射頻消融在早期腎臟腫瘤中的應(yīng)用
發(fā)布時(shí)間：2018-09-05 16:18
【摘要】：背景：早期腎癌的發(fā)病率逐年上升，保留腎單位手術(shù)（NSS）已成為外科治療早期腎癌的“金標(biāo)準(zhǔn)”。但由于NSS手術(shù)本操作步驟復(fù)雜，對術(shù)者要求較高，進(jìn)入腹腔鏡時(shí)代后其難度更大大上升，故腹腔鏡保留腎單位手術(shù)（LNSS）至今的普及率尚不理想。腹腔鏡射頻消融輔助下腎部分切除術(shù)（RFAA-NSS）是近年新發(fā)展起來的一種“零缺血”保留腎單位術(shù)，其利用射頻消融（RFA）的熱凝效應(yīng)，將RFA結(jié)合進(jìn)NSS手術(shù)中，使NSS操作難度降低，出血減少，且無需腎蒂阻斷，避免了腎臟熱缺血損傷。國內(nèi)外對于該技術(shù)的研究多以單純的病例系列報(bào)道為主，對照性研究鮮有提及。鑒于此，本文用回顧性對照研究的方法在腫瘤預(yù)后、腎功能保護(hù)和術(shù)后并發(fā)癥控制等方面比較RFAA-NSS和LNSS兩種術(shù)式的治療效果，進(jìn)一步探討RFAA-NSS在早期腎癌中的應(yīng)用價(jià)值。 材料和方法：研究回顧了2010年1月至2013年10月在仁濟(jì)東院泌尿外科進(jìn)行的46例RFAA-NSS和152例LNSS。利用傾向性分值匹配的方法將這兩組患者做1:1匹配，匹配后比較分析兩組患者間的圍手術(shù)期指標(biāo)（手術(shù)時(shí)間、術(shù)后住院天數(shù)、術(shù)后并發(fā)癥等）、腫瘤控制情況、以及術(shù)后遠(yuǎn)期腎功能的恢復(fù)情況。同時(shí)利用單因素和多因素線性回歸分析影響RFAA-NSS術(shù)后腎功能變化的相關(guān)因素。 結(jié)果：匹配后RFAA-NSS和LNSS組中各有46例患者，年齡、R.E.N.A.L評分、腫瘤最大徑、ASA評分和術(shù)前eGFR等指標(biāo)相比匹配前差異明顯減少。匹配后RFAA-NSS組患者的術(shù)后住院天數(shù)（2.8vs.7.4d，p0.001）和手術(shù)時(shí)間（98.6vs.114.1min，p=0.009）明顯短于LNSS組，術(shù)后Hb減少百分比較少（7.0vs.15.4%，p0.001）。RFAA-NSS組患者的eGFR減少量（7.7vs.16.1ml/min/1.73m2，p=0.006）和eGFR減少百分比（5.5vs.13.0%，p=0.012）均小于LNSS組。兩組患者間術(shù)后并發(fā)癥的發(fā)生情況無明顯差異（15.2vs.17.3%，p=0.951），術(shù)后病理分期類似（p=0.353）除1例接受RFAA-NSS的患者術(shù)后10月因腦出血死亡外，其他患者在隨訪期間均存活，兩組患者均無出現(xiàn)腫瘤復(fù)發(fā)和轉(zhuǎn)移病例�；颊咝g(shù)前eGFR水平是影響術(shù)后腎功能變化的唯一因素（β=0.002，p=0.012），其余各圍手術(shù)期指標(biāo)均不影響RFAA-NSS術(shù)后腎功能變化。 結(jié)論：RFAA-NSS應(yīng)用于早期腎癌中，其近期腫瘤控制效果與傳統(tǒng)NSS手術(shù)相當(dāng)，，在腎功能保護(hù)上具有優(yōu)勢，且RFAA-NSS的手術(shù)操作安全可靠，術(shù)后并發(fā)癥發(fā)生率不高。但當(dāng)應(yīng)用于更復(fù)雜的腎臟腫瘤中時(shí)，其療效和安全性尚待觀察。 背景：對于因高齡、腎功能不全或有嚴(yán)重心血管合并癥而不能耐受腎部分切除術(shù)的偶發(fā)性腎癌患者，射頻消融（RFA）等腎癌微創(chuàng)治療表現(xiàn)出了良好的治療效果。