腹腔镜根治性肾切除术和肿瘤栓子切除术中转开放手术：病因分析、临床特征和治疗策略。
Laparoscopic conversion to open surgery in radical nephrectomy and tumor thrombectomy: causal analysis, clinical characteristics, and treatment strategies.
机构信息
Department of Urology, Peking University Third Hospital, 49 North Garden Rd, Haidian District, Beijing, P.R. China.
Ultrasound diagnosis Department of Peking University Third Hospital, Beijing, 100083, China.
出版信息
BMC Surg. 2020 Aug 13;20(1):185. doi: 10.1186/s12893-020-00845-1.
BACKGROUND
We aimed to explore the causal analysis, clinical characteristics and treatment strategies of laparoscopic conversion to open approach (LCTOA) in radical nephrectomy and tumor thrombectomy.
METHODS
We included all patients with Mayo level I-III renal tumors with inferior vena cava (IVC) tumor thrombus who underwent laparoscopic radical nephrectomy and tumor thrombectomy as the first choice from May 2015 to July 2019.
RESULTS
There were 70 cases of renal tumor with IVC tumor thrombus treated with a laparoscopic approach as the first choice; 31 Mayo level I, 30 Mayo level II, and 9 Mayo level III. A completely laparoscopic approach was performed in 51 cases (72.9%), and 19 cases (27.1%) underwent active or passive LCTOA. The LCTOA group had higher median preoperative serum creatinine (110.0 μmol/L vs 92.0 μmol/L; P = 0.026), longer postoperative hospital stay (9 days vs 7 days; P = 0.008), longer median operation time (374 min vs 311 min; P = 0.017), higher median intraoperative hemorrhage volume (1300 vs 600 ml; P = 0.020), and higher proportion of male patients (94.7% vs 66.7%; P = 0.016) vs the completely laparoscopic group, respectively. Although preoperative serum creatinine and gender were risk factors in the univariate analysis, multivariate analysis revealed no independent risk factors for LCTOA. We divided the reasons for LCTOA into active conversion and passive conversion; 4 (21.1%) cases underwent active conversion, and 15 (78.9%) underwent passive conversion. Most of the patients undergoing passive conversion had multiple concurrent risk factors, among which perirenal adhesion (30.9%), organ invasion (16.4%), and IVC adhesion (25.5%) were the most common. Fourteen (73.7%) cases underwent renal treatment, and 5 (26.3%) cases underwent tumor thrombus treatment.
CONCLUSIONS
The LCTOA group had a higher median preoperative serum creatinine concentration, longer hospital stay, longer median operation time, and higher median intraoperative hemorrhage volume. However, none of the predictors in our study was an independent risk factor for LCTOA. Perirenal adhesion, organ invasion, and IVC adhesion were the most common causes of LCTOA. Considering the limitations of this study, studies with large sample sizes are required to validate our conclusions.
背景
我们旨在探讨腹腔镜根治性肾切除术和肿瘤栓子切除术中转开腹（LCTOA）的因果分析、临床特征和治疗策略。
方法
我们纳入了 2015 年 5 月至 2019 年 7 月所有采用腹腔镜作为首选治疗方案的 Mayo 分级 I-III 级肾肿瘤伴下腔静脉（IVC）肿瘤栓子的患者。
结果
共 70 例肾肿瘤伴 IVC 肿瘤栓子患者采用腹腔镜方法作为首选治疗方法；其中 Mayo 分级 I 级 31 例，II 级 30 例，III 级 9 例。51 例（72.9%）患者行完全腹腔镜手术，19 例（27.1%）行主动或被动 LCTOA。LCTOA 组术前血清肌酐中位数更高（110.0μmol/L vs 92.0μmol/L；P=0.026），术后住院时间更长（9 天 vs 7 天；P=0.008），手术时间中位数更长（374 分钟 vs 311 分钟；P=0.017），术中出血量中位数更高（1300ml vs 600ml；P=0.020），男性患者比例更高（94.7% vs 66.7%；P=0.016），与完全腹腔镜组相比。虽然术前血清肌酐和性别在单因素分析中是危险因素，但多因素分析显示 LCTOA 无独立危险因素。我们将 LCTOA 的原因分为主动转换和被动转换；其中 4 例（21.1%）行主动转换，15 例（78.9%）行被动转换。大多数行被动转换的患者同时存在多种危险因素，其中最常见的是肾周粘连（30.9%）、器官侵犯（16.4%）和 IVC 粘连（25.5%）。14 例（73.7%）行肾脏治疗，5 例（26.3%）行肿瘤栓子治疗。
结论
LCTOA 组术前血清肌酐浓度中位数较高，住院时间较长，手术时间中位数较长，术中出血量中位数较高。然而，我们研究中的预测因素均不是 LCTOA 的独立危险因素。肾周粘连、器官侵犯和 IVC 粘连是 LCTOA 最常见的原因。考虑到本研究的局限性，需要更大样本量的研究来验证我们的结论。
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