后腹腔镜联合经腰小切口"杂交"手术在复杂肾肿瘤保留肾单位手术中的应用

目的：探讨后腹腔镜联合经腰小切口“杂交”手术在复杂肾肿瘤保留肾单位手术中的临床疗效和安全性。方法：回顾性分析2015年4月至2016年12月在北京大学人民医院泌尿外科进行“杂交”保留肾单位手术的复杂肾肿瘤患者的临床资料, 其中男性10例,女性6例,年龄(50.2±10.7）岁,肿瘤位于左侧9例,右侧7例,肿瘤直径（6.1±1.0） cm, R.E.N.A.L.评分平均（9.3±1.3）分。患者均采用后腹腔镜联合经腰小切口的“杂交”手术方式进行保留肾单位手术,即在后腹腔镜下完全游离肾和肾蒂血管,预置肾动脉,然后取12肋下长约10~12 cm的切口进行开放手术,阻断肾动脉,直视下切除肿瘤、缝合创面。记录手术时间、肾缺血时间、术中出血量、术后并发症等围手术期资料以及术后肾功能随访情况。结果： 16例均全部成功完成手术。手术时间 (164.9±23.6) min,肾缺血时间（32.4±6.2） min,术中出血量（204.0±125.1） mL,引流管拔除时间(4.1±1.0) d,术后平均住院时间（6.9±1.5） d。术后发生Clavien Ⅲ级以上并发症2例：1例集合系统损伤;1例患者因术后出血,再次急诊手术探查止血。术后第1天平均血肌酐水平为（126.3±26.4） μmol/L ,与术前（74.3±16.9） μmol/L比较, 差异有统计学意义（P<0.05）。术后1个月平均血肌酐水平为（92.6±18.2） μmol/L、术后3个月平均血肌酐水平为（80.8±18.4） μmol/L,与术前比较差异无统计学意义（P>0.05）。随访3~20个月,均未见肿瘤复发和转移。结论：后腹腔镜联合经腰小切口“杂交”保留肾单位手术能够降低手术难度,提高手术安全性,适用于部分经过选择的复杂肾肿瘤患者,有一定的临床推广价值。

Clinical application of retroperitoneal laparoscopic surgery combined with mini-flank incision "hybrid surgery" for partial nephrectomy of complex renal tumors

Objective: To evaluate the clinical effect and safety of retroperitoneal laparoscopic surgery combined with mini-flank incision "hybrid surgery" for partial nephrectomy of complex renal tumors.Methods: Between April 2015 and December 2016, the clinical data from 16 patients with complex renal tumors who underwent the "hybrid surgery", including 10 males and 6 females, were retrospectively reviewed.The average age was (50.2±10.7) years, 9 cases were located in the left side and 7 cases in the right side, the mean tumor size was (6.1±1.0) cm, and the mean R.E.N.A.L.nephrometry score was 9.3±1.3.All the patients received the "hybrid surgery", the first step was to adequately mobilize the kidney and tumor, prepared the renal artery by retroperitoneal laparoscopy, and then the incision about 10-12 cm was done under the twelve rib to convert to open surgery.After the renal artery was clamped, the tumor was removed and the wound was closed under direct vision.The operative time, ischemia time, estimated blood loss, intraoperative and postoperative complications and short-term renal function were recorded.Results: All the 16 patients'' "hybrid surgeries" were successfully performed.The mean operative time was (164.9±23.6) min, mean ischemia time was (32.4±6.2) min, and mean estimated blood loss was (204.0±125.1) mL.The mean drainage tube removal time was (4.1±1.0) d, and the mean postoperatively hospital stay was (6.9±1.5) d.There were 2 patients with Clavien Ⅲ grade complications.One patient was injured with collecting system, and 1 patient received a second emergency surgery for acute postoperative bleeding.The mean 1 day postoperative serum creatinine level was (126.3±26.4) μmol/L, which was statistically significant (P<0.05) compared with the preoperative serum creatinine level(74.3±16.9)μmol/L.There were no significant differences (P>0.05) in comparing the 1 month postoperative serum creatinine level(92.6±18.2) μmol/L, 3 months postoperative serum creatinine level (80.8±18.4) μmol/L with the preoperative serum creatinine level.During 3 to 20 months follow-up periods, no local recurrence or distant metastasis occurred.Conclusion: This "hybrid surgery" combined retroperitoneal laparoscopic surgery with mini-flank incision for partial nephrectomy is safe and effective.It could decrease the operative difficulty and be worthy of further application for some selected complex renal tumor patients.