石奇剛 孫永恒 任艷勝

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腹腔鏡下保留腎單位手術(shù)與開放手術(shù)治療腎腫瘤的療效比較

石奇剛 孫永恒 任艷勝

目的 比較腹腔鏡下保留腎單位手術(shù)(RLNSS)與開放手術(shù)(ONSS)治療腎腫瘤(RT)的療效。方法 選取腎腫瘤患者90例，其中采用RLNSS治療的45例患者為腔鏡組，采用ONSS進(jìn)行治療的45例為開放組，記錄并比較兩組患者的手術(shù)時(shí)間、術(shù)中出血量、術(shù)中腎臟缺血阻斷時(shí)間、住院天數(shù)、術(shù)后腸道功能恢復(fù)時(shí)間、術(shù)前及術(shù)后復(fù)查的肌酐水平、術(shù)后并發(fā)癥發(fā)生情況。結(jié)果 腔鏡組和開放組患者在年齡、性別、腫瘤大小、腫瘤位置、TNM分期、術(shù)前肌酐等方面差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。腔鏡組良性腫瘤5例，惡性腫瘤40例；開放組良性腫瘤6例，惡性腫瘤39例，兩組對(duì)比差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。腔鏡組平均手術(shù)時(shí)間(128.55±13.56)min，開放組為(127.86±10.41)min，兩組對(duì)比差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。腔鏡組術(shù)中平均出血量為(200.86±20.45)ml，開放組為(362.20±29.42)ml，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。腔鏡組患者平均腎臟缺血阻斷時(shí)間為(29.45±2.50)min，明顯高于開放組的(19.95±2.64)min，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。術(shù)后復(fù)查肌酐水平，兩組比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。腔鏡組患者平均住院天數(shù)為(7.56±1.25)d,明顯短于開放組的(10.50±1.56)d，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。腔鏡組術(shù)后腸道功能恢復(fù)時(shí)間為(1.10±0.80)d，明顯短于開放組的(2.20±1.32)d。腔鏡組患者胸膜損傷2例，開放組胸膜損傷5例，術(shù)中大出血8例，并發(fā)癥發(fā)生率為28.89%，明顯高于腔鏡組的4.44%，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。術(shù)后隨訪過程中，兩組患者均未發(fā)現(xiàn)RT復(fù)發(fā)和轉(zhuǎn)移。結(jié)論 RLNSS在腎腫瘤的治療中有安全性高、術(shù)中出血量少、并發(fā)癥發(fā)生率低等優(yōu)點(diǎn)，術(shù)后無RT復(fù)發(fā)和轉(zhuǎn)移，是一種比ONSS更加有效的治療方法。

腹腔鏡；保留腎單位；腎腫瘤；開放手術(shù)

(ThePracticalJournalofCancer,2017,32:451～454)

腎腫瘤是泌尿系統(tǒng)常見的腫瘤之一，多為惡性腫瘤，主要包括源自腎實(shí)質(zhì)的腎母細(xì)胞瘤、腎細(xì)胞癌和移行細(xì)胞乳頭狀腫瘤，其中腎母細(xì)胞瘤在嬰幼兒中發(fā)病率較高，約占嬰幼兒惡性腫瘤的五分之一[1-2]。根治性腎切除(radical nephrectomy,RN)最早應(yīng)用于對(duì)RT患者的治療，由于其療效顯著很快得到了患者的廣泛認(rèn)可。隨著診斷技術(shù)的不斷進(jìn)步，RT患者早期就能夠被診斷出來，在這種情況下，ONSS出現(xiàn)并得到了快速發(fā)展[3-4]。RN與ONSS的結(jié)合可以對(duì)RT患者進(jìn)行有效的治療，極大地提高了腎腫瘤的治愈率并降低了并發(fā)癥的發(fā)生率。本次研究通過采用ONSS和RLNSS分別對(duì)腎腫瘤患者進(jìn)行治療，將術(shù)后患者病理情況比較，評(píng)估RLNSS在治療腎腫瘤方面的功效，為腎腫瘤治療提出更加有效的治療方案。

1 資料與方法

1.1 一般資料

選取2013年1月至2015年12月間在我醫(yī)院住院治療的腎腫瘤患者90例，其中采用RLNSS治療的45例患者為腔鏡組，男性22例，女性23例，平均年齡(43.35±3.25)歲，年齡17～58歲，采用ONSS進(jìn)行治療的45例為開放組，男性24例，女性21例，平均年齡(46.45±2.75)歲，年齡18～63歲。兩組患者年齡、性別間差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。本研究獲我院倫理委員會(huì)批準(zhǔn)，患者或近親屬對(duì)研究方案簽署知情同意書。

1.2 患者入選標(biāo)準(zhǔn)

患者經(jīng)檢查診斷為單發(fā)局限性腎腫瘤，腫瘤直徑≤4 cm；腫瘤未發(fā)生局部轉(zhuǎn)移；無其他腎病。

1.3 排除標(biāo)準(zhǔn)

患有其他腫瘤如：腎轉(zhuǎn)移癌、尿路上皮癌等； RT已經(jīng)局部或遠(yuǎn)處轉(zhuǎn)移；腫瘤直徑>4 cm；患者不同意參與此次研究。

