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。

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.