机器人辅助腹腔镜下腔静脉节段性切除术治疗肾肿瘤瘤栓侵犯血管壁

doi:10.19723/j.issn.1671-167X.2025.04.027

摘要/Abstract

摘要：

目的: 系统评估机器人辅助腹腔镜下腔静脉节段性切除术在肾肿瘤合并下腔静脉瘤栓治疗中的安全性及肿瘤控制效果。方法: 回顾性分析2021年1月至2025年2月北京大学第三医院泌尿外科收治的，行机器人辅助腹腔镜下腔静脉节段性切除术的肾肿瘤患者临床资料，采集患者基本信息、肿瘤参数、围术期指标及随访信息，通过电子病历系统提取手术记录及病理报告。连续变量以中位数(P₂₅，P₇₅)描述，分类变量以频数(百分比)呈现。结果: 共44例患者纳入本研究，中位年龄62(55，68)岁，男性31例、女性13例，右侧肿瘤39例、左侧5例，中位肿瘤直径8.1(6.1，10.1) cm，Mayo分级Ⅱ级37例、Ⅲ级6例、Ⅳ级1例，23例患者接受了新辅助治疗，17例患者合并下腔静脉血栓。中位手术时间224.0(167.3，303.8) min，术中失血量500.0(300.0，850.0) mL，19例患者接受输血，悬浮红细胞中位输注量800.0(400.0，1 200.0) mL。术后并发症发生率56.8%(25/44)，Clavien-Dindo分级Ⅰ级8例、Ⅱ级17例；手术相关并发症包括下肢深静脉血栓6例、贫血需输血治疗5例、下肢水肿2例、肺栓塞2例，无手术相关死亡事件发生；术后中位肌酐116.0(86.5，157.5) μmol/L。病理组织学分析显示，肾透明细胞癌占大多数，为34例(77.3%)；术后肾肿瘤病理分期T3b期12例、T3c期29例、T4期3例，N1期8例，M1期17例。中位随访时间为10个月(范围1~49个月)，3例患者发生肿瘤特异性死亡，1例患者因其他原因死亡，5例患者随访期间发生肺转移，4例发生肝转移，4例发生局部复发。9例患者术后接受靶向和免疫联合辅助治疗，18例患者仅接受靶向辅助治疗。结论: 机器人辅助腹腔镜下腔静脉节段性切除术可实现复杂静脉瘤栓的精准切除，短期疗效确切，但需警惕血管相关并发症风险。

关键词: 肾肿瘤, 瘤栓, 下腔静脉, 节段性切除术, 机器人手术

Abstract:

Objective: To evaluate the safety and oncological outcomes of robot-assisted laparoscopic inferior vena cava (IVC) segmental resection in renal tumor with IVC tumor thrombus (IVCTT). Methods: Clinical data from renal tumor patients undergoing robot-assisted laparoscopic IVC segmental resection at Peking University Third Hospital from Jan. 2021 to Feb. 2025 were retrospectively analyzed. Data collection included baseline demographics, tumor characteristics, perioperative parameters, and follow-up outcomes. Surgical records and pathological reports were retrieved from the electronic medical record system. Continuous variables were presented as median (P₂₅, P₇₅), and categorical variables as frequency (percentage). Results: Forty-four patients were enrolled. The cohort comprised 31 males and 13 females, with a median age of 62 (55, 68) years. Right-sided tumors were observed in 39 cases and left-sided in 5 cases. Median tumor diameter was 8.1 (6.1, 10.1) cm. Mayo classifications included grade Ⅱ (n=37), Ⅲ (n=6), and Ⅳ (n=1). Neoadjuvant therapy was administered to 23 patients. Seventeen patients were complicated by IVC bland thrombus. Median operative time was 224.0 (167.3, 303.8) min, with intraoperative blood loss of 500.0 (300.0, 850.0) mL. Transfusion was administered to 19 patients, with a median blood transfusion of 800.0 (400.0, 1 200.0) mL. Postoperative complications occurred in 25 cases (56.8%), classified as Clavien-Dindo grade Ⅰ (n=8) and grade Ⅱ (n=17). Procedure-specific complications included deep vein thrombosis (n=6), transfusion-requiring anemia (n=5), lower extremity edema (n=2), and pulmonary embolism (n=2), with no procedure- related mortality. Median postoperative serum creatinine was 116.0 (86.5, 157.5) μmol/L. Pathological examination identified clear cell renal cell carcinoma as the predominant subtype, observed in 34 cases (77.3%). Pathological staging revealed T3b (n=12), T3c (n=29), and T4 (n=3) disease, with nodal involvement (N1) in 8 cases and distant metastasis (M1) in 17. At a median follow-up of 10 months (range: 1-49 months), cancer-specific mortality occurred in 3 patients, while 1 succumbed to other causes. Disease progression included pulmonary metastasis (n=5), hepatic metastasis (n=4), and local recurrence (n=4). Adjuvant therapy regimens comprised targeted-immunotherapy combinations (n=9) and targeted monotherapy (n=18). Conclusion: Robot-assisted laparoscopic IVC segmental resection achieves precise thrombus removal with confirmed short-term efficacy in renal tumor with IVCTT, though vigilance against vascular complications remains critical.

