李浩米慶輝何永俊賈銳

1貴州省黔南州人民醫(yī)院泌尿外科 558000 貴州都勻

論 著

單純性腎囊腫不同治療方法的對(duì)比研究

李浩1米慶輝1何永俊1賈銳1

1貴州省黔南州人民醫(yī)院泌尿外科 558000 貴州都勻

目的:評(píng)價(jià)單純性腎囊腫行腹腔鏡腎囊腫去頂術(shù)和經(jīng)皮腎穿刺硬化術(shù)及開(kāi)放腎囊腫去頂術(shù)的治療效果。方法:回顧性分析85例單純性腎囊腫患者的臨床資料,男53例,女32例。年齡22～72歲,平均43歲。囊腫直徑4.8～13.2 cm,平均6.8 cm。85例患者中,30例行腹腔鏡去頂術(shù)治療,30例開(kāi)放性手術(shù)治療,25例行經(jīng)皮腎穿刺硬化術(shù),對(duì)比分析三組患者手術(shù)時(shí)間、術(shù)中出血量、術(shù)后住院時(shí)間、術(shù)后放置引流管時(shí)間及復(fù)發(fā)率的差異,總結(jié)三種治療方法的特點(diǎn)。結(jié)果:85例患者均順利完成手術(shù),術(shù)中術(shù)后無(wú)明顯并發(fā)癥。腹腔鏡組和開(kāi)放組囊腫去頂術(shù)后,囊腫復(fù)發(fā)率分別3.3%和0,明顯小于經(jīng)皮腎穿刺硬化術(shù)組的24%(P＜0.05);腹腔鏡組和穿刺硬化術(shù)組術(shù)中出血量及術(shù)后引流時(shí)間均少于開(kāi)放手術(shù)組(P＜0.05)。手術(shù)時(shí)間三組病例差異無(wú)統(tǒng)計(jì)學(xué)意義。結(jié)論:三種方法均有良好的效果,各有優(yōu)缺點(diǎn),其中腹腔鏡腎囊腫去頂術(shù)具有手術(shù)時(shí)間短、出血量少以及復(fù)發(fā)率低等綜合優(yōu)勢(shì),值得推廣,最終術(shù)式選擇應(yīng)根據(jù)囊腫特征及術(shù)者對(duì)患者的綜合評(píng)估等多方面因素來(lái)考慮。

腎囊腫去頂術(shù);腹腔鏡;開(kāi)放;穿刺硬化術(shù)

單純性腎囊腫可見(jiàn)于兒童和成人,是一種良性的腎實(shí)質(zhì)囊性病變,無(wú)癥狀單純性腎囊腫可不予以治療,但當(dāng)與惡性腎腫瘤鑒別困難時(shí)或存在癥狀時(shí),應(yīng)積極治療[1]。我們2006年1月～2013年10月共收治85例單純腎囊腫,采用腹腔鏡去頂術(shù)、開(kāi)放性手術(shù)和經(jīng)皮腎穿刺硬化術(shù)進(jìn)行治療,對(duì)其臨床資料進(jìn)行回顧性分析,現(xiàn)報(bào)告如下。

1 資料與方法

1.1 臨床資料

所選85例單純性腎囊腫患者,術(shù)前均行常規(guī)檢查,排除其他疾病,經(jīng)B超,雙腎增強(qiáng)CT檢查證實(shí)為單純性腎囊腫,并確定囊腫的大小和部位及腎實(shí)質(zhì)受壓迫的程度,依據(jù)手術(shù)方式的不同,分為腹腔鏡手術(shù)組、開(kāi)放性手術(shù)組、穿刺硬化術(shù)組。各組資料見(jiàn)表1。

