射频消融在早期肾脏肿瘤中的应用
发布时间：2018-09-05 16:18
【摘要】：背景：早期肾癌的发病率逐年上升，保留肾单位手术（NSS）已成为外科治疗早期肾癌的“金标准”。但由于NSS手术本操作步骤复杂，对术者要求较高，进入腹腔镜时代后其难度更大大上升，故腹腔镜保留肾单位手术（LNSS）至今的普及率尚不理想。腹腔镜射频消融辅助下肾部分切除术（RFAA-NSS）是近年新发展起来的一种“零缺血”保留肾单位术，其利用射频消融（RFA）的热凝效应，将RFA结合进NSS手术中，使NSS操作难度降低，出血减少，且无需肾蒂阻断，避免了肾脏热缺血损伤。国内外对于该技术的研究多以单纯的病例系列报道为主，对照性研究鲜有提及。鉴于此，本文用回顾性对照研究的方法在肿瘤预后、肾功能保护和术后并发症控制等方面比较RFAA-NSS和LNSS两种术式的治疗效果，进一步探讨RFAA-NSS在早期肾癌中的应用价值。 材料和方法：研究回顾了2010年1月至2013年10月在仁济东院泌尿外科进行的46例RFAA-NSS和152例LNSS。利用倾向性分值匹配的方法将这两组患者做1:1匹配，匹配后比较分析两组患者间的围手术期指标（手术时间、术后住院天数、术后并发症等）、肿瘤控制情况、以及术后远期肾功能的恢复情况。同时利用单因素和多因素线性回归分析影响RFAA-NSS术后肾功能变化的相关因素。 结果：匹配后RFAA-NSS和LNSS组中各有46例患者，年龄、R.E.N.A.L评分、肿瘤最大径、ASA评分和术前eGFR等指标相比匹配前差异明显减少。匹配后RFAA-NSS组患者的术后住院天数（2.8vs.7.4d，p0.001）和手术时间（98.6vs.114.1min，p=0.009）明显短于LNSS组，术后Hb减少百分比较少（7.0vs.15.4%，p0.001）。RFAA-NSS组患者的eGFR减少量（7.7vs.16.1ml/min/1.73m2，p=0.006）和eGFR减少百分比（5.5vs.13.0%，p=0.012）均小于LNSS组。两组患者间术后并发症的发生情况无明显差异（15.2vs.17.3%，p=0.951），术后病理分期类似（p=0.353）除1例接受RFAA-NSS的患者术后10月因脑出血死亡外，其他患者在随访期间均存活，两组患者均无出现肿瘤复发和转移病例。患者术前eGFR水平是影响术后肾功能变化的唯一因素（β=0.002，p=0.012），其余各围手术期指标均不影响RFAA-NSS术后肾功能变化。 结论：RFAA-NSS应用于早期肾癌中，其近期肿瘤控制效果与传统NSS手术相当，，在肾功能保护上具有优势，且RFAA-NSS的手术操作安全可靠，术后并发症发生率不高。但当应用于更复杂的肾脏肿瘤中时，其疗效和安全性尚待观察。 背景：对于因高龄、肾功能不全或有严重心血管合并症而不能耐受肾部分切除术的偶发性肾癌患者，射频消融（RFA）等肾癌微创治疗表现出了良好的治疗效果。长期随访研究也表明了RFA在应用于肾脏肿瘤时，控制肿瘤的效果与肾部分切除术相当，且在减少肾功能损伤和控制并发症上具有优势。仁济医院自2008年开展腹腔镜辅助射频消融术（LRFA）以来，已积累了上百例患者，本文将就随访资料完整且具两年以上随访时间的其中71例患者做简要回顾。 材料和方法：研究回顾了2008年12月到2011年3月间在仁济东院接受LRFA术的肾脏占位患者共97名，其中有2年以上随访资料的患者共71名。其中男性44名，女性27名，68名患者一次手术只处理单个病灶，3名患者同时处理2个或2个以上病灶。病灶位于左侧32例，右侧39例，平均最大径为2.5±1.1cm，术前肾脏肿瘤R.E.N.A.L评分为6.4±1.7分，术前eGFR平均值为（95.3±4.1）ml/min/1.73m2。术前ASA评分1分的患者30例，2分34例，3分及3分以上7例；charlson合并症指数0分25例，1分34例，2分7例，3分5例。所有患者均经相关科室行术前状态评估以明确可以耐受LRFA手术。 结果：71例患者中，平均手术时间为（95.2±33.8）min，术中平均出血量为（40.4±37.9）ml，无一例输血，平均住院天数为（3.0±1.8）d，共13例患者出现术后并发症，其中clavien I级10例，clavien II级3例，clavien II级的3例患者中，肉眼血尿、漏尿和输尿管损伤各1例，无clavien III级以上并发症。术后病理结果为恶性的占77.4%，其中T1a期51例，T1b期4例。患者术后平均随访时间为37.9±9.1个月。术后最近一次eGFR平均值为（92.0±4.1）ml/min/1.73m2，与术前eGFR相比无明显差异（p=0.571）。随访期间有2例患者因其他非肾脏肿瘤原因死亡，本组病例首次消融成功率为98.6%，肿瘤复发率为1.4%，肿瘤相关生存率为100%，总体生存率为97.2%。 结论：RFA是一种安全可靠的早期肾癌治疗手段，对高龄或术前内科合并症多的患者耐受较好，术后严重并发症发生率低，安全性高，对肾功能的影响较小，中期肿瘤控制效果理想，远期治疗效果仍有待观察。
[Abstract]:BACKGROUND: The incidence of early renal cell carcinoma is increasing year by year. Nephron-sparing surgery (NSS) has become the "gold standard" for surgical treatment of early renal cell carcinoma. Laparoscopic radiofrequency ablation-assisted partial nephrectomy (RFAA-NSS) is a newly developed "zero ischemia" nephron-sparing surgery in recent years. It uses the thermocoagulation effect of radiofrequency ablation (RFA) to incorporate RFA into the operation of NSS, which reduces the difficulty of operation, reduces the bleeding, and does not require renal pedicle obstruction and avoids the injury of renal warm ischemia. In view of this, we compared the effects of RFAA-NSS and LNSS in tumor prognosis, renal function protection and postoperative complication control by retrospective control study, and further discussed the role of RFAA-NSS in early renal carcinoma. Application value.
