Martin George Lee, Castle Erik P, Martin Aaron D, Desai Premal J, Lallas Costas D, Ferrigni Robert G, Andrews Paul E
Department of Urology, Mayo Clinic, Phoenix, Arizona, USA.
J Endourol. 2008 Aug;22(8):1681-5. doi: 10.1089/end.2008.0035.
We present our experience with laparoscopic radical nephrectomy for T(3b) disease focusing on thrombus within the vena cava.
A total of 14 patients with T(3b) disease were identified from a retrospective laparoscopic renal cancer database from 2000 to 2007. Patient demographics, clinical stage, preoperative imaging, intraoperative parameters, final pathology, and postoperative course were analyzed. In patients with a large tumor thrombus, the infraumbilical extraction excision was performed early and a gel port was placed. This was used when laparoscopic milking or determination of the distal extent of the tumor thrombus was difficult.
Preoperative imaging identified T(3b) disease in all but four patients. Four patients had caval involvement seen on imaging, with one extending well above 2 to 3 cm above the renal vein. Of the 14 patients, procedures in 13 were completed laparoscopically. There was one conversion early in the experience because of a positive frozen section of the renal vein; however, additional vein and caval margins were negative. There was one complication-a pulmonary embolism 5 days postoperatively, managed with anticoagulation, with no disease recurrence 4 years later.
In patients with T(3b) disease, laparoscopy is feasible and safe. Using advanced laparoscopic techniques to milk the tumor thrombus into the proximal renal vein with laparoscopic vascular instruments is critical to success in a purely laparoscopic thrombectomy. Placement of a gel port in the extraction incision early in the procedure may aid in hand-milking of the tumor thrombus into the renal vein in cases of extensive inferior vena cava involvement.
我们介绍腹腔镜根治性肾切除术治疗T(3b)期疾病的经验，重点关注下腔静脉内的血栓。
从2000年至2007年的回顾性腹腔镜肾癌数据库中识别出14例T(3b)期疾病患者。分析患者的人口统计学资料、临床分期、术前影像学检查、术中参数、最终病理结果及术后病程。对于有巨大肿瘤血栓的患者，早期行脐下取出切除术并放置凝胶端口。当腹腔镜挤压或确定肿瘤血栓远端范围困难时使用此端口。
除4例患者外，术前影像学检查均确诊为T(3b)期疾病。4例患者影像学检查显示有腔静脉受累，其中1例延伸至肾静脉上方2至3厘米以上。14例患者中，13例手术通过腹腔镜完成。在经验早期有1例因肾静脉冰冻切片阳性而中转；然而，额外的静脉和腔静脉切缘为阴性。有1例并发症——术后5天发生肺栓塞，经抗凝治疗，4年后无疾病复发。
对于T(3b)期疾病患者，腹腔镜手术可行且安全。使用先进的腹腔镜技术用腹腔镜血管器械将肿瘤血栓挤压至肾静脉近端是单纯腹腔镜血栓切除术成功的关键。在手术早期于取出切口处放置凝胶端口，对于下腔静脉广泛受累的病例，可能有助于将肿瘤血栓手动挤压至肾静脉。
