腹腔镜保留肾单位手术治疗巨大肾血管平滑肌脂肪瘤的疗效与安全性

Efficacy and safety of laparoscopic nephron-sparing surgery for giant renal angio- myolipoma

摘要

目的：巨大肾血管平滑肌脂肪瘤的病例因肿瘤体积大、易破裂出血等因素，手术难度及风险较高。本文旨在探讨巨大肾血管平滑肌脂肪瘤行腹腔镜保留肾单位手术的有效性和安全性。方法：回顾性分析2012年1月至2025年9月于北京大学第三医院接受保留肾单位手术治疗的45例巨大（20∼74）肾血管平滑肌脂肪瘤患者的临床资料，男 11 例，女 34 例，年龄 10.3±2.2 岁，平均肿瘤最大直径（8.0∼15.4 cm）cm（180.6±55.7）。所有患者均行腹腔镜保留肾单位手术，人路包括经后腹腔（32 例）和经腹腔（13 例）。病理分类参考 2022 年世界卫生组织的标准。主要观察指标包括手术时长、肾动脉阻断时长、术后住院时长、手术并发症、术中出血量等。结果：45 例患者的手术均顺利完成，均完整切除瘤体并实现肾单位保留，其中 5 例中转开放手术。手术时长（86∼312 min）min （$21.9\pm 9.8\left)\text{ }\mathrm{m}\mathrm{i}\mathrm{n}\right(6\sim 40\text{ }\mathrm{m}\mathrm{i}\mathrm{n})$），肾动脉阻断时长（$6.2\pm 2.6\left)\text{  }\mathrm{d}\right(3\sim 14\text{ }\mathrm{d})$ ，术后住院时间（5.1±2.2 ，术后拔管时间（2∼14）d（3∼43 d）。术后组织病理均证实为肾血管平滑肌脂肪瘤且切缘均为阴性。1例术后出现肺部感染，1例术后出现肾功能不全。术后患者随访  ^Δ 个月，无肿瘤复发。结论：对于经过筛选的巨大肾血管平滑肌脂肪瘤病例施行保留肾单位手术，可在完整切除肿瘤、保证切缘阴性、避免并发症的基础上，有效保留肾功能。

Abstract

Objective：Giant renal angiomyolipoma（RAML），typically defined as having a maximum diameter of ⩾8 cm ，presents formidable surgical challenges and heightened clinical risks.These challen- ges primarily stem from the tumor＇s extensive volume，highly enriched but fragile vascularization，and significant susceptibility to spontaneous rupture and life-threatening hemorrhage.This study aims to com- prehensively evaluate the clinical effectiveness and safety of laparoscopic nephron-sparing surgery（NSS） for the management of these complex giant lesions. Methods：A retrospective analysis was performed on 45 patients with giant（40.9±14.1）RAML who received NSS at Peking University Third Hospital between January 2012 and September 2025.The cohort comprised 11 males and 34 females with a mean age of （23.7±4.0）years and a mean body mass index（BMI）of（kg/m²） 6-40 min.Preoperatively， 5 patients had a history of spontaneous hemorrhage，and 2 were pregnant.The mean maximum tumor diameter was（10.3 ± 2.2）cm，ranging from 8.0 to 15.4 cm.Surgical procedures included standard laparoscopy（39 cases）and Da Vinci robotic-assisted laparoscopy（6 cases），utilizing either a retro- peritoneal approach（32 cases，71.1％）or a transperitoneal approach（13 cases，28.9％）.Pathological diagnosis and differentiation were conducted in strict accordance with the 2022 World Health Organization （WHO）classification of tumors.Key outcome measures included operative time，warm ischemia time， estimated blood loss，postoperative complications，and length of postoperative hospital stay. Results：All the 45 operations were successfully completed with complete tumor resection and nephron preservation， although 5 cases required conversion to open surgery due to severe adhesions or bleeding.The operative time was（180.6 ± 55.7）min（range：86-312 min），the warm ischemia time was（21.9 ± 9.8）min （range： ⩽30 min）； 36 cases had a warm ischemia time (6.2±2.6) ，while a zero-ischemia technique was employed in 3 cases.The postoperative hospital stay was 5.1±2.2 days（range：3-14 days），and the time to drainage tube removal was（2-14）days（range： ⩾8 days）.Postoperative patho- logy confirmed RAML in all cases，and all surgical margins were negative.Postoperative complications included one case of pulmonary infection and one case of renal insufficiency.During a follow-up of 3 to 43 months，no tumor recurrence or significant loss of renal function was documented. Conclusion：NSS for selected patients with giant RAML is effective in preserving renal function while ensuring complete tumor resection，negative margins，and avoiding short-term and long-term complications.Robotic-assisted systems，in particular，offer distinct advantages in complex wound reconstruction and the reduction of surgical complications.

关键词

肾血管平滑肌脂肪瘤 / 保留肾单位手术 / 腹腔镜检查 / 治疗结果

Key words

Renal angiomyolipoma / Nephron-sparing surgery / Laparoscopy / Treatment outcome

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基金资助

国家自然科学基金(82273389)

国家自然科学基金(82473287)