CAJ | 학술논문

目的探讨机器人辅助腹腔镜下根治性肾切除联合下腔静脉瘤栓取出术的安全性和可行性.方法 2013年5月至2014年3月收治6例肾癌伴下腔静脉瘤栓患者,均为男性.年龄45～ 69岁,中位年龄59岁.肿瘤位于右侧4例,左侧2例.Ⅰ级瘤栓2例、Ⅱ级瘤栓4例.腔静脉瘤栓长度为1 ～7 cm,平均3.5 cm.其中1例术前曾行1个月新辅助靶向药物治疗,4例术前行患侧肾动脉栓塞术.6例均行机器人辅助腹腔镜下根治性肾切除联合下腔静脉瘤栓取出术.术中环形游离下腔静脉、患肾静脉、对侧肾静脉及部分腰静脉.Ⅱ级瘤栓患者游离出肝短静脉和右侧肾上腺中央静脉,并将肝短静脉和右侧肾上腺中央静脉及腰静脉结扎离断,以保证止血带能安全地在瘤栓的上、下端阻断下腔静脉.依次阻断下腔静脉上端、对侧肾静脉(左肾癌患者在阻断右肾静脉的同时需阻断右肾动脉)和下腔静脉下端后,切开下腔静脉,完整取出瘤栓,缝合下腔静脉.最后按根治性肾切除术原则切除患肾.结果本组6例手术均顺利完成,无中转开放手术.手术时间90～195 min,平均120 min.术中估计出血量100～400 ml,平均200 ml,均未输血.术中下腔静脉阻断时间7～15 min,平均11 min.术后均未放置引流管.术后1～3d(平均2d)拔除尿管并下床活动.术后4～7d(平均5d)出院.术后病理诊断均为透明细胞癌,其中Fuhrman分级Ⅱ级3例,Ⅱ～Ⅲ级1例,Ⅲ级2例.术中、术后无严重并发症发生.随访1～13个月,平均6个月,无疾病进展及死亡病例.结论机器人辅助腹腔镜下根治性肾切除联合下腔静脉瘤栓取出术安全、可行,为可切除的肾癌伴静脉瘤栓患者提供了一种有效的微创治疗方法.但评价该术式的疗效和总体生存情况需要进一步、更大样本的研究和长时间的随访.
목적 탐토궤기인보조복강경하근치성신절제연합하강정맥류전취출술적안전성화가행성.방법 2013년5월지2014년3월수치6례신암반하강정맥류전환자,균위남성.년령45～ 69세,중위년령59세.종류위우우측4례,좌측2례.Ⅰ급류전2례、Ⅱ급류전4례.강정맥류전장도위1 ～7 cm,평균3.5 cm.기중1례술전증행1개월신보조파향약물치료,4례술전행환측신동맥전새술.6례균행궤기인보조복강경하근치성신절제연합하강정맥류전취출술.술중배형유리하강정맥、환신정맥、대측신정맥급부분요정맥.Ⅱ급류전환자유리출간단정맥화우측신상선중앙정맥,병장간단정맥화우측신상선중앙정맥급요정맥결찰리단,이보증지혈대능안전지재류전적상、하단조단하강정맥.의차조단하강정맥상단、대측신정맥(좌신암환자재조단우신정맥적동시수조단우신동맥)화하강정맥하단후,절개하강정맥,완정취출류전,봉합하강정맥.최후안근치성신절제술원칙절제환신.결과 본조6례수술균순리완성,무중전개방수술.수술시간90～195 min,평균120 min.술중고계출혈량100～400 ml,평균200 ml,균미수혈.술중하강정맥조단시간7～15 min,평균11 min.술후균미방치인류관.술후1～3d(평균2d)발제뇨관병하상활동.술후4～7d(평균5d)출원.술후병리진단균위투명세포암,기중Fuhrman분급Ⅱ급3례,Ⅱ～Ⅲ급1례,Ⅲ급2례.술중、술후무엄중병발증발생.수방1～13개월,평균6개월,무질병진전급사망병례.결론 궤기인보조복강경하근치성신절제연합하강정맥류전취출술안전、가행,위가절제적신암반정맥류전환자제공료일충유효적미창치료방법.단평개해술식적료효화총체생존정황수요진일보、경대양본적연구화장시간적수방.
Objective To investigate the safety and feasibility of robot assisted laparoscopic radical nephrectomy with inferior vena caval thrombectomy.Methods From 2013 May to 2014 March,six patients with renal cell carcinoma and inferior vena cava thrombus were admitted to our hospital.The six were all male with a median age of 59 years (range 45 to 69 years).Four cases had the tumor on the right side and two on the left side.The tumor embolism was level Ⅰ in 2 cases,level Ⅱ in 4 cases.The mean length of vena caval thrombus was 3.5 cm (range 1 to 7 cm).One case received one month of preoperative neoadjuvant targeted therapy.Four cases received renal arterial embolization on the affected side preoperatively.These six patients underwent robot assisted laparoscopic radical nephrectomy with inferior vena caval thrombectomy.Bilateral renal vein,inferior vena cava (IVC) and part of lumbar vein were all annular dissociated.Accessory hepatic vein and right adrenal central vein also required isolation and ligation in cases with level Ⅱ thrombus in order to guarantee safe blockings on the IVC.After the sequential blocking of IVC upper end,contralateral renal vein (for the left cases,right renal artery was needed to be blocked at the same time) and IVC lower end,the IVC was incised and the thrombus was en bloc removed.Then the IVC was sutured.Finally,radical nephrectomy was performed on the ipsilateral kidney.Results The operations were all successfully performed without conversion to open surgery.The mean operation time was 120 min (range 90 to 195 min) and the mean intraoperative estimated blood loss was 200 ml (range 100 to 400 ml).There were no tranfusion needed during the operation.The mean IVC blocking time was 1 1 min (range 7 to 15 min).No drainage was required on all of the six cases.After the urinary catheter was removed two days after operation,patient was encouraged to ambulate out of bed.The mean postoperative hospital stay was 5 days (range:4 to 7 days).Pathology analysis confirmed all tumors were clear cell renal cell carcinoma with Fuhrman level Ⅱ on 3 cases,Fuhrman level Ⅱ to Ⅲ on 1 case and Fuhrman level Ⅲ on 2 cases.During the perioperative period,there were no severe complications.All the cases received targeted therapy postoperatively and there were no death or recurrence occurring in the follow-up with a median time of six months (1 to 13 months).Conclusions Robot assisted laparoscopic radical nephrectomy with inferior vena caval thrombectomy is safe and feasible for surgeons with robot operation experience.The operation provides an optional minimally invasive treatment for patients with resectable renal cell carcinoma with inferior vena caval thrombus.However,the therapeutic effect and the overall survival rate require further investigation with larger sample and longer follow-up.