1.4 手術(shù)方法

腔鏡組采用后腹腔鏡下腎腫瘤保留腎單位手術(shù)，開放組采用開放保留腎單位手術(shù)，記錄并比較兩組患者的手術(shù)時(shí)間、術(shù)中出血量、術(shù)中腎臟缺血阻斷時(shí)間、住院天數(shù)、術(shù)后腸道功能恢復(fù)時(shí)間、術(shù)前及術(shù)后復(fù)查的肌酐水平、術(shù)后并發(fā)癥發(fā)生情況。術(shù)后對(duì)患者進(jìn)行回訪，觀察RT的復(fù)發(fā)情況。

1.5 隨訪方法

患者術(shù)后1年內(nèi)每3個(gè)月進(jìn)行一次隨訪，術(shù)后第2、3年每6個(gè)月隨訪一次，記錄患者的肌酐水平、腎功能及RT轉(zhuǎn)移復(fù)發(fā)情況，并統(tǒng)計(jì)患者的3～36個(gè)月的術(shù)后生存率。

1.6 統(tǒng)計(jì)學(xué)方法

應(yīng)用SPSS 20.0統(tǒng)計(jì)學(xué)軟件對(duì)實(shí)驗(yàn)所得所有數(shù)據(jù)進(jìn)行處理和分析，組內(nèi)和組間數(shù)據(jù)比較采用t檢驗(yàn)，P<0.05視為差異具有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

2.1 兩組患者一般資料比較

腔鏡組和開放組患者在年齡、性別、腫瘤大小、腫瘤位置、術(shù)前肌酐等方面差異無統(tǒng)計(jì)學(xué)意義(P>0.05)(表1)。

表1 兩組患者一般資料比較

2.2 兩組患者術(shù)中指標(biāo)比較

腔鏡組平均手術(shù)時(shí)間為(128.55±13.56)min，開放組為(127.86±10.41)min，兩組對(duì)比差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。腔鏡組術(shù)中平均出血量(200.86±20.45)ml，開放組為(362.20±29.42)ml，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。腔鏡組患者平均腎臟缺血阻斷時(shí)間為(29.45±2.50)min，明顯高于開放組的(19.95±2.64)min，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。

2.3 兩組患者術(shù)后指標(biāo)比較

術(shù)后肌酐水平比較，兩組差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。腔鏡組患者平均住院天數(shù)為(7.56±1.25)d,明顯短于開放組的(10.50±1.56)d，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。腔鏡組術(shù)后腸道功能恢復(fù)時(shí)間為(1.10±0.80)d，明顯短于開放組的(2.20±1.32)d，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)(表2)。

表2 兩組術(shù)后指標(biāo)比較

2.4 兩組患者術(shù)后并發(fā)癥發(fā)生情況比較

腔鏡組患者胸膜損傷2例，術(shù)中無大出血；開放組胸膜損傷5例，術(shù)中大出血8例，并發(fā)癥發(fā)生率為28.89%，明顯高于腔鏡組的4.44%，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。

2.5術(shù)后隨訪

隨訪36個(gè)月，無死亡患者，腔鏡組和開放組均未出現(xiàn)腫瘤復(fù)發(fā)及轉(zhuǎn)移現(xiàn)象。

3 討論

早些年間由于醫(yī)療技術(shù)落后，手術(shù)條件差，導(dǎo)致腎腫瘤患者的死亡率保持在較高水平，這對(duì)人們的身體健康和生活質(zhì)量都會(huì)造成嚴(yán)重的不良影響[5-7]。保留腎單位手術(shù)在這種情況下不能得到快速的發(fā)展，直到上個(gè)世紀(jì)五十年代，保留腎單位手術(shù)才開始應(yīng)用于對(duì)腎腫瘤直徑較小患者的治療[8-10]。腎臟小腫瘤的診斷困難，不能及時(shí)的發(fā)現(xiàn)治療，RN的出現(xiàn)為腎腫瘤的治療提供了1種更加有效的方法，得到了迅速發(fā)展[11-12]。但并不是所有腎腫瘤患者都能夠采用此種方法治療，RN的實(shí)施會(huì)極大提高患者術(shù)后腎功能衰竭的概率，因此術(shù)前應(yīng)該對(duì)患者的病情進(jìn)行全面的評(píng)估[13-14]。1992年腹腔鏡手術(shù)出現(xiàn)，大量研究表明RLNSS不僅能夠使患者的腎組織保留，還可以減少手術(shù)對(duì)患者的創(chuàng)傷，這一手術(shù)方式也得到了醫(yī)生和患者的認(rèn)可，目前RLNSS已經(jīng)廣泛應(yīng)用于國內(nèi)外對(duì)腎腫瘤的治療[15-16]。

