CAJ | 학술논문

目的探讨后腹腔镜下根治性肾切除并肾静脉及腔静脉取栓术的可行性及手术效果. 方法 2008年11月至2012年3月收治肾肿瘤伴静脉瘤栓患者12例(右侧3例,左侧9例).CT检查右肾静脉内充盈缺损3例,2例略突入腔静脉内,1例瘤栓尖部达右肾静脉、腔静脉交界处；左肾静脉瘤栓尖部位于肾脏与腹主动脉间5例,骑跨于腹主动脉上或跨过腹主动脉但未进入腔静脉4例.全麻下行后腹腔镜下根治性肾切除及静脉取栓术.手术放置4个穿刺套管.右肾肿瘤患者切断右肾动脉后游离腔静脉和肾静脉,血管阻断钳部分阻断腔静脉,切开取栓.左肾肿瘤患者切断左肾动脉后游离左肾静脉,必要时游离部分肠系膜上动脉、腹主动脉和下腔静脉,扩大空间直至可置入血管阻断钳. 结果腹腔镜下完成手术11例,2例右肾静脉瘤栓长度分别为2.5 cm和3.7cm,9例左肾静脉瘤栓长度2.0～7.5 cm,平均4.1 cm.中转开放手术1例.患者术后恢复良好,术后4～11 d,平均7d出院.病理报告肾上皮样血管平滑肌脂肪瘤1例,肾透明细胞癌1级2例、1～2级2例、2级5例,肾嫌色细胞癌1例,1例肾盂尿路上皮癌2～3级.失访1例,11例术后随访5～42个月,平均20个月,1例术后14个月出现对侧肾上腺转移,其余患者未见复发和转移. 结论在腔镜技术熟练的基础上,对肾肿瘤并肾静脉及腔静脉瘤栓的患者选择性行后腹腔镜下根治性肾切除及静脉取栓术安全可行,且手术可达到良好的肿瘤控制效果.
목적 탐토후복강경하근치성신절제병신정맥급강정맥취전술적가행성급수술효과. 방법 2008년11월지2012년3월수치신종류반정맥류전환자12례(우측3례,좌측9례).CT검사우신정맥내충영결손3례,2례략돌입강정맥내,1례류전첨부체우신정맥、강정맥교계처；좌신정맥류전첨부위우신장여복주동맥간5례,기과우복주동맥상혹과과복주동맥단미진입강정맥4례.전마하행후복강경하근치성신절제급정맥취전술.수술방치4개천자투관.우신종류환자절단우신동맥후유리강정맥화신정맥,혈관조단겸부분조단강정맥,절개취전.좌신종류환자절단좌신동맥후유리좌신정맥,필요시유리부분장계막상동맥、복주동맥화하강정맥,확대공간직지가치입혈관조단겸. 결과 복강경하완성수술11례,2례우신정맥류전장도분별위2.5 cm화3.7cm,9례좌신정맥류전장도2.0～7.5 cm,평균4.1 cm.중전개방수술1례.환자술후회복량호,술후4～11 d,평균7d출원.병리보고신상피양혈관평활기지방류1례,신투명세포암1급2례、1～2급2례、2급5례,신혐색세포암1례,1례신우뇨로상피암2～3급.실방1례,11례술후수방5～42개월,평균20개월,1례술후14개월출현대측신상선전이,기여환자미견복발화전이. 결론 재강경기술숙련적기출상,대신종류병신정맥급강정맥류전적환자선택성행후복강경하근치성신절제급정맥취전술안전가행,차수술가체도량호적종류공제효과.
Objective To evaluate the feasibility of retroperitoneal laparoscopic radical nephrectomy and thrombectomy for renal tumor with renal vein and vena cava thrombus.Methods Twelve cases of renal tumor with renal vein and vena cava thrombus were reported.Contrast-enhanced CT showed renal tumor extended to renal vein and vena cava in two cases,and filling defects were found in right or left renal vein in ten cases.All the patients received retroperitoneal laparoscopic radical nephrectomy and thrombectomy.Four trocars were placed during the procedure,early arterial division and "milking" of the thrombus away from the inferior vena cava may facilitate laparoscopic surgery,a laparoscopic clamp was used to occlude the vena cava partially containing the thrombus in two cases.Hem-o-lok was used to dissect the renal vein for left renal tumors.During the operation,inferior mesenteric artery,abdominal aorta and inferior vena cava were mobilized in order to expand the operating space.Results One patient was conver~d to open procedure.The two right tumor thrombi were 2.5 cm and 3.7 cm,respectively.The mean length of left tumor thrombi was 4.1 cm (2.0-7.5 cm).Post-operative pathology showed renal epithelioid angiomyolipoma in one patient,clear cell carcinoma in 9 cases (grade 1 in 2 cases,grade 1-2 in 2 cases,grade 2 in 5 cases),chromophobe carcinoma in 1 case and renal pelvic urothelial carcinoma in 1 case.Mean hospital stay was 7 d (4-11 d).Contralateral adrenal metastasis occurred in one case 14 months after surgery.No tumor recurrence or metastasis occurred with a mean follow-up of 20 months (5-42 months) for others.Conclusion Retroperitoneal laparoscopic radical nephrectomy and thrombectomy can be applied safely and effectively with adherence to proper techniques in carefully selected patients.