目的:探讨肾癌合并静脉癌栓患者行根治性肾切除术及静脉癌栓清除术中大出血的危险因素。
方法:对2014年1月至2020年6月北京大学第三医院泌尿外科单中心241例肾癌合并癌栓患者进行回顾性分析。所有患者均接受根治性肾切除术和静脉癌栓去除。术前相关指标,术中情况,术后资料采用SPSS18.0统计软件进行统计分析。研究的主要终点是术中出血量大于2000mL。采用Logistic回归分析确定相关影响因素。首先,采用单因素Logistic回归对影响因素进行初步筛选,单因素Logistic回归分析P<0.05的变量纳入多因素Logistic回归分析。在所有的统计分析中,P<0.05被认为具有统计学意义。
结果:在包括的241例患者中,有60例大出血,48名男性和12名女性,平均年龄为62岁。非大出血为181例。有136名男性和45名女性,平均年龄为59岁。单因素分析显示,临床症状(包括全身症状和局部症状,或2.794,95CI1.087-7.181,P=0.033),手术方法(开放手术,或9.365,95CI4.447-19.72,P<0.001),Mayo等级(Mayo3-4,OR5.257,95CI2.806-10.886,P<0.001),美国麻醉医师协会(ASA)评分(ASA3级,OR2.842,95CI1.338-6.036,P=0.007),术前血红蛋白(OR0.978,95CI0.965-0.991,P=0.001),术前血小板计数(OR0.996,95CI0.992-1.000,P=0.037),最大肿瘤血栓宽度(OR1.061,95CI1.033-1.091,P<0.001),合并轻度血栓(OR4.493,95CI2.264-8.915,P<0.001),肾上腺切除术(OR3.101,95CI1.614-5.958,P=0.001),下腔静脉部分切除术(OR2.857,95CI1.395-5.852,P=0.004)。在这些方面差异有统计学意义(P<0.05)。多因素Logistic回归分析显示手术入路(开放手术、OR6.730,95CI2.947-15.368;P<0.001),Mayo等级(Mayo3-4,OR2.294,95CI1.064-4.948,P=0.034),合并轻度血栓(OR3.236,95CI1.492-7.020,P=0.003)。
结论:结合单因素和多因素Logistic回归分析结果,手术方法,梅奥等级,肿瘤血栓合并常规血栓是肾细胞癌合并肿瘤血栓术中大出血的相关危险因素。接受开放手术的患者,Mayo等级很高,肿瘤血栓和常规血栓合并大出血的风险相对较高。
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).
CONCLUSIONS: 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.