摘要目的 探讨低R.E.N.A.L.评分的局限性小肾肿瘤患者行后腹腔镜节段性肾动脉阻断保留肾单位手术(SRPN)后远期患肾功能的影响因素.方法 回顾性分析2010年1月至2012年4月采用SRPN治疗的33例局限性小肾肿瘤患者的临床资料,其中贵州医科大学附属医院26例,天津市第三中心医院7例.男14例,女19例.年龄(56.5 ±11.8)岁,体重指数(24.1 ±3.1)kg/m2.术前肾脏CT血管成像显示肿瘤血供来源于肾脏二级或三级血管;T1a期肿瘤,直径≤4 cm;R.E.N.A.L.评分为4～6分;术前血清肌酐均正常;肾动态显像技术测定患侧及健侧肾小球滤过率均正常.术前患肾体积为(141.2±28.8) cm3,术前患肾肾小球滤过率(aGFR)为(45.0±4.9)ml/min.所有患者均行SRPN.记录术后aGFR、术后aGFR残存率(术后与术前aGFR的比值)、术后患肾体积、术后患肾体积残存率(术后与术前患肾体积的比值).术后各随访时间点患肾功能与术前的比较采用配对t检验,体重指数、手术时间、节段性肾动脉阻断时间和肿瘤距肾集合系统的距离对术后患肾功能的影响采用多元线性回归模型分析,术后aGFR残存率与患肾体积残存率的关系采用Pearson相关系数分析.结果 本组33例手术均顺利完成.手术时间(108.4 ±9.1)min,术中节段性肾动脉阻断时间(23.3±3.0)min.术后病理检查结果:肾透明细胞癌17例,乳头状癌5例,嫌色细胞癌3例,切缘均阴性;血管平滑肌脂肪瘤8例.本组所有病例随访时间均＞5年,5年总生存率(OS)为100％,肿瘤特异性生存率(CSS)为100％.术后3、6、12、24、60个月aGFR分别为(34.6±4.6)、(34.7±4.8)、(34.9±4.4)、(35.1±4.4)、(35.2±4.2) ml/min,较术前分别下降(10.4±2.4)、(10.4±2.6)、(10.1±2.4)、(9.9±2.4)、(9.8±2.5) ml/min,与术前比较差异均有统计学意义(P＜0.05).多元线性回归分析提示,体重指数、手术时间、肾动脉阻断时间和肿瘤距肾集合系统的距离对术后患肾功能未产生影响(P＞0.05).随访3、6、12、24、60个月,术后aGFR残存率与患肾体积残存率的相关系数分别为0.659、0.667、0.663、0.629、0.604,差异均有统计学意义(P＜0.01).结论 对于局限性小肾肿瘤,SRPN术后患肾功能下降与术后患肾体积有关,与手术时间、节段性肾动脉阻断时间和肿瘤距肾集合系统的距离无明显相关性.

abstractsObjective To analyze the influencing factors of affected renal function after laparoscopic nephron-sparing nephrectomy with segmental renal artery blocking (SRPN) for low R.E.N.A.L.score small localized renal tumor with follow-up data.Methods The data of 33 patients was collected,who underwent SRPN for small renal tumor from January 2010 to April 2012,and were followed-up for 5 years successfully.In 33 integrated data of 5-year follow-up,there were 14 males and 19 females,aged(56.5 ± 11.8)years.The preoperative affected renal glomerular filtration rate (aGFRpre),postoperative affected renal glomerular filtration rate (aGFRpost),the residual ratio of aGFR (aGFRpost/aGFRpre),preoperative affected renal volume (aVolpre),postoperative affected renal volume (aVolpost) and the residual ratio of aVol (aVolpost/aVolpre) were collected at the postoperative 3rd,6th,12th,24th and 60th month in follow-up period.Preoperative and postoperative data were analyzed by paired-sample T test.Multivariate linear regression analysis determined the influence of body mass index,operation time,localized warm ischemia time and distance from tumor to renal collecting system.Compare the correlation between aGFRpost/aGFRpre and aVolpost/aVolpre.Results All 33 cases were performed successfully.The mean operation time was (108.4 ± 9.1) min,and the mean time of segmental renal artery blocking was (23.3 ± 3.0) min.Postoperative pathologic 17 (51.5％) of clear cell carcinoma,5 (15.2％) of papillary carcinoma,3 (9.1％) of chromophobe cell carcinoma.All of above margins were negative.8 (24.2％) of angiomyolipoma (9.1％).All 33 cases were followed up for more than 5 years.The 5-year overoll survival (OS) and cancer specific survival (CSS) were 100％.In the 3rd,6th,12th,24th and 60th month,aGFRpost were (34.6 ± 4.6) ml/min,(34.7 ± 4.8) ml/min,(34.9 ± 4.4) ml/min,(35.1 ± 4.4) ml/min,(35.2 ± 4.2) ml/min,decreased of (10.4 ± 2.4) ml/min,(10.4 ± 2.6) ml/min,(10.1 ± 2.4) ml/min,(9.9 ± 2.4) ml/min,(9.8 ± 2.5) ml/min compared with aGFRpre (P ＜ 0.05).Multivariate linear regression analysis showed that body mass index,operation time,localized warm ischemia time in SRPN and distance from tumor to renal collecting system were unable to influence aGFRpost (P ＞ 0.05).The correlation coefficients between aGFRpost/aGFRpre and aVolpost/aVolpre were 0.659,0.667,0.663,0.629,0.604 respectively,and the difference was statistically significant (P ＜ 0.05).Conclusions For low R.E.N.A.L.score small localized renal tumor with SRPN,the decrease of postoperative affected renal function is relevant to postoperative affected renal volume,not as to operation time,localized warm ischemia time in SRPN and distance from tumor to renal collecting system.