目的： 探讨后腹腔入路机器人根治性肾切除联合静脉瘤栓取出术的安全性及可行性。方法： 入选4例瘤栓患者,2例为左侧肾癌伴静脉瘤栓（Mayo分级均为0级,301瘤栓分级均为0a级）,2例为右侧肾癌伴静脉瘤栓（Mayo分级分别为Ⅰ级、Ⅱ级,301瘤栓分级均为Ⅰ级）（下文均为Mayo瘤栓分级）。手术采用经后腹腔入路,术中通过第三臂牵拉固定肾脏,制造操作空间,沿腰大肌深面显露并充分游离瘤栓所在下腔静脉段及各属支。对于左侧肾癌伴0级瘤栓,术中游离左肾静脉至肠系膜上动脉夹角处后离断左肾静脉。对于右侧肾癌伴Ⅰ级瘤栓,采用milk技术处理瘤栓近心端,利用Satinsky钳钳夹部分腔静脉侧壁,将瘤栓推回患侧肾静脉内,于肾静脉与下腔静脉交汇处离断右肾静脉,无须阻断下腔静脉。对于右侧肾癌伴Ⅱ级瘤栓,环形游离下腔静脉后依次阻断下腔静脉远心端、左肾静脉及下腔静脉近心端后剖开取栓,完整剥离瘤栓,重建下腔静脉。最后行肾根治性切除术。结果： 所有手术均经后腹腔入路完成,无中转开放手术。手术时间为110~210 min,平均158.75 min,术中估计出血量为200~1 000 mL,平均487.5 mL,无输血病例。术后放置引流管3 d,平均术后3 d拔除尿管,平均住院4 d。无术后出血、肺栓塞并发症发生。结论： 经后腹腔入路机器人根治性切除联合静脉瘤栓取出术安全、可行,为肾癌伴静脉瘤栓患者提供了一种有效的微创治疗方式,同时不同侧别的肿瘤具有不同手术适应证及技术特点。但其临床疗效及预后评价仍需扩大样量进一步验证。

Objective： To investigate the safety and feasibility of robot-assisted retroperitoneal nephrectomy with vena thrombectomy.Methods： Of four enrolled patients, there were two cases of left renal cell carcinoma with tumor thrombus and the Mayo grade 0 (grade 0a in the 301 classification system); one case of right renal cell carcinoma with the Mayo grade I; and one case of right renal cell carcinoma with the Mayo gradeⅡ (The latter two cases were of grade I in the 301 classification system). All operations were performed via the retroperitoneal approach. The third arm was used to fix the kidney to create the operation space. The IVC with tumor thrombus and its branches along the psoasmuscle were exposed and dissociated then. The renal vein was blocked by the Satinsky forceps at the proximal end of the tumor for the patients with Mayo grade 0 and grade I, and the tumor thrombus was pushed back into the renal vein. Then the Endo-GIA was placed at the junction of the renal vein and the IVC to disconnect the right renal vein. There was no need to disconnect the IVC. For the patients with tumor thrombus of Mayo grade I, venous branches of the IVC, the lumbar vein and the short hepatic vein were released and disconnected. The distal end of the IVC, the left renal vein, and the IVC near the cardiac end were sequentially blocked, and the thrombus was removed. The inferior vena cava was reconstructed and the above-mentioned occlusion band was released. After the blood vessel was not oozing, the operation was performed according to the radical nephrectomy procedures.Results： All operations were completed successfully via the retroperitoneal approach without conversion to laparotomy. The average operative time was 158.75 min (range from 110 min to 210 min). The intraoperative blood loss was estimated to be 487.5 mL (ranger from 200 mL to 1 000 mL) and no blood transfusion was needed. The drainage tube was placed for 3 days. The catheter was removed after 3 days. Patients were discharged 4 days after surgery. There was no bleeding, pulmonary embolism and other complications after surgery.Conclusions： Robot-assisted retroperitoneal nephrectomy with vena thrombectomy is safe and feasible, which provides an effective minimally invasive treatment for renal cell carcinoma with tumor thrombus, and there are different surgical indications and technical characteristics for different-sided renal cell carcinoma. However, the clinical efficacy and prognosis of this procedure still need to be expanded to confirm by a larger sample.