保留肾单位手术后肾功能预后的影响因素分析

目的:探讨肾肿瘤行保留肾单位手术(NSS)后肾功能预后的影响因素。方法:回顾性分析西京医院2016年12月至2018年12月行NSS治疗的115例肾肿瘤患者的临床资料。男75例,女40例。年龄(49.50±12.94)岁;体质指数(24.59±3.59)kg/m 2;肿瘤最大径(3.66±1.32)cm;R.E.N.A.L.评分(6.43±1.60)分。术前患肾肾小球滤过率(GFR)(48.22±11.48)ml/(min·1.73m 2),健肾GFR(49.73±11.96)ml/(min·1.73m 2),总GFR(97.95±21.32)ml/(min·1.73m 2)。术前患肾有功能肾组织体积(FPV)(132.23±9.11)cm 3。61例行腹腔镜肾部分切除术,54例行机器人辅助腹腔镜肾部分切除术。记录手术时间、热缺血时间(WIT)、术后病理结果。记录术后6个月的血肌酐、患肾GFR、健肾GFR、总GFR、GFR保存率(术后GFR与术前GFR的比值)、患肾FPV、患肾FPV保存率(术后患肾FPV与术前FPV的比值)。患肾FPV通过手术前后的CT影像使用椭球体近似法测量。手术前后GFR和患肾FPV比较采用配对样本t检验。采用Spearman秩相关分析评估各研究因素与患肾GFR保存率间的相关性。多因素分析采用多元线性回归模型分析患肾功能的独立预测因素。以WIT=25 min为截断点将患者分为≤25 min组和>25 min组,比较两组术前患肾GFR,以及术后6个月的患肾GFR和患肾GFR保存率。结果:本组115例手术均顺利完成,中位手术时间135(75~245)min,WIT(24.57±5.51)min。患肾术后GFR(35.50±7.81)ml/(min·1.73 m 2),与术前比较差异有统计学意义(P<0.001),患肾GFR保存率为(74.65±11.10)%。术后6个月患肾FPV保存率为(84.28±4.37)%,与术前比较明显减少(P<0.001)。患肾FPV保存率与患肾GFR保存率呈极强正相关(r=0.802);WIT与患肾GFR保存率呈中等程度负相关(r=-0.503)。多元线性回归分析结果显示,术前患肾GFR(b=-0.150,P=0.008)、WIT(b=-0.443,P<0.001)、患肾FPV保存率(b=1.638,P<0.001)是患肾GFR保存率的独立预测因素。WIT>25 min组和≤25 min组的患肾GFR保存率分别为(68.77±10.88)%和(79.34±8.88)%,差异有统计学意义(P<0.001)。结论:在WIT较短(<30 min)的情况下,正常肾组织数量的保留是影响NSS术后肾功能预后的重要因素,有限的WIT起次要作用。在保证肿瘤完整切除的前提下,应尽可能保留更多的正常肾组织,同时尽量将WIT控制在25 min以内。

Analysis of the prognostic factors of renal function after nephron sparing surgery

Objective To investigate the prognostic factors of renal function after nephron sparing surgery(NSS)in renal tumor patients.Methods The data of 115 patients who underwent NSS in our hospital from December 2016 to December 2018 were retrospectively analyzed.There were 75 males and 40 females,aged(49.50±12.94)years.The body mass index was(24.59±3.59)kg/m2.The maximum diameter of the tumor was(3.66±1.32)cm.The R.E.N.A.L.score was(6.43±1.60).Laparoscopic partial nephrectomy was performed in 61 cases and robot-assisted laparoscopic partial nephrectomy was performed in 54 cases,and all of which were successfully completed.Operative time,WIT and postoperative pathological results were recorded.Blood creatinine value,GFR of affected kidney,GFR of healthy kidney,total GFR,GFR preserving rate(the ratio of postoperative GFR to preoperative GFR),functioning parenchymal volume(FPV)of the affected kidneys,and FPV preserving rate of the affected kidneys(the ratio of postoperative FPV and preoperative FPV)were recorded 6 months after surgery.FPV was measured by the ellipsoid approximation on CT images before and after surgery.Paired sample t test was used to compare GFR and FPV before and after surgery.Spearman rank correlation analysis was used to evaluate the correlation between the study factors and GFR preserving rate of the affected kidneys.Multivariate linear regression models were used to analyze independent predictors of renal function of the affected kidneys.Independent sample t test was used for comparison between group of WIT≤25 min and group of WIT>25 min.Results All of the 115 patients in this study underwent successfully operations,with the median operation time of 135(75-245)min,and WIT(24.57±5.51)min.Postoperative GFR of the affected kidneys(35.50±7.81)ml/(min·1.73 m2)was significantly different from preoperative GFR(P<0.001).The FPV preserving rate of the affected kidneys was(84.28±4.37)%,which was significantly lower than that preoperative FPV of the affected kidneys(P<0.001).Spearman rank correlation analysis showed that there was a strong positive correlation between the FPV preserving rate of the affected kidneys and the GFR preserving rate of the affected kidneys(r=0.802),WIT was negatively correlated with the GFR preserving rate of the affected kidneys(r=-0.503).Multiple linear regression analysis showed that preoperative GFR of the affected kidneys(b=-0.150,P=0.008),WIT(b=-0.443,P<0.001)and the FPV preserving rate of the affected kidneys(b=1.638,P<0.001)were independent predictors of the GFR preserving rate of the affected kidneys.WIT>25 min group had a significantly lower GFR preserving rate of the affected kidneys than WIT≤25 min group[(68.77±10.88)%vs.(79.34±8.88)%,P<0.001].Conclusions In the case of short WIT(<30 min),the reservation of normal renal tissue is the most important variable prognostic factor of renal function after NSS,and short WIT plays a secondary role.Under the premise of complete tumor resection,normal renal tissue should be reserved as much as possible and WIT should be controlled within 25 min.