Key words: Kidney neoplasms, Tumor thrombus, Inferior vena cava, Segmental resection, Robotic surgical procedures

中图分类号:

R737.11

刘帅, 刘茁, 管允鹤, 王国良, 田晓军, 张洪宪, 刘磊, 马潞林, 张树栋. 机器人辅助腹腔镜下腔静脉节段性切除术治疗肾肿瘤瘤栓侵犯血管壁[J]. 北京大学学报（医学版）, 2025, 57(4): 796-802.

Shuai LIU, Zhuo LIU, Yunhe GUAN, Guoliang WANG, Xiaojun TIAN, Hongxian ZHANG, Lei LIU, Lulin MA, Shudong ZHANG. Robot-assisted laparoscopic inferior vena cava segmental resection for renal tumor with tumor thrombus invading the vascular wall[J]. Journal of Peking University (Health Sciences), 2025, 57(4): 796-802.

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参考文献 28

1	Bray F , Laversanne M , Sung H , et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J]. CA Cancer J Clin, 2024, 74 (3): 229- 263.
2	Liu Z , Zhang Q , Zhao X , et al. Inferior vena cava interruption in renal cell carcinoma with tumor thrombus: Surgical strategy and perioperative results[J]. BMC Surg, 2021, 21 (1): 402.
3	Hirono M , Kobayashi M , Tsushima T , et al. Impacts of clinicopathologic and operative factors on short-term and long-term survi-val in renal cell carcinoma with venous tumor thrombus extension: A multi-institutional retrospective study in Japan[J]. BMC Can-cer, 2013, 13, 447.
4	Zhang R , Liu Z , Zhang M , et al. The value of a postoperative nomogram based on the primary tumor score for overall survival of patients with renal cell carcinoma and inferior vena cava tumor thrombus[J]. Urol Oncol, 2025, 43 (3): 190.e21- 190.e28.
5	Wang S , Gaurab P , Cui J , et al. Impact of left renal vein ligation on renal function following en bloc resection of segmental inferior vena cava and right kidney[J]. Ann Surg Oncol, 2024, 31 (7): 4787- 4794.
6	叶剑飞, 马潞林, 赵磊, 等. 腔静脉节段切除术在处理侵犯腔静脉的肾肿瘤瘤栓中的应用[J]. 北京大学学报(医学版), 2018, 50 (1): 183- 187. doi: 10.3969/j.issn.1671-167X.2018.01.031
7	刘茁, 王国良, 田晓军, 等. 下腔静脉节段性切除术在肾癌伴下腔静脉癌栓中的应用[J]. 现代泌尿外科杂志, 2018, 23 (9): 677- 681.
8	Du S , Huang Q , Yu H , et al. Initial series of robotic segmental inferior vena cava resection in left renal cell carcinoma with caval tumor thrombus[J]. Urology, 2020, 142, 125- 132.
9	Otaola-Arca H , Krebs A , Bermúdez H , et al. Long-term oncological and functional outcomes after robot-assisted partial nephrectomy for clinically localized renal cell carcinoma[J]. Ann Surg Oncol, 2022, 29 (4): 2484- 2494.
10	Adams LC , Ralla B , Bender YY , et al. Renal cell carcinoma with venous extension: Prediction of inferior vena cava wall invasion by MRI[J]. Cancer Imaging, 2018, 18 (1): 17.
11	Blute ML , Leibovich BC , Lohse CM , et al. The Mayo clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus[J]. BJU Int, 2004, 94 (1): 33- 41.
12	Paner GP , Stadler WM , Hansel DE , et al. Updates in the eighth edition of the tumor-node-metastasis staging classification for urologic cancers[J]. Eur Urol, 2018, 73 (4): 560- 569.
13	Mitropoulos D , Artibani W , Biyani CS , et al. Validation of the Clavien-Dindo grading system in urology by the European Association of Urology Guidelines Ad Hoc Panel[J]. Eur Urol Focus, 2018, 4 (4): 608- 613.
14	赵勋, 颜野, 黄晓娟, 等. 癌栓粘连血管壁对非转移性肾细胞癌合并下腔静脉癌栓患者手术及预后的影响[J]. 北京大学学报(医学版), 2021, 53 (4): 665- 670. doi: 10.19723/j.issn.1671-167X.2021.04.007
