肾血管平滑肌脂肪瘤破裂出血的手术时机

doi:10.19723/j.issn.1671-167X.2024.02.020

摘要/Abstract

摘要：

目的: 探讨不同的手术时机对肾血管平滑肌脂肪瘤(renal angiomyolipoma，RAML)破裂出血患者手术治疗效果的影响。方法: 选择北京大学第三医院泌尿外科2013年6月至2023年2月收治的31例RAML破裂出血患者的病例资料进行回顾性分析，记录患者人口学和围手术期资料，将出血后小于7 d手术定义为近期手术组，出血后7 d至6个月手术定义为中期手术组，出血后超过6个月手术定义为远期手术组，比较组间的围手术期相关指标。结果: 收集到行RAML破裂出血手术治疗的患者共31例，其中男性13例，女性18例，平均年龄(46.2±11.3)岁。近期手术组7例，中期手术组12例，远期手术组12例。肿瘤直径方面，远期手术组患者显著低于近期手术组[(6.6±2.4) cm vs. (10.0±3.0) cm, P=0.039]；手术时间方面，远期手术组显著低于中期手术组[(157.5±56.8) min vs. (254.8±80.1) min, P=0.006]，其余组间比较差异无统计学意义；出血量方面，远期手术组低于中期手术组[35 (10，100) mL vs. 650 (300，1 200) mL，P＜0.001]，其余组间比较差异无统计学意义；术中输血量方面，远期手术组显著低于中期手术组[ 0 (0，0) mL vs. 200 (0，700) mL, P=0.014]，其余组间比较差异无统计学意义；术后住院天数方面，远期手术组显著低于中期手术组[5 (4, 7) d vs. 7 (6, 10) d，P=0.011]，其余组间比较差异无统计学意义。结论: 对于RAML破裂出血的患者，6个月以上再行手术是一个相对安全的时间，手术时间相对最短，术中出血量相对最少，因此更推荐待保守治疗血肿机化后再进行手术治疗。

关键词: 血管平滑肌脂肪瘤, 破裂出血, 保留肾单位手术, 手术时机, 手术出血

Abstract:

Objective: To investigate the effect of different surgical timing on the surgical treatment of renal angiomyolipoma (RAML) with rupture and hemorrhage. Methods: The demographic data and perioperative data of 31 patients with rupture and hemorrhage of RAML admitted to our medical center from June 2013 to February 2023 were collected. The surgery within 7 days after hemorrhage was defined as a short-term surgery group, the surgery between 7 days and 6 months after hemorrhage was defined as a medium-term surgery group, and the surgery beyond 6 months after hemorrhage was defined as a long-term surgery group. The perioperative related indicators among the three groups were compared. Results: This study collected 31 patients who underwent surgical treatment for RAML rupture and hemorrhage, of whom 13 were males and 18 were females, with an average age of (46.2±11.3) years. The short-term surgery group included 7 patients, the medium-term surgery group included 12 patients and the long-term surgery group included 12 patients. In terms of tumor diameter, the patients in the long-term surgery group were significantly lower than those in the recent surgery group [(6.6±2.4) cm vs. (10.0±3.0) cm, P=0.039]. In terms of operation time, the long-term surgery group was significantly shorter than the mid-term surgery group [(157.5±56.8) min vs. (254.8±80.1) min, P=0.006], and there was no significant difference between other groups. In terms of estimated blood loss during surgery, the long-term surgery group was significantly lower than the mid-term surgery group [35 (10, 100) mL vs. 650 (300, 1 200) mL, P < 0.001], and there was no significant difference between other groups. In terms of intraoperative blood transfusion, the long-term surgery group was significantly lower than the mid-term surgery group [0 (0, 0) mL vs. 200 (0, 700) mL, P=0.014], and there was no significant difference between other groups. In terms of postoperative hospitalization days, the long-term surgery group was significantly lower than the mid-term surgery group [5 (4, 7) d vs. 7 (6, 10) d, P=0.011], and there was no significant difference between other groups. Conclusion: We believe that for patients with RAML rupture and hemorrhage, reoperation for more than 6 months is a relatively safe time range, with minimal intraoperative bleeding. Therefore, it is more recommended to undergo surgical treatment after the hematoma is systematized through conservative treatment.

Key words: Renal angiomyolipoma, Rupture and hemorrhage, Nephron-sparing surgery, Operation time, Intraoperative hemorrhage

中图分类号:

R737.11

陈克伟,邓绍晖,刘茁,张洪宪,马潞林,张树栋. 肾血管平滑肌脂肪瘤破裂出血的手术时机[J]. 北京大学学报（医学版）, 2024, 56(2): 326-331.