本次研究通過采用ONSS和RLNSS分別對(duì)腎腫瘤患者進(jìn)行治療，將術(shù)后患者病理情況比較，結(jié)果發(fā)現(xiàn)：腔鏡組和開放組患者在年齡、性別、腫瘤大小、腫瘤位置、TNM分期、術(shù)前肌酐等方面差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。術(shù)后兩組患者病理比較：腔鏡組良性腫瘤5例，惡性腫瘤40例；開放組良性腫瘤6例，惡性腫瘤39例，兩組對(duì)比差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。腔鏡組平均手術(shù)時(shí)間(128.55±13.56)min，開放組為(127.86±10.41)min，兩組對(duì)比差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。腔鏡組術(shù)中平均出血量(200.86±20.45)ml，開放組為(362.20±29.42)ml，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。腔鏡組患者平均腎臟缺血阻斷時(shí)間(29.45±2.50)min，明顯高于開放組的(19.95±2.64)分鐘，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。術(shù)后復(fù)查的肌酐水平比較，兩組對(duì)比差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。腔鏡組患者平均住院天數(shù)為(7.56±1.25)d明顯短于開放組的(10.50±1.56)d，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。腔鏡組術(shù)后腸道功能恢復(fù)時(shí)間為(1.10±0.80)d，明顯短于開放組的(2.20±1.32)d。腔鏡組患者胸膜損傷2例，開放組胸膜損傷5例，術(shù)中大出血8例，并發(fā)癥發(fā)生率為28.89%，明顯高于腔鏡組的4.44%，差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。術(shù)后隨訪過程中，兩組患者均未發(fā)現(xiàn)RT復(fù)發(fā)和轉(zhuǎn)移。RLNSS這一手術(shù)方式保存患者的腎組織，患者的腎功能無太大損傷，因此患者的各方面病理情況都好于ONSS。ONSS和RLNSS都是有效治療腎腫瘤的手術(shù)方式，但是與ONSS相比，RLNSS在腎腫瘤的治療中有安全性高、術(shù)中出血量少、并發(fā)癥發(fā)生率低等優(yōu)點(diǎn)，降低了患者腎功能衰竭的概率，因此RLNSS在腎腫瘤的治療中療效更加顯著，患者的治愈率更高。

綜上所述，RLNSS是1種比ONSS更加有效的治療腎腫瘤的手術(shù)方式，具有安全性高、術(shù)中出血量少、并發(fā)癥發(fā)生率低等優(yōu)點(diǎn)，有望被廣泛應(yīng)用于對(duì)腎腫瘤的臨床治療。

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(編輯：吳小紅)

Comparison of Nephron-sparing Surgery with Nephron-laparoscopic Surgery Versus Open Surgery for Renal Neoplasms

SHI Qigang,SUN Yongheng,REN Yansheng.

People’s Hospital of Puyang,Puyang,457000

Objective To compare the efficacy of laparoscopic surgery (RLNSS) and open surgery (ONSS) in the treatment of renal tumor (RT).Methods A total of 90 cases of patients with renal tumors were divided into 2 groups each with 45 cases.Laparoscopic group was treated with RLNSS,open group was treated by ONSS,the operation time,intraoperative blood loss,intraoperative renal ischemia time,blocking hospital stay,postoperative intestinal function recovery time,preoperative and postoperative serum creatinine levels,postoperative complications of the 2 groups were recorded and compared.Results There had no statistically significant difference between the 2 groups in age,gender,tumor size,tumor location,TNM staging,preoperative serum creatinine (P>0.05).Laparoscopic group had 5 cases of benign tumors,40 cases of malignant tumors;open group had 6 cases of benign tumors and 39 cases of malignant tumors,there had no significant difference between the 2 groups (P>0.05).The average operation time of laparoscopic group was (128.55+13.56) min,the open group was(127.86+10.41) min,there was no significant difference between the 2 groups (P>0.05).In laparoscopic group,the average amount of bleeding was(200.86+20.45) ml,the open group was(362.20+29.42) ml,the difference was statistically significant (P<0.05).The average kidney ischemia occlusion time in the observation group was(29.45+2.50) min,which was significantly higher than that of open group,(19.95+2.64) min,the difference was statistically significant (P<0.05).There was no significant difference between the 2 groups (P>0.05).The average hospital stay in the observation group was (7.56+1.25) d,which was significantly shorter than the open group,(10.50+1.56) d,the difference was statistically significant (P<0.05).Laparoscopic group,postoperative intestinal function recovery time was (1.10+0.80) d,which was significantly shorter than the open group,(2.20+1.32) d.2 cases in laparoscopic group had pleural injury,5 cases of open group had pleural injury,intraoperative hemorrhage was 8 cases,the complication rate was 28.89%,which was significantly higher than the laparoscopic group,4.44%,the difference was statisti cally significant (P<0.05).No RT recurrence and metastasis were found in the 2 groups during the follow-up.Conclusion RLNSS has the advantages of high safety,low blood loss and low complication rate in the treatment of renal tumor.It is a more effective method than ONSS for RT recurrence and metastasis.

Laparoscopy;Retention nephron (RT);Kidney neoplasms;Open surgery

457000 河南省濮陽市人民醫(yī)院

10.3969/j.issn.1001-5930.2017.03.030

R737.11

A

1001-5930(2017)03-0451-04

2016-10-09

2016-11-04)