表1 三組患者臨床資料比較

1.2 手術(shù)方法

1.2.1 腹腔鏡組 全身麻醉,健側(cè)臥位,抬高腰橋,在腋后線12肋下緣切開(kāi)皮膚2 cm,鈍性分離肌層,腰背筋膜,手指分離后腹腔間隙,放入自制水囊,充水250～450 ml,擴(kuò)張后腹腔間隙,置入相應(yīng)Trocar,置入腹腔鏡及操作器械,于腎臟背側(cè)打開(kāi)腎周筋膜及腎周脂肪,暴露腎囊腫及周圍腎實(shí)質(zhì),提起囊壁,用電凝鉤環(huán)形切除腎囊腫壁(一般保留腎實(shí)質(zhì)周圍0.5 cm),吸引器吸凈囊液,殘余壁予以電凝止血,取出腎囊壁送病檢,充分止血,生理鹽水沖洗術(shù)野,檢查無(wú)活動(dòng)出血,放置引流管,縫合關(guān)閉切口。

1.2.2 開(kāi)放手術(shù)組 常規(guī)麻醉好,患者取患側(cè)臥位,第12肋下切口,長(zhǎng)度12～16 cm;切開(kāi)分離肌層,分離腎周脂肪組織,打開(kāi)脂肪囊,暴露腎囊腫,剪開(kāi)腎囊壁,吸凈囊液,距腎實(shí)質(zhì)邊緣5 mm剪除腎囊壁,電凝止血,常規(guī)放置膠管引流。

1.2.3 穿刺硬化組 局部麻醉,患者多采用俯臥位或健側(cè)臥位,腰部墊高,在B超引導(dǎo)下,根據(jù)B超動(dòng)態(tài)檢查結(jié)果,將穿刺針刺入腎囊腫內(nèi),當(dāng)針尖達(dá)囊腫液性暗區(qū)1/2處時(shí)抽取囊液,抽凈囊液后注入無(wú)水乙醇,注入量為囊液量的1/4～1/5,保留20 min后抽凈無(wú)水乙醇,再注入5 ml無(wú)水乙醇于囊內(nèi),拔出穿刺針,無(wú)菌輔料覆蓋,觀察15 min后患者無(wú)異常,手術(shù)結(jié)束。

1.3 術(shù)后隨訪

術(shù)后隨訪采用電話詢問(wèn)方式,術(shù)后每6個(gè)月～1年隨訪一次?；颊咝g(shù)后定期進(jìn)行腹部超聲復(fù)查,發(fā)現(xiàn)術(shù)后部位囊腫再次出現(xiàn)定為復(fù)發(fā)。

1.4 統(tǒng)計(jì)學(xué)方法

應(yīng)用SPSS 13.0軟件進(jìn)行統(tǒng)計(jì)學(xué)分析,計(jì)量資料用ˉx±s表示,計(jì)數(shù)資料采用χ2檢驗(yàn),以t檢驗(yàn)處理組間計(jì)量資料;P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

三組圍手術(shù)期資料比較見(jiàn)表2。腹腔鏡組與穿刺硬化組在手術(shù)出血,留置導(dǎo)尿管和引流管的時(shí)間、術(shù)后住院時(shí)間方面明顯優(yōu)于開(kāi)放手術(shù)(P＜0.01);出院后隨訪,復(fù)查B超穿刺硬化組6例出現(xiàn)囊腫復(fù)發(fā),腹腔鏡組與開(kāi)放手術(shù)組復(fù)發(fā)例數(shù)明顯小于穿刺硬化組(P＜0.01)在治療上有明顯優(yōu)勢(shì);手術(shù)時(shí)間方面,三者差異無(wú)統(tǒng)計(jì)學(xué)意義。

表2 三組圍手術(shù)期資料比較

3 討論

腎囊腫在泌尿外科疾病中較為常見(jiàn),其中以單純性腎囊腫為主,其發(fā)病率相當(dāng)高,40歲以上的發(fā)病率超過(guò)20%[2]。一般無(wú)臨床癥狀,多數(shù)患者在B超檢查、CT檢查時(shí)偶然發(fā)現(xiàn);一般認(rèn)為,對(duì)直徑小于3 cm的無(wú)癥狀性腎囊腫,無(wú)需處理;對(duì)3～5 cm大小的腎囊腫可超聲引導(dǎo)經(jīng)皮穿刺注射硬化劑(如無(wú)水乙醇)治療;而體積較大有壓迫癥狀、穿刺可能損傷其他器官或穿刺治療無(wú)效者則可采用手術(shù)治療,治療方法包括穿刺硬化手術(shù)、開(kāi)放性腎囊腫去頂減壓術(shù)、腹腔鏡腎囊腫去頂術(shù)[3～5]。

