摘要目的 探讨区域血流荧光可视化成像在行肾动脉分支阻断的机器人肾部分切除术中的临床应用价值.方法 回顾性分析2016年10月至2017年6月我院收治的12例肾肿瘤患者的临床资料.男9例,女3例.年龄36～ 78岁,平均(51.2±11.0)岁.体重指数20.1 ～36.2 kg/m2,平均(25.6±4.8)kg/m2.肿瘤最大径2.0 ～ 5.1 cm,平均(3.3±0.9)cm.肾肿瘤R.E.N.A.L评分4～10分,平均(7.3±2.0)分.术前估算肾小球滤过率(estimated glomerular filtration rate,eGFR)82～133 ml/(min·1.73 m2),平均(101.9±13.7)ml/(min·1.73 m2).术前单侧肾小球滤过率ECT-GFR:术侧44.5～ 70.6 ml/min,平均(53.8±8.5) ml/min;健侧48.2 ～71.1 ml/min,平均(56.8±6.8)ml/min;总肾功能92.7 ～ 139.1 ml/min,平均(109.8±14.6)ml/min.12例均全麻下行机器人辅助腹腔镜下肾部分切除术,术中均应用基于吲哚菁绿的区域血流荧光可视化成像肾动脉分支阻断技术.分析纳入患者的手术时间、术中出血量、热缺血时间、手术并发症、病理学结果及随访资料.结果 12例手术均顺利完成,无中转开放手术或根治性肾切除术.手术时间95 ～ 203 min,平均(170.6±38.6)min.术中出血量60～1 000 ml,平均(178.3±206.9)ml.根据荧光显影血流灌注区域可视化成像结果,1例采用肾动脉无阻断肾部分切除术;1例因阻断效果不满意,直接改行肾动脉主干阻断肾部分切除术,缺血时间18 min;10例采用肾动脉分支阻断,阻断时间17 ～46 min,平均(25.5±10.5)min,其中1例切除肿瘤过程中因创面出血严重行补救性主干阻断完成肾部分切除手术,术中出血量1 000 ml,肾动脉分支阻断46 min,主干阻断时间16 min.术后住院时间5～8d,平均(5.8±0.9)d,引流管留置时间3～4d,平均(3.5±0.5)d,无术后并发症发生.术后病理诊断:切缘均为阴性,透明细胞癌11例,嗜酸细胞腺瘤1例.9例肾动脉分支阻断病例出院前eGFR 56 ～ 140 ml/(min·1.73m2),平均(94.5±22.5)ml/(min · 1.73 m2),较术前平均下降5％,其中4例术后1个月分肾功能ECT-GFR检查示,术侧20.8 ～ 55.8 ml/min,平均(37.6±13.2) ml/min;健侧51.2 ～ 68.4ml/min,平均(58.5±6.9)ml/min;总肾功能79.3～124.3 ml/min,平均(98.7±16.2) ml/min,与术前相比术侧平均下降29％,健侧平均代偿性增高2％,总肾功能平均下降10％.结论 基于吲哚菁绿的荧光显影区域血流可视化成像可清楚、直观地显示机器人肾部分切除术中分支动脉阻断的效果,指导优化手术切除策略,提高手术安全性及临床疗效.

abstractsObjective To explore the clinical utilization value of regional blood flow fluorescence visualization in selective arterial clamping robotic partial nephrectomy.Methods 12 cases of robotic partial nephrectomy with indocyanine green-based regional blood flow fluorescence visualization selective arterial clamping between October 2016 and June 2017 by our team were retrospectively analyzed.There were 9 males and 3 females with age between 36-78 years,mean age(51.2 ± 11.0) years,BMI 20.1-36.2 kg/m2,mean of (25.6 ± 4.8) kg/m2,tumor diameter 2.0-5.1 cm,mean of(3.3 ± 0.9) cm,and R.E.N.A.L.score 4-10,mean(7.3 ± 2.0).Preoperative renal function status of eGFR (estimated glomerular filtration rate) was 82-133 ml/(min · 1.73 m2),mean (101.9 ± 13.7)ml/(min · 1.73 m2) and split ECT-GFR of 44.5-70.6 ml/min,mean of(53.8 ± 8.5) ml/min in operated kidney;48.2-71.1 ml/min,mean of(56.8 ±6.8) ml/min in contralateral kidney;in total,92.7-139.1 ml/min,mean of(109.8 ± 14.6)ml/min.Perioperative information including operative time,blood loss,warm ischemia time,surgical complications,pathologic outcomes and follow-up data of included patients were analyzed.Results All procedures were done smoothly without open or radical conversion,with operative time of 95-203 min,mean of (170.6 ±38.6)min,and estimated blood loss of 60-1 000 ml,mean of(178.3 ± 206.9)ml.According to the visualize uptake of fluorescence imaging perfusion area visualization after selective arterial clamping,1 case underwent unclamping robotic partial nephrectomy,1 case converted to main renal artery clamping with warm ischemia time of 18 min,10 cases performed via renal arterial branch clamping with an average ischemia time of (25.5 ± 10.5) (range 17-46)min,1 of which due to parenchymal bleeding obscuring visualization necessitated clamping of the main renal artery with 1000 ml blood loss,46 min of arterial branch occlusion and 16 min of main artery clamping.The average postoperative hospital stay was (5.8 ± 0.9) (range 5-8)days,and the duration of drainage was (3.5 ± 0.5) (range 3-4) days.No postoperative complications occurred.Postoperative pathology:all margins were all negative,11 cases of clear cell carcinoma,eosinophilic adenoma in 1 case.The average eGFR of 9 cases of renal arterial branch clamping was (94.5 ±22.5)(range 56-140)ml/(min · 1.73 m2) at discharge with a 5％ percentage decrease versus preoperative level.Among them,4 cases obtained with ECT-GFR data 1 month postoperatively had a mean of(37.6 ±13.2)(range 20.8-55.8) ml/min with 29％ percentage decrease on the surgical side,an average of (58.5 ± 6.9) (range 51.2-68.4) ml/min with 2％ compensatory increase of the contralateral side,and (98.7 ± 16.2) (range 79.3-124.3) ml/min in total with a 10.4％ overall decrease.Conclusions The visualization of blood flow imaging based on indocyanine green fluorescence can clearly and intuitively show the effect of branching arterial occlusion in robotic partial nephrectomy,guide the optimization of surgical resection strategy,and improve safety and clinical outcome.