Materials and Methods: 46 cases of RFAA-NSS and 152 cases of LNSS in the urology department of Renji East Hospital from January 2010 to October 2013 were reviewed. Tumor control and long-term recovery of renal function after RFAA-NSS were analyzed by univariate and multivariate linear regression analysis.
Results: There were 46 patients in the matched RFAA-NSS and LNSS groups, respectively. Age, R.E.N.A.L score, tumor maximum diameter, ASA score and preoperative eGFR were significantly lower than those before matching. The postoperative hospital stay (2.8 vs. 7.4 d, P 0.001) and operation time (98.6 vs. 114.1 min, P = 0.009) in the matched RFAA-NSS group were significantly shorter than those in the LNSS group. The reduction of eGFR (7.7 vs. 16.1 ml/min/1.73 m2, P = 0.006) and the decrease of eGFR (5.5 vs. 13.0%, P = 0.012) in the RFAA-NSS group were smaller than those in the LNSS group (7.0 vs. 15.4%, P 0.001). There was no significant difference in the incidence of postoperative complications between the two groups (15.2 vs. 17.3%, P = 0.951), except for one patient receiving RFAA-NSS (p = 0.353). No recurrence or metastasis occurred in the two groups. The preoperative eGFR level was the only factor affecting the postoperative renal function (beta = 0.002, P = 0.012). The other perioperative parameters did not affect the renal function after RFAA-NSS.
CONCLUSION: RFAA-NSS for early renal cancer has the same short-term tumor control effect as traditional NSS surgery, and has the advantage of protecting renal function. RFAA-NSS is safe and reliable in operation, and the incidence of postoperative complications is low.
Background: Radiofrequency ablation (RFA) and other minimally invasive treatments for incidental renal cell carcinoma (RCC) patients who are unable to tolerate partial nephrectomy due to advanced age, renal insufficiency or severe cardiovascular complications have shown good results. Long-term follow-up studies have also shown that RFA is effective in controlling tumors and partial nephrectomy in the treatment of renal tumors. Since the laparoscopic radiofrequency ablation (LRFA) was carried out in Renji Hospital in 2008, hundreds of patients have been accumulated. 71 of them have been followed up for more than two years.
Materials and Methods: From December 2008 to March 2011, 97 patients underwent LRFA in Renji East Hospital, including 71 patients with more than 2 years follow-up data. Among them, 44 were males and 27 were females. There were 32 cases on the left side and 39 cases on the right side with an average maximum diameter of 2.5 (+ 1.1 cm), preoperative renal tumor R.E.N.A.L score was 6.4 (+ 1.7) and preoperative eGFR average was (95.3 (+ 4.1) ml/min/1.73 m2. Preoperative ASA score was 1 in 30 patients, 2 in 34, 3 in 7 and above; Charlson comorbidity index was 0 in 25, 1 in 34, 2 in 7, and 3 in 5. Preoperative evaluation was performed to confirm the tolerability of LRFA.
Results: Among the 71 patients, the average operation time was (95.2 Postoperative pathological findings were malignant in 77.4% of the patients, including 51 in T1a and 4 in T1b. The average follow-up time was 37.9 (+ 9.1) months. The latest eGFR was (92.0 (+ 4.1) ml / min / 1.73 m2, no significant difference compared with preoperative eGFR (p = 0.571). The first ablation success rate was 98.6%, the recurrence rate was 1.4%, the tumor-related survival rate was 100%, and the overall survival rate was 97.2%.
Conclusion: RFA is a safe and reliable treatment for early renal cell carcinoma. It is well tolerated in elderly patients or preoperative patients with many complications. The incidence of severe complications after operation is low and the safety is high. It has little influence on renal function. The effect of tumor control in the middle stage is ideal. The long-term effect remains to be observed.
