单孔多通道后腹腔镜肾脏肿瘤冷冻消融术2例报告

目的 完善相关术前评估并取得患者知情同意后,在国内首次尝试进行单孔多通道后腹腔镜下肾脏肿瘤冷冻消融术,探讨该手术的可行性和安全性,总结操作经验。方法 2012年3月14日和19日我科先后完成单孔多通道(TriPortTM)后腹腔镜下肾肿瘤冷冻消融术2例。例1为79岁男性,Charlson合并症指数(Age-weighted)为4,肿瘤最大径2.7 cm, R.E.N.A.L.评分为2+2+3+p+3=10p,术前eGFR为61.5 ml/(min·1.73 m2)；例2为43岁女性,Charlson合并症指数(Age-weighted)为3,肿瘤最大径2.6 cm, R.E.N.A.L.评分为1+1+1+a+2=5a,术前eGFR为187.8 ml/(min·1.73 m2)。手术方法 :于腋中线水平,髂嵴最高点与第12肋下缘连线中点处取一2 cm纵行皮肤切口,充分游离暴露肿瘤表面,腹腔镜监视下将两把2 mm直角冷刀经皮穿刺后置入瘤体内,按照EndoCare冷刀手术操作系统完成两个循环后退出冷冻刀头。结果 2例手术均顺利完成,手术时间、冷冻时间、术中出血分别为:185 /170 min,30 /30 min,50/30 ml；术后第1、2、3天患者视觉疼痛模拟评分分别为:2/1,1/1,0/0；术后住院时间分别为:6/5 d；无任何术中、术后并发症。术后病理组织学评估2例均为透明细胞癌,Furhman分级分别为Ⅱ和Ⅰ。术后1个月复查肾功能分别为:60.2和144.3 ml/(min·1.73 m2)；术后1周、1个月复查肾脏增强CT提示肿瘤已完全消退,无局部复发。结论 初步经验表明单孔多通道后腹腔镜下肾脏肿瘤冷冻消融术切口小、肾功能损害小,术后患者疼痛轻、恢复快,肿瘤治疗近期疗效确切,但需严格把握临床适应证。远期疗效有待前瞻性大样本的长期随访对照研究。

Retroperitoneal laparoendoscopic single-site (LESS) renal cryoablation: the first clinical series in China

Objective To summarize our experience on the first clinical series of retroperitoneal laparoendoscopic single-site(LESS) renal cryoablation in mainland China and to assess its safety and feasibility after obtaining the informed consents.Methods Two patients with small renal masses underwent retroperitoneal laparoendoscopic single-site renal cryoablation by the same urologic surgical team at March 14,2012 and March 19,2012 in our department.The male patient was 79 years old,with the Charlson comorbidity index(CCI,Age-weighted) being 4,maximal tumor diameter being 2.7 cm,R.E.N.A.L.score being 2+2+3+p+3=10p,and preoperation eGFR being 61.5 ml/(min·1.73 m2).The female patient was 43 years old with CCI(Age-weighted) being 3,maximal tumor diameter being 2.6 cm,R.E.N.A.L.score being 1+1+1+a+2=5a,and preoperation eGFR being 187.8 ml/(min·1.73 m2).At the level of midaxillary line,we made a 2-cm longitudinal skin incision at the mid-point between the iliac crest and the inferior margin of 12th rib.The renal masses were fully isolated and exposed,and then two 2-mm cryoprobes were percutaneously introduced and placed into the tumor under laparoscopic visualization.Two freeze-thaw cryoablation cycles were performed according to the instruction of EndoCare Cryo-Care Surgery System.Results The two procedures were smoothly completed without any extra skin incision.The operative duration,cyroablation time,estimated blood loss,and postoperative hospital stay of the male and female patients were 185/170 min,30/30 min,50 /30 ml,6/5 d,respectively;and the postoperative pain scores measured by the visual analogscale(VAS) were 2/1,1/1,and 0/0 at day 1,day 2,and day 3,respectively.Pathologic examination revealed clear cell renal cell carcinoma in both patients(Fuhrman gradeⅡandⅠ).The eGFR at 1-month after operation was 60.2/144.3 ml/(min·1.73 m2) in both patients.CT scan found no evidence of recurrence at the cyroablative region 1 week and 1 month after operation.Conclusion Our initial experience shows that laparoendoscopic single-site renal cryoablation is a safe,feasible and effective procedure,with small incision,less pain,less damage of renal function,rapid recovery,and satisfactory short-term effect,but the patients should be carefully chosen.And the long-term effect should be confirmed by large sample study.