摘要目的 探讨机器人辅助腹腔镜MayoⅢ～Ⅳ级下腔静脉癌栓取出术的可行性.方法 回顾性分析2014年11月至2017年1月收治的5例肾肿瘤伴MayoⅢ～Ⅳ级下腔静脉癌栓患者的临床资料.男4例,女1例.年龄54～71岁,中位年龄59岁.肿瘤位于左侧1例,右侧4例;肿瘤直径5～9 cm,平均6.8 cm.术前临床分期T3b期3例,T3.期2例.5例中Ⅲ级癌栓4例,Ⅳ级癌栓1例;癌栓长度为7～11 cm,中位值9 cm.Ⅲ级癌栓需要翻左右肝叶,阻断第一肝门血管及肝上膈下下腔静脉.Ⅳ级癌栓需要体外循环支持,由泌尿外科联合肝胆外科及心外科多学科合作完成,需要翻肝、阻断上腔及下腔静脉回流后切开右心房及肝静脉以下的下腔静脉分段取栓.结果 5例手术均顺利完成,中位手术时间440 min (320 ～630 min).术中使用血液回收装置,估计术中中位出血量2 500 ml(500 ～6 000 ml),5例均予输血.术中下腔静脉阻断中位时间35 min(25 ～50 min).术后转ICU病房中位时间4 d(2 ～8 d),术后引流管放置中位时间9 d(7～ 12 d).5例术后病理均为透明细胞癌.术后3例出现肾功能不全,2例出现肝功能不全,药物治疗后均好转.5例均获得随访,中位随访时间19.6个月(12 ～48个月),1例术后6个月死亡,1例疾病进展.结论 机器人辅助腹腔镜Ⅲ～Ⅳ级下腔静脉癌栓取出术,尽管风险很高,但在选择合适患者的前提下,对机器人手术经验丰富的医生来说是可行的.

abstractsObjective To explore the feasibility of robot-assisted laparoscopic inferior vena cava (IVC) thrombectomy in treating renal tumor with Mayo level Ⅲ-Ⅳ inferior vena cava thrombus.Methods From November 2014 to January 2017,5 cases of renal tumor with Mayo level Ⅲ-Ⅳ inferior vena cava tumor thrombus were treated with robot-assisted surgery.There were 4 males and 1 female with the median age of 59 years (range 54-71 years).Four cases had the renal tumor on the right side and one on the left side.The mean tumor size was 6.8 cm (range 5-9 cm) with 3 cases of T3b and 2 cases of T3c.There were 4 cases of level Ⅲ and 1 case of level Ⅳ inferior vena cava thrombus with the median length of 9 cm (range 7-11 cm).The surgical procedure for Mayo level Ⅲ inferior vena cava thrombus included mobilization of both left and right robes of liver,subsequently controlling the suprahepatic infradiaphramatic IVC and first porta hepatis simultaneously.The surgical procedure for Mayo level Ⅳ inferior vena cava thrombus included cardiopulmonary bypass by multi-disciplinary cooperation among urologists,hepatobiliary and cardiovascular surgeons.The procedures included live mobilization,control of the superior vena cava and first porta hepatis and remove thrombus in the atrium and IVC respectively.Results All operations were completed successfully.The median operative time was 440 min (320-630 min).The blood recovery device was used and the intraoperative estimated blood loss was 2 500 ml (500-6 000 ml) and all cases required intraoperative blood transfusion.The median time of intraoperative occlusion of IVC was 35 min (25-50 min).All patients were transferred to the intensive care unit for median of 4 days (2-8 days) after surgery.The median time to remove the postoperative drainage tube was 9 days (7-12 days).Postoperative pathological diagnosis revealed 5 cases of clear cell carcinoma.Postoperative renal dysfunction occurred in 3 patients and liver dysfunction occurred in 2 patients who improved after medical therapy.During median 19.6 months (12-48 months) of follow-up,1 patient died and 1 patient progressed.Conclusions Despite the high risk of surgery,robot-assisted laparoscopic IVC thrombectomy for renal tumor with Mayo level Ⅲ-Ⅳ thrombus is feasible for experienced surgeons in selected patients.However,the oncological outcomes need further investigation.