Service de chirurgie pédiatrique, CHU, Saint Etienne, France.
Service de chirurgie pédiatrique, Hôpital Armand Trousseau - AP-HP, Sorbonne Université, Paris, France.
Ann Surg Oncol. 2024 Dec;31(13):9248-9255. doi: 10.1245/s10434-024-16057-3. Epub 2024 Sep 2.
Total nephrectomies for the treatment of Wilms' tumor (WT) are more and more performed by laparoscopy, although indications for this approach following the UMBRELLA guidelines are currently very restrictive. The purpose of this study was to assess the compliance to the criteria of the UMBRELLA protocol for minimally invasive approach of WT.
This retrospective multicenter study included children operated on by laparoscopic total nephrectomy for suspected WT before 2020. Imaging was reviewed centrally.
Fifty-six patients (50 WT and 6 nephrogenic rests) were operated on at a median age of 3.3 ± 2.6 years. Thirteen (23%) patients had metastasis at diagnosis. The mean operative time was 213 ± 84 min. There were eight (14.3%) conversions and five peroperative complications. A local stage III was confirmed in seven (12.5%) cases, including two for tumor rupture. Only one (1.8%) of the procedures followed the SIOP-UMBRELLA indications for laparoscopy. The criterion "ring of normal parenchyma" was met only once. Conservative surgery seemed possible in ten (17.9%) cases. The extension of the tumor beyond the ipsilateral edge of the vertebra after chemotherapy and a volume over 200 mL were associated with an increased risk of conversion (p = 0.0004 and p = 0.001 respectively). After a mean follow-up of 5.2 ± 4.0 years, although there was no local recurrence, one death occurred due to metastatic progression at 15 months postoperatively.
The laparoscopic approach of WT beyond the UMBRELLA recommendations was feasible with low risk of local recurrence. Its indications may be updated and validated.
尽管 UMBRELLA 指南目前对这种方法的适应证限制非常严格，但越来越多的医生选择通过腹腔镜进行肾切除术治疗肾母细胞瘤（WT）。本研究的目的是评估符合 UMBRELLA 协议微创治疗 WT 标准的情况。
这是一项回顾性多中心研究，纳入了 2020 年前接受腹腔镜全肾切除术治疗疑似 WT 的儿童患者。对中心的影像学资料进行了回顾。
56 例患者（50 例 WT 和 6 例肾生殖细胞肿瘤）接受了手术，中位年龄为 3.3±2.6 岁。13 例（23%）患者在诊断时存在转移。平均手术时间为 213±84 分钟。有 8 例（14.3%）中转开腹，5 例发生术中并发症。7 例（12.5%）患者局部分期为 III 期，其中 2 例为肿瘤破裂。只有 1 例（1.8%）手术符合 SIOP-UMBRELLA 的腹腔镜适应证。“正常肾实质环”这一标准仅满足 1 次。10 例（17.9%）患者似乎可以进行保肾手术。化疗后肿瘤超出对侧椎骨边缘和体积超过 200ml 与中转开腹风险增加相关（p=0.0004 和 p=0.001）。中位随访 5.2±4.0 年后，尽管没有局部复发，但有 1 例患者在术后 15 个月因转移进展而死亡。
在 UMBRELLA 建议之外，腹腔镜治疗 WT 是可行的，局部复发风险低。其适应证可能需要更新和验证。