穿刺硬化手術(shù)治療腎囊腫是一種簡(jiǎn)便易行,創(chuàng)傷小,開(kāi)展條件容易滿足的方法,它是經(jīng)皮腎穿刺抽取囊液,再以無(wú)水酒精使囊腫壁發(fā)生脫水、變性、壞死,從而喪失分泌功能,繼而囊壁皺縮粘連,最終囊腫消失,但是囊腫復(fù)發(fā)率較高,有報(bào)道顯示其囊腫復(fù)發(fā)例為17%～44%[3]。本組病歷中,有25例選擇這種方法,有6例復(fù)發(fā),復(fù)發(fā)率為24%,腹腔鏡組有1例復(fù)發(fā),復(fù)發(fā)率為3.3%,開(kāi)放手術(shù)組,復(fù)發(fā)率為0,差異有統(tǒng)計(jì)學(xué)意義。

傳統(tǒng)的開(kāi)放性手術(shù)雖然效果好,腎囊腫去頂?shù)某晒β士蛇_(dá)100%,缺點(diǎn)是手術(shù)創(chuàng)傷大,恢復(fù)慢,影響體力勞動(dòng),并發(fā)癥高,患者往往難以接受。但在一些情況下仍需采用該項(xiàng)治療方法;如嚴(yán)重感染腎囊腫,合并腎臟腫瘤、腎、輸尿管畸形,結(jié)石等復(fù)雜情況,或者腹腔鏡手術(shù)失敗的補(bǔ)救治療措施[6]。本組病例中,開(kāi)放手術(shù)組在術(shù)中出血量,住院時(shí)間及術(shù)后引流天數(shù)等方面與腹腔鏡組比較,差異有統(tǒng)計(jì)學(xué)意義。

近十幾年來(lái)腹腔鏡手術(shù)在我國(guó)泌尿外科的應(yīng)用得到快速發(fā)展,應(yīng)用腹腔鏡行腎囊腫去頂治療與傳統(tǒng)的開(kāi)放性手術(shù)比較,具有創(chuàng)傷小,術(shù)后恢復(fù)快等優(yōu)點(diǎn),被認(rèn)為是目前治療單純性腎囊腫的理想方法[7]。近幾年機(jī)器人輔助腹腔鏡下行腎囊腫去頂也取得成功,但是由于其手術(shù)費(fèi)用昂貴,不利于進(jìn)行廣泛推廣[8]。

腹腔鏡腎囊腫去頂術(shù)有經(jīng)腹腔和后腹腔兩種徑路,經(jīng)腹腔徑路解剖標(biāo)志清楚,手術(shù)空間大,易操作,且可同時(shí)處理雙側(cè)病變,對(duì)于腎盂周圍囊腫、肥胖、術(shù)中有污染機(jī)會(huì)的患者尤為可取;但對(duì)既往有腹腔內(nèi)手術(shù)、腹腔內(nèi)感染的病例限制了腹腔鏡的應(yīng)用[9]。其對(duì)于腹腔內(nèi)干擾較大,有引起腸管、腸黏膜和血管損傷等并發(fā)癥;經(jīng)后腹腔途徑較直接,不受腹腔臟器的干擾,減少了胃腸道反應(yīng)及術(shù)后腹腔感染和粘連的機(jī)會(huì)。但其手術(shù)空間較小,缺乏明確標(biāo)志,立體感差,對(duì)巨大腎囊腫,存在感染局部粘連,體型過(guò)于肥胖、患側(cè)上尿路曾有過(guò)手術(shù)史及腎盂囊腫應(yīng)慎用此途徑[10]。

