Hayn Matthew H, Averch Timothy D, Jackman Stephen V
Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
Can J Urol. 2009 Aug;16(4):4770-3.
Surgical stress in patients with liver disease is associated with hepatorenal syndrome, coagulopathy, encephalopathy, sepsis, ARDS, and abnormalities of volume and electrolytes. These risks as well as the surgical difficulties associated with portal hypertension, varices, ascites, and thrombocytopenia limit the treatment options available to cirrhotic patients with renal masses. The decreased stress of laparoscopy may benefit patients with significant liver disease.
We performed a retrospective chart review of three patients with cirrhosis and renal masses who underwent laparoscopic renal surgery.
The mean patient age was 56 years old. Two patients had Child-Pugh class B cirrhosis and one had Child-Pugh class A cirrhosis. Two hand-assisted laparoscopic radical nephrectomies and one laparoscopic partial nephrectomy were performed via a transperitoneal approach. Relevant data for the radical nephrectomies includes: mass size 4.5 cm and 4.0 cm, operative time 145 and 230 minutes, estimated blood loss 25 cc and 150 cc, and postoperative hospitalization of 4 and 3 days, respectively. Data for the partial nephrectomy includes: mass size 1.3 cm, operative time 130 minutes, estimated blood loss 50 cc, and postoperative hospitalization of 2 days. No case required open conversion nor suffered postoperative complications. Final pathology revealed clear cell renal cell carcinoma, stage pT1a, Fuhrman grade 2/4 in two patients and sarcomatoid renal cell carcinoma, stage pT1b, Fuhrman grade 4/4 in one patient. Intraoperative findings included thickened peritoneum with dense vascular adhesions due to chronic ascites. Platelets and fresh frozen plasma were administered intraoperatively during the partial nephrectomy to prevent bleeding. A peritoneal drain was placed during one of the radical nephrectomies for postoperative monitoring of ascites volume.
Patients with cirrhosis and a renal mass represent challenging cases. With careful patient selection and management in conjunction with their hepatologist, laparoscopic renal surgery can be performed safely by experienced laparoscopists.
肝病患者的手术应激与肝肾综合征、凝血病、肝性脑病、脓毒症、急性呼吸窘迫综合征以及容量和电解质异常相关。这些风险以及与门静脉高压、静脉曲张、腹水和血小板减少相关的手术困难限制了患有肾肿块的肝硬化患者的治疗选择。腹腔镜检查应激的降低可能对患有严重肝病的患者有益。
我们对三名接受腹腔镜肾手术的肝硬化合并肾肿块患者进行了回顾性病历审查。
患者平均年龄为56岁。两名患者为Child-Pugh B级肝硬化，一名患者为Child-Pugh A级肝硬化。通过经腹途径进行了两例手辅助腹腔镜根治性肾切除术和一例腹腔镜部分肾切除术。根治性肾切除术的相关数据包括：肿块大小4.5厘米和4.0厘米，手术时间145分钟和230分钟，估计失血量25毫升和150毫升，术后住院时间分别为4天和3天。部分肾切除术的数据包括：肿块大小1.3厘米，手术时间130分钟，估计失血量50毫升，术后住院时间2天。无一例需要转为开放手术，也无术后并发症。最终病理显示两名患者为透明细胞肾细胞癌，pT1a期，Fuhrman分级2/4，一名患者为肉瘤样肾细胞癌，pT1b期，Fuhrman分级4/4。术中发现包括由于慢性腹水导致的腹膜增厚和密集的血管粘连。在部分肾切除术中术中给予血小板和新鲜冰冻血浆以防止出血。在其中一例根治性肾切除术中放置了腹腔引流管，用于术后监测腹水量。
肝硬化合并肾肿块的患者是具有挑战性的病例。通过与肝病专家一起仔细选择和管理患者，经验丰富的腹腔镜手术医生可以安全地进行腹腔镜肾手术。