15	Xie L , Hong G , Nabavizadeh R , et al. Outcomes in patients with renal cell carcinoma undergoing inferior vena cava ligation without reconstruction versus thrombectomy: A retrospective, case controlled study[J]. J Urol, 2021, 205 (2): 383- 391.
16	Kaneko J , Hayashi Y , Kazami Y , et al. Resection and reconstruction of the largest abdominal vein system (the inferior vena cava, hepatic, and portal vein): A narrative review[J]. Transl Gastroenterol Hepatol, 2024, 9, 23.
17	Liu Z , Zhao X , Zhang HX , et al. Peking University Third Hospital score: A comprehensive system to predict intra-operative blood loss in radical nephrectomy and thrombectomy[J]. Chin Med J (Engl), 2020, 133 (10): 1166- 1174.
18	Zini L , Destrieux-Garnier L , Leroy X , et al. Renal vein ostium wall invasion of renal cell carcinoma with an inferior vena cava tumor thrombus: Prediction by renal and vena caval vein diameters and prognostic significance[J]. J Urol, 2008, 179 (2): 450- 454.
19	Gohji K , Yamashita C , Ueno K , et al. Preoperative computerized tomography detection of extensive invasion of the inferior vena cava by renal cell carcinoma: Possible indication for resection with partial cardiopulmonary bypass and patch grafting[J]. J Urol, 1994, 152 (6 Pt 1): 1993- 1996.
20	Li QY , Li N , Huang QB , et al. Contrast-enhanced ultrasound in detecting wall invasion and differentiating bland from tumor thrombus during robot-assisted inferior vena cava thrombectomy for renal cell carcinoma[J]. Cancer Imaging, 2019, 19 (1): 79.
21	Dason S , Mohebal J , Blute ML , et al. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus[J]. Urol Clin North Am, 2023, 50 (2): 261- 284.
22	Gu L , Peng C , Li H , et al. Neoadjuvant therapy in renal cell carcinoma with tumor thrombus: A systematic review and meta-analysis[J]. Crit Rev Oncol Hematol, 2024, 196, 104316.
23	Chopra S , Simone G , Metcalfe C , et al. Robot-assisted level Ⅱ-Ⅲ inferior vena cava tumor thrombectomy: Step-by-step technique and 1-year outcomes[J]. Euro Urol, 2017, 72 (2): 267- 274.
24	Gu L , Ma X , Gao Y , et al. Robotic versus open level Ⅰ-Ⅱ inferior vena cava thrombectomy: A matched group comparative ana-lysis[J]. J Urol, 2017, 198 (6): 1241- 1246.
25	Wang B , Li H , Ma X , et al. Robot-assisted laparoscopic inferior vena cava thrombectomy: Different sides require different techniques[J]. Euro Urol, 2016, 69 (6): 1112- 1119.
26	Wang B , Huang Q , Liu K , et al. Robot-assisted level Ⅲ-Ⅳ inferior vena cava thrombectomy: Initial series with step-by-step procedures and 1-yr outcomes[J]. Euro Urol, 2020, 78 (1): 77- 86.
27	Zheng C , Zhang D , Kong Y , et al. Dynamic regulation of drug biodistribution by turning tumors into decoys for biomimetic nanoplatform to enhance the chemotherapeutic efficacy of breast cancer with bone metastasis[J]. Exploration (Beijing), 2023, 3 (4): 20220124.
28	Guo L , Chen H , Ding J , et al. Surface engineering Salmonella with pH-responsive polyserotonin and self-activated DNAzyme for better microbial therapy of tumor[J]. Exploration (Beijing), 2023, 3 (6): 20230017.

