根治性肾切除和静脉癌栓取出术大出血的危险因素

doi:10.19723/j.issn.1671-167X.2023.05.008

摘要/Abstract

摘要：

目的: 探讨分析肾癌伴静脉癌栓患者行根治性肾切除术和静脉癌栓取出术出现大出血的相关危险因素。方法: 回顾性分析2014年1月至2020年6月北京大学第三医院泌尿外科单中心肾癌伴癌栓患者241例，所有患者均行根治性肾切除术和静脉癌栓取出术, 对其中的相关术前指标、术中情况及术后资料应用SPSS 18.0统计学软件进行数据统计分析，研究的主要结局终点是术中出血量大于2 000 mL，应用Logistic回归分析确定相关影响因素，首先采用单因素Logistic回归分析进行影响因素的初筛，将单因素Logistic回归分析P < 0.05的变量纳入多因素Logistic回归分析模型。所有统计分析中P < 0.05认为差异有统计学意义。结果: 纳入的241例患者中出现大出血病例数为60例，男性48例，女性12例，中位年龄62岁。非大出血病例数为181例，男性136例，女性45例，中位年龄59岁。单因素分析结果显示两组患者在临床症状(同时存在系统症状和局部症状, OR 2.794, 95%CI 1.087~7.181, P=0.033)、手术入路方式(开放手术, OR 9.365, 95%CI 4.447~19.72, P < 0.001)、Mayo分级(Mayo 3~4级, OR 5.257, 95%CI 2.806~10.886, P < 0.001)、美国麻醉医师协会(American Society of Anesthesiologists, ASA)分级(ASA 3级, OR 2.842, 95%CI 1.338~6.036, P=0.007)、术前血红蛋白(OR 0.978, 95%CI 0.965~0.991, P=0.001)、术前血小板计数(OR 0.996, 95%CI 0.992~1.000, P=0.037)、最大癌栓宽度(OR 1.061, 95%CI 1.033~1.091, P < 0.001)、癌栓合并血栓(OR 4.493, 95%CI 2.264~8.915, P < 0.001)、肾上腺切除术(OR 3.101, 95%CI 1.614~5.958, P=0.001)、下腔静脉节段性切除术(OR 2.857, 95%CI 1.395~5.852, P=0.004)这些方面的对比，差异有统计学意义(P < 0.05)。多因素Logistic回归分析显示，患者的手术入路方式(开放手术, OR 6.730, 95%CI 2.947~15.368, P < 0.001)、Mayo分级(Mayo 3~4, OR 2.294, 95%CI 1.064~4.948, P=0.034)、癌栓合并血栓(OR 3.236, 95%CI 1.492~7.020, P=0.003)这些方面的对比，差异有统计学意义(P < 0.05)。结论: 结合单因素和多因素Logistic回归分析结果，手术入路方式、Mayo分级、癌栓合并血栓是导致肾癌伴癌栓手术中出现大出血的相关危险因素; 采取开放手术、Mayo分级高以及癌栓合并血栓的患者出现大出血的风险相对更高。

关键词: 肾癌, 静脉癌栓, 出血

Abstract:

Objective: To investigate and analyze the risk factors of massive hemorrhage in patients with renal cell carcinoma and venous tumor thrombus undergoing radical nephrectomy and removal of venous tumor thrombus. Methods: From January 2014 to June 2020, 241 patients with renal cancer and tumor thrombus in a single center of urology at Peking University Third Hospital were retrospectively analyzed. All patients underwent radical nephrectomy and removal of venous tumor thrombus. The relevant preoperative indicators, intraoperative conditions, and postoperative data were statistically analyzed by using statistical software of SPSS 18.0. The main end point of the study was intraoperative bleeding volume greater than 2 000 mL. Logistic regression analysis was used to determine the relevant influencing factors. First, single factor Logistic regression was used for preliminary screening of influencing factors, and variables with single factor Logistic regression analysis P < 0.05 were included in multivariate Logistic regression. In all statistical analyses, P < 0.05 is considered statistically significant. Results: Among the 241 patients included, there were 60 cases of massive hemorrhage, 48 males and 12 females, with a median age of 62 years. The number of non-massive hemorrhage was 181. There were 136 males and 45 females, with a median age of 59 years. Univariate analysis showed that the clinical symptoms (both systemic and local symptoms, OR 2.794, 95%CI 1.087-7.181, P=0.033), surgical approach (open surgery, OR 9.365, 95%CI 4.447-19.72, P < 0.001), Mayo grade (Mayo 3-4, OR 5.257, 95%CI 2.806-10.886, P < 0.001), American Society of Anesthesiologists (ASA) score (ASA level 3, OR 2.842, 95%CI 1.338-6.036, P=0.007), preoperative hemoglobin (OR 0.978, 95%CI 0.965-0.991, P=0.001), preoperative platelet count (OR 0.996, 95%CI 0.992-1.000, P=0.037), maximum tumor thrombus width (OR 1.061, 95%CI 1.033-1.091, P < 0.001), Complicated with bland thrombus (OR 4.493, 95%CI 2.264-8.915, P < 0.001), adrenalectomy (OR 3.101, 95%CI 1.614-5.958, P=0.001), segmental resection of the inferior vena cava (OR 2.857, 95%CI 1.395-5.852, P=0.004). There was a statistically significant difference in these aspects(P < 0.05). Multivariate Logistic regression analysis showed that there was a statistically significant difference in surgical approach (open surgery, OR 6.730, 95%CI 2.947-15.368;P < 0.001), Mayo grade (Mayo 3-4, OR 2.294, 95%CI 1.064-4.948, P=0.034), Complicated with bland thrombus (OR 3.236, 95%CI 1.492-7.020, P=0.003). Conclusion: Combining the results of univariate and multivariate Logistic regression analysis, the surgical approach, Mayo grade, and tumor thrombus combined with conventional thrombus were associated risk factors for massive hemorrhage during surgery for renal cell carcinoma with tumor thrombus. Patients who undergo open surgery, high Mayo grade, and tumor thrombus combined with conventional thrombus are at a relatively higher risk of massive hemorrhage.