Kewei CHEN,Shaohui DENG,Zhuo LIU,Hongxian ZHANG,Lulin MA,Shudong ZHANG. Discussion on the surgical timing of rupture and hemorrhage of renal angiomyolipoma[J]. Journal of Peking University (Health Sciences), 2024, 56(2): 326-331.

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参考文献 18

1	Castle SM , Gorbatiy V , Ekwenna O , et al. Radiofrequency ablation (RFA) therapy for renal angiomyolipoma (AML): An alternative to angio-embolization and nephron-sparing surgery[J]. BJU Int, 2012, 109 (3): 384- 387. doi: 10.1111/j.1464-410X.2011.10376.x
2	Seyam RM , Alkhudair WK , Kattan SA , et al. The risks of renal angiomyolipoma: Reviewing the evidence[J]. J Kidney Cancer VHL, 2017, 4 (4): 13- 25. doi: 10.15586/jkcvhl.2017.97
3	Yamakado K , Tanaka N , Nakagawa T , et al. Renal angiomyolipoma: Relationships between tumor size, aneurysm formation, and rupture[J]. Radiology, 2002, 225 (1): 78- 82. doi: 10.1148/radiol.2251011477
4	Kothary N , Soulen MC , Clark TW , et al. Renal angiomyolipoma: Long-term results after arterial embolization[J]. J Vasc Interv Radiol, 2005, 16 (1): 45- 50. doi: 10.1097/01.RVI.0000143769.79774.70
5	孙青风, 王侠, 吴斌. 154例肾血管平滑肌脂肪瘤诊治原则的探讨[J]. 中国自然医学杂志, 2008, 10 (4): 259- 262.
6	Nelson CP , Sanda MG . Contemporary diagnosis and management of renal angiomyolipoma[J]. J Urol, 2002, 168 (4 Pt 1): 1315- 1325.
7	Eble JN . Angiomyolipoma of kidney[J]. Semin Diagn Pathol, 1998, 15 (1): 21- 40.
8	Neumann HP , Schwarzkopf G , Henske EP . Renal angiomyolipomas, cysts, and cancer in tuberous sclerosis complex[J]. Semin Pediatr Neurol, 1998, 5 (4): 269- 275. doi: 10.1016/S1071-9091(98)80005-3
9	Parmar N , Langdon J , Kaliannan K , et al. Wunderlich syndrome: Wonder what it is[J]. Curr Probl Diagn Radiol, 2022, 51 (2): 270- 281. doi: 10.1067/j.cpradiol.2020.12.002
10	Xu XF , Hu XH , Zuo QM , et al. A scoring system based on clinical features for the prediction of sporadic renal angiomyolipoma rupture and hemorrhage[J]. Medicine (Baltimore), 2020, 99 (20): e20167. doi: 10.1097/MD.0000000000020167
11	Earthman WJ , Mazer MJ , Winfield AC . Angiomyolipomas in tuberous sclerosis: Subselective embolotherapy with alcohol, with long-term follow-up study[J]. Radiology, 1986, 160 (2): 437- 441. doi: 10.1148/radiology.160.2.3726123
12	Ewalt DH , Diamond N , Rees C , et al. Long-term outcome of transcatheter embolization of renal angiomyolipomas due to tuberous sclerosis complex[J]. J Urol, 2005, 174 (5): 1764- 1766. doi: 10.1097/01.ju.0000177497.31986.64
13	郑汉雄, 汪曾荣, 夏昕晖, 等. 手术切除与介入栓塞治疗肾错构瘤破裂出血的疗效比较[J]. 现代肿瘤医学, 2015, 23 (22): 3296- 3298.
14	Bissler JJ , Racadio J , Donnelly LF , et al. Reduction of postembolization syndrome after ablation of renal angiomyolipoma[J]. Am J Kidney Dis, 2002, 39 (5): 966- 971. doi: 10.1053/ajkd.2002.32770
15	陈挺, 张宝金, 颜力昊, 等. 肾错构瘤破裂出血的急诊处理[J]. 临床泌尿外科杂志, 2003, 18 (10): 588- 589.
16	江洪涛, 陈昭典, 沈周俊, 等. 肾错构瘤破裂出血的诊治(附10例报告)[J]. 临床泌尿外科杂志, 2000, 15 (8): 347- 348.
17	李四化, 陈羽, 张俊隆, 等. 肾血管平滑肌脂肪瘤破裂出血不同手术时机的围手术期风险评估[J]. 中山大学学报(医学版), 2018, 39 (3): 400.
18	杨兴国, 聂勇, 程帆, 等. 多中心肾错构瘤破裂出血急诊手术与非手术治疗疗效比较(附53例报告)[J]. 临床泌尿外科杂志, 2016, 31 (2): 115- 119.