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Items	Data
Age/years, median (P₂₅, P₇₅)	62 (55, 68)
Male, n(%)	31 (70.5)
Body mass index, median (P₂₅, P₇₅)	24.5 (22.1, 27.3)
Side, n(%)
Left	5 (11.4)
Right	39 (88.6)
Size/cm, median (P₂₅, P₇₅)	8.1 (6.1, 10.1)
Mayo classification, n(%)
Ⅰ	0 (0)
Ⅱ	37 (84.1)
Ⅲ	6 (13.6)
Ⅳ	1 (2.3)
ASA class, n(%)
Ⅰ	2 (4.5)
Ⅱ	28 (63.6)
Ⅲ	14 (31.8)
Operative time/min, median (P₂₅, P₇₅)	224.0 (167.3, 303.8)
Estimated blood loss/mL, median (P₂₅, P₇₅)	500.0 (300.0, 850.0)
Patients receiving transfusion, n(%)	19 (43.2)
Lymph node dissection, n(%)	29 (65.9)
Adrenalectomy, n(%)	31 (70.5)
Postoperative hospital stay/d, median (P₂₅, P₇₅)	6 (5, 8)
Preoperative serum creatinine/(μmol/L), median (P₂₅, P₇₅)	102.5 (82.3, 115.3)
Postoperative serum creatinine/(μmol/L), median (P₂₅, P₇₅)	116.0 (86.5, 157.5)
Venous tumor thrombus combined with bland thrombus, n(%)	17 (38.6)
Histological type, n(%)
Clear cell renal cell carcinoma	34 (77.3)
Papillary renal cell carcinoma	2 (4.5)
Unclassified renal cell carcinoma	2 (4.5)
Spindle cell sarcoma	1 (2.3)
Leiomyosarcomas	1 (2.3)
TFE3-rearranged renal cell carcinoma	1 (2.3)
Fumarate hydratase-deficient renal cell carcinoma	1 (2.3)
Indeterminate histology due to treatment response	2 (4.5)
Four-tiered WHO/ISUP grading system, n(%)
Ⅰ	1 (2.3)
Ⅱ	8 (18.2)
Ⅲ	10 (22.7)
Ⅳ	15 (34.1)
Not graded	10 (22.7)
T stage, n(%)
T3b	12 (27.3)
T3c	29 (65.9)
T4	3 (6.8)
N1, n(%)	8 (18.2)
M1, n(%)	17 (38.6)
Adrenal metastasis, n(%)	3 (6.8)
Invade the wall of the vena cava, n(%)	36 (81.8)
Complication, n(%)	25 (56.8)