Key words: Renal cell carcinoma, Venous tumor thrombus, Hemorrhage

中图分类号:

R737.1

兰东,刘茁,李宇轩,王国良,田晓军,马潞林,张树栋,张洪宪. 根治性肾切除和静脉癌栓取出术大出血的危险因素[J]. 北京大学学报（医学版）, 2023, 55(5): 825-832.

Dong LAN,Zhuo LIU,Yu-xuan LI,Guo-liang WANG,Xiao-jun TIAN,Lu-lin MA,Shu-dong ZHANG,Hong-xian ZHANG. Risk factors for massive hemorrhage after radical nephrectomy and removal of venous tumor thrombus[J]. Journal of Peking University (Health Sciences), 2023, 55(5): 825-832.

图/表 2

表1

大出血组与非大出血组的临床病理特征比较"

Items	Non-massive hemorrhage group (n=181)	Massive hemorrhage group (n=60)	P
Gender, n (%)			0.488
Male	136 (75.1)	48 (80.0)
Female	45 (24.9)	12 (20.0)
Age/years, M (P₂₅, P₇₅)	59 (53, 66)	62 (54, 68)	0.122
Clinical symptoms, n (%)			0.175
None	44 (24.3)	9 (15.0)
Local symptoms	93 (51.4)	31 (51.7)
Systematic symptoms	16 (8.8)	4 (6.7)
Both	28 (15.5)	16 (26.7)
BMI/(kg/m²), M (P₂₅, P₇₅)	23.3 (21.1, 25.8)	24.3 (21.4, 26.1)	0.107
Surgical approach, n (%)			< 0.001^*
Laparoscopic surgery	118 (65.2)	10 (16.7)
Open	63 (34.8)	50 (83.3)
Mayo classification, n (%)			< 0.001^*
0	56 (30.9)	4 (6.7)
1	40 (22.1)	2 (3.3)
2	63 (34.8)	28 (46.7)
3	16 (8.9)	11 (18.3)
4	6 (3.3)	15 (25.0)
ASA grade, n (%)			0.001^*
1	16 (8.8)	0 (0)
2	146 (80.7)	45 (75.0)
3	19 (10.5)	15 (25.0)
Preoperative serum creatinine/(μmol/L),	91 (80.5, 107)	93 (81, 112)	0.431
M (P₂₅, P₇₅)
Preoperative hemoglobin/(g/L), M (P₂₅, P₇₅)	124 (109.5, 139.5)	113 (97, 125)	＜0.001^*
Preoperative neutrophil/(×10⁹/L), M (P₂₅, P₇₅)	4.5 (3.4, 5.5)	4.4 (3.7, 5.1)	0.754
Preoperative lymphocyte/(×10⁹/L), M (P₂₅, P₇₅)	1.3 (1.0, 1.6)	1.2 (0.9, 1.5)	0.043^*
Preoperative monocyte/(×10⁹/L), M (P₂₅, P₇₅)	0.4 (0.3, 0.5)	0.4 (0.3, 0.5)	0.422
Preoperative platelet/(×10⁹/L), M (P₂₅, P₇₅)	241 (189.0, 303.5)	213 (167.0, 291.0)	0.033^*
Lesion side, n (%)			0.646
Left	66 (36.5)	24 (40.0)
Right	115 (63.5)	36 (60.0)
Tumor diameter/cm, M (P₂₅, P₇₅)	8.8 (6.7, 10.5)	8.7 (6.8, 10.9)	0.786
Maximum tumor thrombus width/mm, M (P₂₅, P₇₅)	20 (15, 30)	30 (20, 35)	＜0.001^*
Clinical phase of M, n (%)			0.669
M0	126 (69.6)	40 (66.7)
M1	55 (30.4)	20 (33.3)
Complicated with bland thrombus, n (%)			< 0.001^*
No	159 (87.8)	37 (61.7)
Yes	22 (12.2)	23 (38.3)
Adrenalectomy, n (%)			0.011^*
No	92 (50.8)	15 (25.0)
Yes	89 (49.2)	45 (75.0)
Segmental resection of IVC, n (%)			0.003^*
No	159 (87.8)	43 (71.7)
Yes	22 (12.2)	17 (28.3)
Lymph node dissection, n (%)			0.248
No	100 (55.2)	28 (46.7)
Yes	81 (44.8)	32 (53.3)
Operation time/min, M (P₂₅, P₇₅)	289 (218, 374)	408 (342, 499)	＜0.001^*
Blood loss/mL, M (P₂₅, P₇₅)	400 (150, 800)	3 000 (2 250, 4 000)	＜0.001^*
Intraoperative infusion volume/mL, M (P₂₅, P₇₅)	0 (0, 400)	2 000 (1 300, 2 800)	＜0.001^*
Pathological type, n (%)			0.854
Clear cell carcinoma	148 (81.7)	52 (86.7)
Papillary cell carcinoma	22 (12.2)	5 (8.3)
Chromophobe cell carcinoma	2 (1.1)	0 (0)
Unclassified cell carcinoma	7 (3.9)	3 (5.0)
Xp11.2 cell carcinoma	2 (1.1)	0 (0)
Nuclear classification, n (%)			0.358
1	3 (1.7)	0 (0)
2	68 (37.5)	17 (28.3)
3	74 (40.9)	26 (43.4)
4	36 (19.9)	17 (28.3)
Sarcomatoid features, n (%)			0.128
No	160 (88.4)	48 (80.0)
Yes	21 (11.6)	12 (20.0)
Perirenal fat infiltration, n (%)			0.063
No	129 (71.3)	35 (58.3)
Yes	52 (28.7)	25 (41.7)
Postoperative hospital stay/d, M (P₂₅, P₇₅)	8 (6, 10)	12 (8, 15)	＜0.001^*
Serum creatinine after one week/(μmol/L), M (P₂₅, P₇₅)	98 (79.0, 115.5)	93 (80.0, 121.0)	0.799
Postoperative complications, n (%)			＜0.001^*
No	139 (76.8)	18 (30.0)
Yes	42 (23.2)	42 (70.0)
Severe postoperative complications, n (%)			0.016^*
No	173 (95.6)	51 (85.0)
Yes	8 (4.4)	9 (15.0)

