清除率分别为(64.7±16.9),(48.9±14.5)、(52.1±12.4)、(54.5±13.8)和(54.6±11.7)ml/min,多个相关样本检验显示,各组之间肌酐清除率比较差异有统计学意义(P=0.001).术后第5天和第10天比较差异无统计学意义(P=0.125),其余组间比较差异有统计学意义(P=0.043),术后第5天肌酐清除率基本稳定.结论 原位肾低温灌注腹腔镜下肾部分切除术安全可行,同时解决了腹腔镜下动脉阻断和低温灌注难题,有利于延长肾缺血时间、保护肾功能.     

Renal artery pseudoaneurysm after laparoscopic partial nephrectomy

Delayed bleeding from a renal artery pseudoaneurysm is a rare occurrence after partial nephrectomy. We present 2 cases of renal artery pseudoaneurysm after laparoscopic partial nephrectomy. One patient presented with gross hematuria and flank pain and the other presented with flank pain and a decreasing hematocrit. The patients were treated with selective angioembolization of the pseudoaneurysm. The etiology and management of this potentially life-threatening condition are discussed.