機器人腹腔鏡下左側腎癌合并癌栓的技術改進:免介入栓塞7例報告（“大家泌尿網”觀看手術視頻）

A modified surgical technique of robot-assisted inferior vena cava thrombectomy for patients with left renal cell carcinoma and tumor emboli：a report of 7 cases eliminating preoperative interventional embolization

WANG Shengzheng，CUI Jinshan，LI Zhenhao，LIU Yunlong，YU Shuanbao，FAN Yafeng，ZHU Zhaowei，TAO Jin，ZHANG Xuepei

（Department of Urology，The First Affiliated Hospital of Zhengzhou University，Zhengzhou 450001，China）

ABSTRACT：Objective To explore the safety and feasibility of the disconnection of the left renal artery preferentially during robot-assisted inferior vena cava （IVC） thrombectomy for patients with left renal cell carcinoma and tumor emboli.Methods Clinical data of 7 patients who underwent robot-assisted IVC thrombectomy and radical nephrectomy in the First Affiliated Hospital of Zhengzhou University during Dec.2021 and Oct.2024 were retrospectively analyzed.Thrombectomy was performed first，followed by nephrectomy.The “IVC-first， kidney-last”robotic technique was developed to minimize chances of IVC thrombus. When patients in" left lateral decubitus position， the left renal artery was severed from the right side through the inferior vena cava and abdominal aorta. After removal of thrombus from IVC was completed， patients" changed to the right lateral position to complete radical left nephrectomy. Results Imaging examinations revealed that the median diameter of the renal cell carcinomas was 83（46-99） mm; the median length of the inferior vena cava cancerous emboli was 49（2-91） mm.According to the Mayo classification，the cancerous emboli were gradeⅠ in 2 cases，gradeⅡ in 4 cases，and grade Ⅲ in 1 case.All surgeries were successful.The median operation time was 248（201-331） minutes，blood loss 500（200-1000） mL，and 6 cases required intraoperative blood transfusion.The median time for transition into the intensive care unit was 1（1-4） days，and drainage tube removal 6（5-12） days.Serum creatinine increased significantly in 5 cases，4 of which returned to normal after 1 week，but 1 had renal insufficiency （creatinine 166 μmol/L）.Chylous fistula occurred in 1 patient，and lower extremity venous thrombosis developed in 3 patients.Pathological examinations indicated 6 cases of renal cell carcinoma and 1 case of MiT family translocation renal cell carcinoma.During the median follow-up of 17（1-35） months，5 cases were tumor-free，while 2 had lung and retroperitoneal metastases.They received targeted therapy of axitinib combined immunotheraphy and lived with tumors.Conclusion In the left lateral position for left renal cell carcinoma with cancerous emboli，robot-assisted laparoscopic thrombectomy by crossing the inferior vena cava and abdominal aorta and disconnecting the left renal artery first is safe and feasible.

KEY WORDS：renal neoplasm; left side; interventional embolization；inferior vena cava cancerous emboli; renal artery; robot-assisted laparoscopy；radical nephyectomy

摘要：目的 探討機器人腹腔鏡治療左側腎癌合并癌栓時優先離斷左腎動脈這一技術改進的安全性和可行性。方法 回顧性分析2021年12月—2024年10月于鄭州大學第一附屬醫院完成的7例機器人下腔靜脈癌栓取栓術+根治性左腎切除術患者的臨床資料。術中均采取先取栓再切除腎臟的策略：患者先取左側臥位，從右側入路越過下腔靜脈和腹主動脈，優先離斷左腎動脈，再離斷下腔靜脈屬支后完成取栓術，然后改為右側臥位行左腎根治性切除術。結果 影像學檢查提示7例左腎腫瘤中位直徑83（46～99）mm、下腔靜脈癌栓長度49（21～91）mm，Mayo分級Ⅰ級2例、Ⅱ級4例、Ⅲ級1例。所有手術均成功完成，中位手術時間248（201～331）min、術中失血量500（200～1000）mL，6例術中輸血。中位術后重癥監護室中轉時間1（1～4）d、引流管拔除時間6（5～12）d。術后血肌酐明顯升高5例，其中4例1周后恢復正常，1例腎功能不全（血肌酐166 μmol/L）；術后出現乳糜瘺1例、下肢靜脈新發血栓3例。術后病理提示腎透明細胞癌6例，小眼畸形轉錄因子（MiT）家族易位性腎細胞癌1例。7例患者中位隨訪時間17（1～35）個月，5例無瘤存活，2例肺轉移并腹膜后轉移患者口服阿昔替尼聯合免疫治療，均帶瘤存活。結論 左側腎癌合并癌栓在左側臥位下行機器人腹腔鏡下取栓術時越過下腔靜脈和腹主動脈優先離斷左腎動脈是安全可行的。

關鍵詞：腎腫瘤；左側；介入栓塞；下腔靜脈癌栓；腎動脈；機器人輔助腹腔鏡；根治性腎切除術

中圖分類號：R692 文獻標志碼：ADOI：10.3969/j.issn.1009-8291.2025.02.007

腎癌合并下腔靜脈癌栓切開取栓術是泌尿外科高風險手術之一，術后5年腫瘤特異性生存率為40%～68%^［1］?！?br>