表1

表2

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Items	Univariate		Multivariate
Items	OR (95%CI)	P	OR (95%CI)	P
Gender
Male	Referent
Female	0.756 (0.369-1.547)	0.443
Age	1.022 (0.993-1.052)	0.132
Clinical symptoms
None	Referent		Referent
Clinical symptoms	1.630 (0.715-3.716)	0.246		0.727
Clinical symptoms	1.222 (0.33-4.527)	0.764		0.396
Both	2.794 (1.087-7.181)	0.033^*		0.276
BMI	1.050 (0.972-1.135)	0.212
Surgical approach
Laparoscopic surgery	Referent		Referent
Open surgery	9.365 (4.447-19.720)	< 0.001^*	6.730 (2.947-15.368)	< 0.001^*
Mayo classification
0-2	Referent		Referent
3-4	5.527 (2.806-10.886)	< 0.001^*	2.294 (1.064-4.948)	0.034^*
ASA grade
1-2	Referent		Referent
3	2.842 (1.338-6.036)	0.007^*		0.236
Preoperative serum creatinine	1.002 (0.998-1.005)	0.340
Preoperative hemoglobin	0.978 (0.965-0.991)	0.001^*		0.105
Preoperative neutrophil	1.024 (0.976-1.075)	0.327
Preoperative lymphocyte	0.538 (0.282-1.026)	0.060
Preoperative monocyte	1.642 (0.381-7.080)	0.506
Preoperative platelet	0.996 (0.992-1.000)	0.037^*		0.101
Lesion side
Left	Referent
Right	0.861 (0.473-1.566)	0.861
Tumor diameter	1.047 (0.955-1.148)	0.328
Maximum tumor thrombus width	1.061 (1.033-1.091)	< 0.001^*		0.782
Clinical phase of M
M0	Referent
M1	1.145 (0.614-2.136)	0.669
Complicated with bland thrombus	4.493 (2.264-8.915)	< 0.001^*	3.236 (1.492-7.020)	0.003^*
Adrenalectomy	3.101 (1.614-5.958)	0.001^*		0.051
Segmental resection of IVC	2.857 (1.395-5.852)	0.004^*		0.870
Lymph node dissection	1.411 (0.785-2.534)	0.249

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