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Items	Group of surgery within 14 days (n=7)	Group of surgery between 7 days and 6 months (n=12)	Group of surgery over 6 months (n=12)	F/χ²	P
Age/years, $\bar x \pm s$	44.0±10.4	44.0±10.4	49.7±12.6	0.921	0.409
Gender, n(%)				0.003	0.998
Male	3 (42.9)	5 (41.7)	5 (41.7)
Female	4 (57.1)	7 (58.3)	7 (58.3)
Height/cm, $\bar x \pm s$	166.0±7.6	165.8±9.2	165.8±7.7	0.002	0.997
Weight/kg, $\bar x \pm s$	65.9±15.2	71.3±9.2	68.3±7.8	0.631	0.540
BMI/(kg/m²), $\bar x \pm s$	23.6±3.5	25.9±2.8	24.8±1.7	1.748	0.193
Underlying disease, n(%)	2 (28.6)	3 (25.0)	5 (41.7)	0.819	0.664
Clinical symptom, n(%)
Back pain	7 (100.0)	10 (83.3)	6 (50.0)	8.148	0.017
Hematuria	1 (14.3)	2 (16.7)	1 (8.3)	0.384	0.825
Fever	3 (42.9)	1 (8.3)	1 (8.3)	4.243	0.120
Renal cyst	0 (0.0)	3 (25.0)	5 (41.7)	4.105	0.130
Max diameter of RAML/cm, $\bar x \pm s$	10.0±3.0	8.7±2.9	6.6±2.4	3.846	0.033
Side, n(%)				0.444	0.801
Left	4 (57.1)	6 (50.0)	5 (41.7)
Right	3 (42.9)	6 (50.0)	7 (58.3)
Multiple site, n(%)	5 (71.4)	6 (50.0)	4 (33.3)	2.589	0.274
Polar position, n(%)				3.125	0.537
Upper pole	2 (28.6)	5 (41.7)	6 (50.0)
Middle pole	0 (0.0)	2 (16.7)	2 (16.7)
Lower pole	5 (71.4)	5 (41.7)	4 (33.3)

Items	Group of surgery within 7 d (n=7)	Group of surgery between 7 d and 6 months (n=12)	Group of surgery over 6 months (n=12)	F/χ²	P
Surgical approach, n(%)				5.424	0.247
Laparoscopy	4 (57.1)	7 (58.3)	10 (83.3)
Open	2 (28.6)	5 (41.7)	2 (16.7)
Robot-assisted laparoscopy	1 (14.3)	0 (0.0)	0 (0.0)
Operation time/min, $\bar x \pm s$	197.7±73.4	254.8±80.1	157.5±56.8	5.794	0.008
Warm ischemia time/min, $\bar x \pm s$	18.9±12.5	22.3±13.6	16.2±7.7	0.661	0.526
Estimated blood loss/mL, M(P₂₅, P₇₅)	400 (100, 600)	650 (350, 1 200)	35 (10, 100)	13.340	0.001
Blood transfusion rate, n(%)	2 (28.6)	6 (50.0)	0 (0.0)	7.870	0.020
Blood transfusion volume/mL, M(P₂₅, P₇₅)	0 (0, 400)	200 (0, 700)	0 (0, 0)	7.904	0.019
Nephrectomy rate, n(%)	0 (0.0)	2(16.7)	2 (16.7)	1.340	0.510
Preoperative serum creatine/(μmoI/L), $\bar x \pm s$	61.3±13.2	78.5±18.0	76.3±12.6	3.169	0.058
Postoperative serum creatine/(μmoI/L), $\bar x \pm s$	77.3±21.3	85.8±33.9	72.6±12.1	0.883	0.424
Serum creatine changes/(μmoI/L), $\bar x \pm s$	16.0±11.1	7.3±25.2	-3.8±10.3	2.881	0.073
ASA, n(%)				4.722	0.320
1	2 (28.6)	5 (41.7)	1 (8.3)
2	5 (71.4)	7 (58.3)	10 (83.3)
3	0 (0.0)	0 (0.0)	1 (8.3)
Postoperative hospitalization time/d, M(P₂₅, P₇₅)	5 (5, 6)	6.5 (6, 9.5)	5 (4, 7)	9.021	0.011

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