【学位授予单位】：上海交通大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R737.11
本文编号：2224799
[Abstract]:BACKGROUND: The incidence of early renal cell carcinoma is increasing year by year. Nephron-sparing surgery (NSS) has become the "gold standard" for surgical treatment of early renal cell carcinoma. Laparoscopic radiofrequency ablation-assisted partial nephrectomy (RFAA-NSS) is a newly developed "zero ischemia" nephron-sparing surgery in recent years. It uses the thermocoagulation effect of radiofrequency ablation (RFA) to incorporate RFA into the operation of NSS, which reduces the difficulty of operation, reduces the bleeding, and does not require renal pedicle obstruction and avoids the injury of renal warm ischemia. In view of this, we compared the effects of RFAA-NSS and LNSS in tumor prognosis, renal function protection and postoperative complication control by retrospective control study, and further discussed the role of RFAA-NSS in early renal carcinoma. Application value.
Materials and Methods: 46 cases of RFAA-NSS and 152 cases of LNSS in the urology department of Renji East Hospital from January 2010 to October 2013 were reviewed. Tumor control and long-term recovery of renal function after RFAA-NSS were analyzed by univariate and multivariate linear regression analysis.
Results: There were 46 patients in the matched RFAA-NSS and LNSS groups, respectively. Age, R.E.N.A.L score, tumor maximum diameter, ASA score and preoperative eGFR were significantly lower than those before matching. The postoperative hospital stay (2.8 vs. 7.4 d, P 0.001) and operation time (98.6 vs. 114.1 min, P = 0.009) in the matched RFAA-NSS group were significantly shorter than those in the LNSS group. The reduction of eGFR (7.7 vs. 16.1 ml/min/1.73 m2, P = 0.006) and the decrease of eGFR (5.5 vs. 13.0%, P = 0.012) in the RFAA-NSS group were smaller than those in the LNSS group (7.0 vs. 15.4%, P 0.001). There was no significant difference in the incidence of postoperative complications between the two groups (15.2 vs. 17.3%, P = 0.951), except for one patient receiving RFAA-NSS (p = 0.353). No recurrence or metastasis occurred in the two groups. The preoperative eGFR level was the only factor affecting the postoperative renal function (beta = 0.002, P = 0.012). The other perioperative parameters did not affect the renal function after RFAA-NSS.
CONCLUSION: RFAA-NSS for early renal cancer has the same short-term tumor control effect as traditional NSS surgery, and has the advantage of protecting renal function. RFAA-NSS is safe and reliable in operation, and the incidence of postoperative complications is low.
Background: Radiofrequency ablation (RFA) and other minimally invasive treatments for incidental renal cell carcinoma (RCC) patients who are unable to tolerate partial nephrectomy due to advanced age, renal insufficiency or severe cardiovascular complications have shown good results. Long-term follow-up studies have also shown that RFA is effective in controlling tumors and partial nephrectomy in the treatment of renal tumors. Since the laparoscopic radiofrequency ablation (LRFA) was carried out in Renji Hospital in 2008, hundreds of patients have been accumulated. 71 of them have been followed up for more than two years.
Materials and Methods: From December 2008 to March 2011, 97 patients underwent LRFA in Renji East Hospital, including 71 patients with more than 2 years follow-up data. Among them, 44 were males and 27 were females. There were 32 cases on the left side and 39 cases on the right side with an average maximum diameter of 2.5 (+ 1.1 cm), preoperative renal tumor R.E.N.A.L score was 6.4 (+ 1.7) and preoperative eGFR average was (95.3 (+ 4.1) ml/min/1.73 m2. Preoperative ASA score was 1 in 30 patients, 2 in 34, 3 in 7 and above; Charlson comorbidity index was 0 in 25, 1 in 34, 2 in 7, and 3 in 5. Preoperative evaluation was performed to confirm the tolerability of LRFA.
Results: Among the 71 patients, the average operation time was (95.2 Postoperative pathological findings were malignant in 77.4% of the patients, including 51 in T1a and 4 in T1b. The average follow-up time was 37.9 (+ 9.1) months. The latest eGFR was (92.0 (+ 4.1) ml / min / 1.73 m2, no significant difference compared with preoperative eGFR (p = 0.571). The first ablation success rate was 98.6%, the recurrence rate was 1.4%, the tumor-related survival rate was 100%, and the overall survival rate was 97.2%.
Conclusion: RFA is a safe and reliable treatment for early renal cell carcinoma. It is well tolerated in elderly patients or preoperative patients with many complications. The incidence of severe complications after operation is low and the safety is high. It has little influence on renal function. The effect of tumor control in the middle stage is ideal. The long-term effect remains to be observed.
【学位授予单位】：上海交通大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R737.11
【参考文献】
相关期刊论文 前2条
1 殷长军;邵鹏飞;秦超;;肾段动脉阻断技术在腹腔镜肾部分切除手术中的应用与技术要点分析(附光盘)[J];现代泌尿外科杂志;2013年06期
2 王波;郑军华;;射频消融治疗肾癌新进展[J];上海医学;2012年03期
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