经腹途径肾癌伴右心房下下腔静脉癌栓手术疗效观察

目的探讨经腹途径非体外循环下肾癌伴右心房下下腔静脉癌栓手术疗效及预后影响因素。方法回顾性分析44例行经腹途径非体外循环下肾癌根治性切除术和下腔静脉癌栓取出术的肾癌伴右心房下下腔静脉癌栓患者的临床资料。依据术后病理分期分为转移性肾癌组和非转移性肾癌组。转移性肾癌组包括男性6例，女性3例，平均年龄（62±11）岁；下腔静脉癌栓I级2例、Ⅱ级3例、Ⅲ级3例及Ⅳ级1例。非转移性肾癌组依据下腔静脉癌栓分级水平分为低分级癌栓组：共12例，包括下腔静脉癌栓I级3例、Ⅱ级9例，男性8例，女性4例，平均（57±10）岁；高分级癌栓组：共23例，包括下腔静脉癌栓Ⅲ级18例、Ⅳ级5例，男性18例，女性5例，平均（59±9）岁。结果38例（86％）成功实施经腹途径非体外循环下右心房下下腔静脉癌栓取出术，平均手术时间（215±90）min，下腔静脉平均阻断时间（19±4）min，平均失血量为（1220±995）ml，平均输血量为（950±840）ml。围手术期7例（15．9％）出现并发症，无1例围手术期死亡。随访中18例死亡，平均生存时间为（28±16）个月。26例患者存活，平均随访（30±13）个月，其中12例为无瘤生存，14例发生肾癌转移。转移性肾癌组平均生存时间为（12．2±1．2）个月，显著低于非转移性。肾癌组的（48．0±3．0）个月（P〈0．05）。非转移性肾癌患者5年生存率为12％，其中低分级癌栓组平均生存时间为（50．8±4．2）个月，与高分级癌栓组平均生存时间（44．7±3．3）个月相比，差异无统计学意义（P=0．422）。结论肾癌伴右心房下下腔静脉癌栓可经腹途径非体外循环下完成，病理分期而非下腔静脉癌栓级别是其重要预后影响因素。

Surgical management of renal cell carcinoma with thrombus in the inferior vena cava under the right atriumthrough an exclusive transabdominal approach without cardiopulmonary bypass

Objective To investigate surgical management and prognosis of renal cell carcinoma （RCC） with thrombus in the inferior vena cava under the right atrium through an exclusive transahdominal approach without cardiopulmonary bypass. Methods Clinical data was retrospective analyzed in 44 patients with renal cell carcinoma with thrombus in the inferior vena cava under the right atrium, who underment radical nephrectomy and thrombectomy through an exclusive transabdominal approach without eardiopulmonary bypass. According to the stage of pathology, they were subgroup to metastatic RCC group and nonmetastatic RCC group. The former group included 6 male and 7 female, the mean age was （62±ll）years, and level of thrombus was level I in 2, level II in 3, level III in 3 and IV in 1 case. The latter group was subdivided low level thrombus group Fineluding 8 male and 4 female, the mean age （57±10）years, and level of thrombus was level I in 3, level II in 9, as LLT group] and high level thrombus group Eincluding 18 male and 5 female, the mean age （59±9） years, and level of thrombus was level III in 18, level IV in 5 as HLT group]. Results Thirty eight patients （86%） successfully completed the thrombectomy through an exclusive transabdominal approach without cardiopulmonary bypass , and mean operative time was （ 215 ± 90 ） min , mean inferior vena cava clamping time （19 ± 4） min, mean estimated blood loss （ 1 220 ± 995） ml, with a mean transfusion being （ 950 ± 840） ml. The complication rate was 15.9% （7/44） and no one died during the peroperative period. Eighteen patients died with a mean survival time of （28±16）months. Twentiy six cases survived with a mean follow-up of （30±13）months including 12 cases with the disease free survival and 14 cases with metastasis. The mean survival time of the metastatic RCC group was （12.2 ± 1.2）months, significantly lower than that of the nonmetastatic RCC group （48.04-3.0）months. However, there was no significant difference in mean survival time between high level thrombus group and low level thrombus group （44. 7±3.3）months vs （50.84±4.2）months], and the five years survival was 12%0 in the nonmetastatic RCC group. Conclusions Thrombectomy could well be treated through an exclusive transabdominal approach without cardiopulmonary bypass in the patients with renal cell carcinoma with thrombus in the inferior vena cava under the right atrium. It is an important prognostic factor that the stage of pathology rather than level of thrombus in the inferior vena eava.