| Objective: Section one,To compare the efficacy and safety of retroperitoneal space approach laparoscopic radical nephrectomy and open radical nephrectomy in the treatment of large renal carcinoma(Maximum tumor diameter ≥7.0cm)Section two,To compare the integrity of perirenal fascia and lipotomy in laparoscopic radical nephrectomy for renal cancer via peritoneal and retroperitoneal approaches.METHODS: Section one,The clinical data of 126 patients with renal carcinoma with maximum tumor diameter > 7.0cm who received radical nephrectomy in the Lanzhou University Second Hospital from July 2007 to December 2018 were retrospectively analyzed.There were 76 males and 50 females,aged 28-74 years old,with an average of(53.9±9.0)years old.The tumors were located on the left in 68 cases and on the right in 58 cases.The maximum diameter of tumors was 7.5-20 cm,with an average of(9.4±1.8)cm.Preoperative clinical stages were T2-T3.All patients underwent radical nephrectomy,49 underwent laparoscopic retroperitoneal space radical nephrectomy,and 77 underwent open radical nephrectomy.Patients with tumor thrombogenesis in the inferior vena cava,preoperative lymph node and distant metastasis,multiple tumors,and a history of abdominal surgery were excluded.There was no statistical significance in gender,age,tumor maximum diameter,tumor location and other general clinical data between the two groups(P > 0.05).The operative time,intraoperative blood loss,postoperative drainage volume,blood transfusion rate,postoperative ventilation time,postoperative hospital stay and follow-up data of the two groups were compared.Section two,Prospective comparison of clinical data of 121 cases of renal carcinoma treated by laparoscopic surgery from November 2018 to January 2021.The maximum diameter of the tumor was 2.4 ～ 18.0(7.0 ± 3.3)cm.There were 73 males and 48 females,aged 31-86(57.0 ± 11.4)years old.There were 58 tumors on the left and 63 on the right.Preoperative clinical stage T1 – T3 a.Patients with T3 b and above were excluded from this study.The retroperitoneal space pathway was used in 70 cases and the peritoneal space pathway was used in 51 cases.There were no statistically significant differences in age,gender,tumor size and tumor location between the two groups(P>0.05).Postoperative specimen integrity was divided into0～6 points and 7 grades: 0 points,complete rupture of renal tumor,rupture of contents(necrotic tumor tissues or infected purulent secretions)into the operative field,high risk of implant recurrence;1 point,the fascia and adipose capsule around the pole of renal tumor were opened,the renal parenchyma and tumor surface were visible,and the tumor capsule was incomplete or partially ruptured;2 point,the fascia and adipose capsule around the pole of renal tumor were opened,the renal parenchyma and tumor surface were visible,but the tumor capsule was intact;3 point,the fascia around the pole of renal tumor was opened,the adipose capsule was intact,and the renal parenchyma and tumor surface were not visible;4 point,the fascia and adipose capsule around the other pole of renal tumor were opened,and the renal parenchyma was visible,but the fascia around the pole of renal tumor was not opened;5point,the perirenal fascia of the other pole of the tumor was opened,the adipose capsule was completely removed,the renal parenchyma was not visible,but the perirenal fascia of the pole of the tumor was not opened;6 point,the perirenal fascia was not opened,complete resection was performed,perirenal adipose capsule and renal parenchyma were not visible.The specimen scores of the two groups were compared.Results: Section one,The operative time of retroperitoneal space laparoscopic radical nephrectomy and open radical nephrectomy were(204.2±78.7)min and(162.3±62.1)min,respectively.The intraoperative blood loss was(262.8±275.8)ml and(570.4±876.0)ml,respectively,and the postoperative hospital stay was(8.9±2.4)days and(11.2±5.7)days,respectively.The difference was statistically significant(P <0.05).There was no significant difference in postoperative drainage volume,blood transfusion rate and postoperative ventilation time between the two groups(P > 0.05).Postoperative follow-up was 3-151 months,with a median follow-up time of 64months(51.00-77.00 months).In the retroperitoneal space laparoscopic group,there were 12 cases of recurrence and 12 cases of death,including 5 cases of lung metastasis,5 cases of bone metastasis and 2 cases of multiple systemic metastasis.In the open group,there were 19 cases of recurrence and 21 cases of death,including 13 cases of lung metastasis,4 cases of bone metastasis,1 case of multiple metastasis,2cases of heart disease and 1 case of breast cancer.There was no significant difference in overall survival rate and progression-free survival rate between the two groups(P=0.549;P = 0.651).Section two,The integrity score of 0-6 was 0,0,7,12,18,8,6 cases and 1,1,35,24,6,2,1 case,respectively,in the peritoneal space group and the retroperitoneal space group.The score of the peritoneal space group was higher than that of the retroperitoneal space group,and the difference was statistically significant(Z=5.749,P=0.000).All the 121 patients were diagnosed as renal cell carcinoma.Conclusion: Section one,Retroperitoneal space laparoscopic radical nephrectomy has advantages over open radical nephrectomy in terms of intraoperative blood loss and postoperative hospital stay,but the operative time is longer.There was no statistically significant difference in oncology prognosis between the two groups.Section two,The integrity of peritoneal fascia and lipotomy in laparoscopic radical nephrectomy for renal cancer is better than that in retroperitoneal approach. |
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