不論采用何種治療方法、治療的最理想目標(biāo)是將腎囊腫徹底清除,且確保其不再?gòu)?fù)發(fā),穿刺硬化治療腎囊腫復(fù)發(fā)率高,但其操簡(jiǎn)便,住院時(shí)間短手術(shù)費(fèi)用少,恢復(fù)快,并發(fā)癥較小,尤其適合于老年體弱,接受麻醉、手術(shù)風(fēng)險(xiǎn)相對(duì)較大的患者。開(kāi)放性腎囊腫去頂減壓術(shù)、創(chuàng)傷大,恢復(fù)慢,主要應(yīng)用于一些復(fù)雜的腎囊腫,腹腔鏡手術(shù)治療與開(kāi)放性手術(shù)相比,對(duì)患者創(chuàng)傷小,手術(shù)時(shí)間短,術(shù)中出血少,術(shù)后腸道功能恢復(fù)明顯優(yōu)于開(kāi)放性手術(shù),而且能夠切除囊腫壁且復(fù)發(fā)率低,同時(shí)可切除任何部位的腎囊腫,尤其是雙腎多發(fā)性腎囊腫,或者不能排除惡性者或經(jīng)皮腎穿刺困難者[5]。

綜上所述,三種腎囊腫治療方法各有其優(yōu)缺點(diǎn),術(shù)者需根據(jù)單位醫(yī)療條件及操作熟練程度,結(jié)合囊腫情況合理選擇手術(shù)方式。腹腔鏡技術(shù)在不斷的提高,手術(shù)器械設(shè)備也在不斷完善,腹腔鏡腎囊腫去頂減壓術(shù)具有創(chuàng)傷小、并發(fā)癥低等優(yōu)點(diǎn),其療效是非常確切的,基本上可以取代傳統(tǒng)的開(kāi)放手術(shù)治療,已成為腎囊腫外科手術(shù)治療方法的首選,值得基層廣大醫(yī)院推廣使用。

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[3]Monville H,Wagner L,Dibo D,et al.Percutaneous ethanol sclerotherapy of symptomatic renal cysts:Results after 4 years of follow-up.Prog Urol,2014,24(6):353-358.

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[6]張旭,葉章群,宋曉東,等.腹腔鏡與開(kāi)放性腎囊腫去頂術(shù)的比較(附30例報(bào)告).臨床泌尿外科雜志,2001,16(4): 220-222.

[7]張經(jīng)中,王昆峰,金周明,等.腹腔鏡經(jīng)腹腔途徑治療腎囊腫23例體會(huì).中華全科醫(yī)師雜志,2003,2(1):57-58.

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A comparative study on the results of simple renal cyst decortication between 3 different approaches

L
i Hao1Mi Qinghui1He Yongjun1Jia Rui1
(1Department of Urology,People＇s Hospital of Guizhou Province Qiannan,Duyun Guizhou 558000,China)

Li Hao,lihao2018＠163.com

Objective:To evaluate the clinical significance of laparoscopic renal cyst decortication,open renal cyst decortication and renal cyst puncture sclerotherapy.Methods:The clinical data of 85 patients with simple renal cyst were analyzed retrospectively.There were 53 males and 32 females.The mean age was 43(22-72)years old.The average diameter of renal cysts was 6.8(4.8-13.2)cm.Of all the 85 patients,30 cases underwent laparoscopic renal cyst decortication,30 cases underwent open renal cyst decortication and 25 cases underwent percutaneous renal cyst sclerotherapy.The mean operative time,blood loss,post-operative hospital stay,postoperative drainage time and recurrence rate were compared between different surgical groups.Results:All the 85 patients underwent cyst decortication successfully without any obvious complication during or after surgery.The recurrence rate of laparoscopic or open surgery group was lower than in the puncture sclerotherapy group,accounting for 3.3%,0%and 24%,respectively(P＜0.05).Compared with open surgery group,the average blood loss,postoperative drainage time and postoperative hospital stay were less than in the laparoscopic and open surgery group(P＜0.05).There was no significant difference in the operative time between different surgery groups.Conclusions:All the 3 surgical procedures could get quite good results with different advantages in decortication of simple renal cyst.In general,laparoscopic renal cyst decortication is relatively better than the other 2 procedures with less blood loss,postoperative drainage time and postoperative hospital stay.Nevertheless,the final surgical choice should be made according to cyst characteristics and comprehensive assessment of the patient.

renal cyst decortication;laparoscopic;open surgery;sclerotherapy

R692

A

2095-5146(2014)05-271-03

李浩,lihao2018＠163.com

2014-08-16