Pautler Stephen E, Choyke Peter L, Pavlovich Christian P, Daryanani Kailash, Walther McClellan M
Urological Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA.
J Urol. 2002 Oct;168(4 Pt 1):1352-5. doi: 10.1016/S0022-5347(05)64447-3.
Adrenal cortical sparing surgery is a relatively new approach to adrenal tumors. Laparoscopic partial nephrectomy is a technically feasible but challenging operation. We describe the use of intraoperative ultrasound to facilitate laparoscopic partial nephrectomy in a population with a hereditary predisposition to multifocal pheochromocytoma.
All patients underwent a history, physical examination, serum and urine catecholamine determinations, abdominal computerized tomography-magnetic resonance imaging and metaiodobenzylguanidine scan. The adrenal gland was exposed using a standard 3 or 4 port approach. Intraoperative ultrasound was performed using a 7.5 MHz. 10 mm. transducer placed through a 12 mm. port. After imaging the whole gland and adjacent structures partial adrenalectomy was performed based on intraoperative ultrasound images using a harmonic scalpel or alternatively using a cut and sew technique that provided a 5 mm. margin. Tumors were removed intact and sent for pathological examination.
Since 1998, 11 patients have undergone laparoscopic partial adrenalectomy. Intraoperative ultrasound was performed in 7 patients with suspected multiple adrenal masses, including 4 and 3 who underwent unilateral and bilateral laparoscopic partial nephrectomy, respectively. Six of the 7 patients had germline defects in the von Hippel-Lindau disease gene and 1 had no identifiable alteration in the von Hippel-Lindau disease or RET gene. A solitary tumor was identified in 3 cases and multiple lesions were noted in 4. In 1 case intraoperative ultrasound localized a tumor not identified on preoperative imaging that was not readily visible via laparoscopy. Intraoperative ultrasound guided surgical dissection in all cases and identified an extra-adrenal mass in 1 patient with bilateral adrenal masses. There were no complications due to intraoperative ultrasound and no conversions to open surgery. Mean operative time was 335 minutes and mean estimated blood loss was 179 ml. Histological study demonstrated pheochromocytoma in 14 lesions and the extra-adrenal mass proved to be a splenic rest. At short-term followup no recurrences have been noted. All patients retained sufficient adrenal cortical function to avoid steroid replacement therapy.
Laparoscopic ultrasound differentiates normal adrenal parenchyma from adrenal tumors and facilitates laparoscopic partial adrenalectomy.
肾上腺皮质保留手术是一种相对较新的肾上腺肿瘤治疗方法。腹腔镜部分肾切除术是一项技术上可行但具有挑战性的手术。我们描述了在具有多灶性嗜铬细胞瘤遗传易感性的人群中，使用术中超声辅助腹腔镜部分肾切除术的情况。
所有患者均接受了病史采集、体格检查、血清和尿儿茶酚胺测定、腹部计算机断层扫描 - 磁共振成像以及间碘苄胍扫描。采用标准的三孔或四孔法暴露肾上腺。使用7.5兆赫、10毫米的探头通过12毫米的端口进行术中超声检查。在对整个腺体及相邻结构成像后，根据术中超声图像，使用谐波手术刀或采用提供5毫米切缘的切割缝合技术进行部分肾上腺切除术。肿瘤完整切除并送去做病理检查。
自1998年以来，11例患者接受了腹腔镜部分肾上腺切除术。7例疑似肾上腺多发肿块的患者进行了术中超声检查，其中4例和3例分别接受了单侧和双侧腹腔镜部分肾切除术。7例患者中有6例存在冯·希佩尔 - 林道病基因的种系缺陷，1例在冯·希佩尔 - 林道病或RET基因中未发现可识别的改变。3例发现单个肿瘤，4例发现多个病灶。1例患者术中超声发现了术前影像学未发现且腹腔镜下不易看到的肿瘤。术中超声在所有病例中均指导了手术分离，并在1例双侧肾上腺肿块患者中发现了肾上腺外肿块。未发生因术中超声导致的并发症，也没有转为开放手术的情况。平均手术时间为335分钟，平均估计失血量为179毫升。组织学研究显示14个病灶为嗜铬细胞瘤，肾上腺外肿块经证实为脾残余组织。短期随访未发现复发。所有患者均保留了足够的肾上腺皮质功能，无需进行类固醇替代治疗。
腹腔镜超声可区分正常肾上腺实质与肾上腺肿瘤，有助于腹腔镜部分肾上腺切除术。