長期隨訪研究也表明了RFA在應(yīng)用于腎臟腫瘤時(shí)，控制腫瘤的效果與腎部分切除術(shù)相當(dāng)，且在減少腎功能損傷和控制并發(fā)癥上具有優(yōu)勢。仁濟(jì)醫(yī)院自2008年開展腹腔鏡輔助射頻消融術(shù)（LRFA）以來，已積累了上百例患者，本文將就隨訪資料完整且具兩年以上隨訪時(shí)間的其中71例患者做簡要回顧。 材料和方法：研究回顧了2008年12月到2011年3月間在仁濟(jì)東院接受LRFA術(shù)的腎臟占位患者共97名，其中有2年以上隨訪資料的患者共71名。其中男性44名，女性27名，68名患者一次手術(shù)只處理單個(gè)病灶，3名患者同時(shí)處理2個(gè)或2個(gè)以上病灶。病灶位于左側(cè)32例，右側(cè)39例，平均最大徑為2.5±1.1cm，術(shù)前腎臟腫瘤R.E.N.A.L評分為6.4±1.7分，術(shù)前eGFR平均值為（95.3±4.1）ml/min/1.73m2。術(shù)前ASA評分1分的患者30例，2分34例，3分及3分以上7例；charlson合并癥指數(shù)0分25例，1分34例，2分7例，3分5例。所有患者均經(jīng)相關(guān)科室行術(shù)前狀態(tài)評估以明確可以耐受LRFA手術(shù)。 結(jié)果：71例患者中，平均手術(shù)時(shí)間為（95.2±33.8）min，術(shù)中平均出血量為（40.4±37.9）ml，無一例輸血，平均住院天數(shù)為（3.0±1.8）d，共13例患者出現(xiàn)術(shù)后并發(fā)癥，其中clavien I級10例，clavien II級3例，clavien II級的3例患者中，肉眼血尿、漏尿和輸尿管損傷各1例，無clavien III級以上并發(fā)癥。術(shù)后病理結(jié)果為惡性的占77.4%，其中T1a期51例，T1b期4例�；颊咝g(shù)后平均隨訪時(shí)間為37.9±9.1個(gè)月。術(shù)后最近一次eGFR平均值為（92.0±4.1）ml/min/1.73m2，與術(shù)前eGFR相比無明顯差異（p=0.571）。隨訪期間有2例患者因其他非腎臟腫瘤原因死亡，本組病例首次消融成功率為98.6%，腫瘤復(fù)發(fā)率為1.4%，腫瘤相關(guān)生存率為100%，總體生存率為97.2%。 結(jié)論：RFA是一種安全可靠的早期腎癌治療手段，對高齡或術(shù)前內(nèi)科合并癥多的患者耐受較好，術(shù)后嚴(yán)重并發(fā)癥發(fā)生率低，安全性高，對腎功能的影響較小，中期腫瘤控制效果理想，遠(yuǎn)期治療效果仍有待觀察。
[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.
【學(xué)位授予單位】：上海交通大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2014
【分類號】：R737.11
本文編號：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.
【學(xué)位授予單位】：上海交通大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2014
【分類號】：R737.11
【參考文獻(xiàn)】
相關(guān)期刊論文 前2條
1 殷長軍;邵鵬飛;秦超;;腎段動脈阻斷技術(shù)在腹腔鏡腎部分切除手術(shù)中的應(yīng)用與技術(shù)要點(diǎn)分析(附光盤)[J];現(xiàn)代泌尿外科雜志;2013年06期
2 王波;鄭軍華;;射頻消融治療腎癌新進(jìn)展[J];上海醫(yī)學(xué);2012年03期
本文編號：2224799
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