机器人腹腔镜下左侧肾癌合并癌栓的技术改进：免介入栓塞7例报告（“大家泌尿网”观看手术视频）

A modified surgical technique of robot-assisted inferior vena cava thrombectomy for patients with left renal cell carcinoma and tumor emboli: a report of 7 cases eliminating preoperative interventional embolization

摘要

目的 探讨机器人腹腔镜治疗左侧肾癌合并癌栓时优先离断左肾动脉这一技术改进的安全性和可行性。方法 回顾性分析2021年12月-2024年10月于郑州大学第一附属医院完成的7例机器人下腔静脉癌栓取栓术+根治性左肾切除术患者的临床资料。术中均采取先取栓再切除肾脏的策略：患者先取左侧卧位，从右侧入路越过下腔静脉和腹主动脉，优先离断左肾动脉，再离断下腔静脉属支后完成取栓术，然后改为右侧卧位行左肾根治性切除术。结果 影像学检查提示7例左肾肿瘤中位直径83（46～99）mm、下腔静脉癌栓长度49（21～91）mm，Mayo分级Ⅰ级2例、Ⅱ级4例、Ⅲ级1例。所有手术均成功完成，中位手术时间248（201～331）min、术中失血量500（200～1000）mL，6例术中输血。中位术后重症监护室中转时间1（1～4）d、引流管拔除时间6（5～12）d。术后血肌酐明显升高5例，其中4例1周后恢复正常，1例肾功能不全（血肌酐166 μmol/L）；术后出现乳糜瘘1例、下肢静脉新发血栓3例。术后病理提示肾透明细胞癌6例，小眼畸形转录因子（MiT）家族易位性肾细胞癌1例。7例患者中位随访时间17（1～35）个月，5例无瘤存活，2例肺转移并腹膜后转移患者口服阿昔替尼联合免疫治疗，均带瘤存活。结论 左侧肾癌合并癌栓在左侧卧位下行机器人腹腔镜下取栓术时越过下腔静脉和腹主动脉优先离断左肾动脉是安全可行的。

Abstract

Objective To explore the safety and feasibility of the disconnection of the left renal artery preferentially during robot-assisted inferior vena cava (IVC) thrombectomy for patients with left renal cell carcinoma and tumor emboli. Methods Clinical data of 7 patients who underwent robot-assisted IVC thrombectomy and radical nephrectomy in the First Affiliated Hospital of Zhengzhou University during Dec. 2021 and Oct. 2024 were retrospectively analyzed. Thrombectomy was performed first, followed by nephrectomy. The “IVC-first, kidney-last” robotic technique was developed to minimize chances of IVC thrombus. When patients in left lateral decubitus position, the left renal artery was severed from the right side through the inferior vena cava and abdominal aorta. After removal of thrombus from IVC was completed, patients changed to the right lateral position to complete radical left nephrectomy. Results Imaging examinations revealed that the median diameter of the renal cell carcinomas was 83 (46-99) mm; the median length of the inferior vena cava cancerous emboli was 49 (2-91) mm. According to the Mayo classification, the cancerous emboli were grade Ⅰ in 2 cases, grade Ⅱ in 4 cases, and grade Ⅲ in 1 case. All surgeries were successful. The median operation time was 248 (201-331) minutes, blood loss 500 (200-1000) mL, and 6 cases required intraoperative blood transfusion. The median time for transition into the intensive care unit was 1 (1-4) days, and drainage tube removal 6 (5-12) days. Serum creatinine increased significantly in 5 cases, 4 of which returned to normal after 1 week, but 1 had renal insufficiency (creatinine 166 μmol/L). Chylous fistula occurred in 1 patient, and lower extremity venous thrombosis developed in 3 patients. Pathological examinations indicated 6 cases of renal cell carcinoma and 1 case of MiT family translocation renal cell carcinoma. During the median follow-up of 17 (1-35) months, 5 cases were tumor-free, while 2 had lung and retroperitoneal metastases. They received targeted therapy of axitinib combined immunotheraphy and lived with tumors. Conclusion In the left lateral position for left renal cell carcinoma with cancerous emboli, robot-assisted laparoscopic thrombectomy by crossing the inferior vena cava and abdominal aorta and disconnecting the left renal artery first is safe and feasible.

关键词

肾肿瘤 / 左侧 / 介入栓塞 / 下腔静脉癌栓 / 肾动脉 / 机器人辅助腹腔镜 / 根治性肾切除术

Key words

renal neoplasm / left side / interventional embolization / inferior vena cava cancerous emboli / renal artery / robot-assisted laparoscopy / radical nephyectomy

参考文献

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基金资助

河南省科技攻关项目(242102311074)

河南省医学科技攻关项目(SBGJ202402051)