Reissigl A, Janetschek G, Eberle J, Colleselli K, Weimann S, Schwanninger J, Bartsch G
Department of Urology, Innsbruck University Clinic, Austria.
Br J Urol. 1995 Feb;75(2):138-42. doi: 10.1111/j.1464-410x.1995.tb07300.x.
To describe the technique and results of a thoraco-abdominal approach to removing the caval thombi in patients with renal cell carcinoma extending into the vena cava.
Between 1970 and 1990 35 patients presenting with renal cell carcinoma extending into the vena cava were treated at the Department of Urology, Innsbruck. Twenty-three of these patients underwent radical tumour nephrectomy including cavotomy and thrombectomy or caval resection. A transabdominal approach had been used in this department for radical tumour nephrectomy including cavotomy and thrombectomy or caval resection until 1987. Since 1988, a thoraco-abdominal approach has been employed. In group I patients the approach was via the seventh intercostal space, whereas in group II and III patients the thoraco-abdominal incision was made through the fifth intercostal space. In the present study the anatomy of the thoraco-abdominal approach is described.
Tumour staging and grading yielded stage T3b in 15 patients (grade I, 1; grade II, 6; grade III, 8); another eight patients with stage T3b were found to have metastatic disease (N1, 6; N2, 2; M1, 3). On the basis of the extension of the caval thrombus the patients were classified as follows: group I, 16; group II, 3; group III, 4. In T3b N0 M0 patients the 5-year-survival rate was 62.5%, while in patients with positive lymph nodes the mean survival rate was 15.5 months.
Our results suggest that the thoracoa-abdominal approach is the method of choice for the safe removal of renal cell carcinomas associated with caval thombi. If resection of the caval tumour is complete, prognosis is dependent on known factors, such as tumour invasion, nodal involvement and distant metastases rather than the extension of the tumour thrombus. An aggressive approach is not warranted in patients with nodal involvement and/or distant metastases, as it does not improve survival.
描述胸腹联合入路切除肾细胞癌侵犯下腔静脉内血栓的技术及结果。
1970年至1990年间，因肾细胞癌侵犯下腔静脉就诊于因斯布鲁克泌尿外科的患者共35例。其中23例患者接受了根治性肿瘤肾切除术，包括切开下腔静脉和取栓术或下腔静脉切除术。1987年以前，该科室采用经腹入路进行根治性肿瘤肾切除术，包括切开下腔静脉和取栓术或下腔静脉切除术。自1988年起，采用胸腹联合入路。I组患者经第七肋间间隙入路，而II组和III组患者经第五肋间间隙做胸腹联合切口。本研究描述了胸腹联合入路的解剖结构。
肿瘤分期和分级显示，15例患者为T3b期（I级1例；II级6例；III级8例）；另有8例T3b期患者发现有转移（N1期6例；N2期2例；M1期3例）。根据下腔静脉血栓的延伸情况，将患者分为以下几组：I组16例；II组3例；III组4例。T3b N0 M0患者的5年生存率为62.5%，而淋巴结阳性患者的平均生存率为15.5个月。
我们的结果表明，胸腹联合入路是安全切除与下腔静脉血栓相关的肾细胞癌的首选方法。如果下腔静脉肿瘤切除完整，预后取决于肿瘤侵犯、淋巴结受累和远处转移等已知因素，而非肿瘤血栓的延伸情况。对于有淋巴结受累和/或远处转移的患者，不应采取积极的手术方法，因为这并不能提高生存率。
