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54歳男性.両側腎癌,右cT1b/左cT1bN0M0(右腎腫瘍径6.8cm,R.E.N.A.L. nephrometry score[RNS]10点,左腎腫瘍径6.0cm,RNS 9点)に対して2期的に両側腎部分切除術を行った.術前に3次元(3D)模型を作成し,血管・尿路・腫瘍の位置関係を把握し,手術のシミュレーションを行った.解剖学的に腎盂損傷のリスクが低く,確実な機能温存が期待できる経腹的左腎部分切除術を先に行った.動静脈温阻血7分で,腫瘍に入る動静脈分枝を選択的に切離して切除を完遂した.術後1ヵ月での総腎機能がCre 0.9mg/dl(推定糸球体濾過率[eGFR]68.9ml/min/1.73m2)で,99mTc-DTPA腎シンチグラフィーによる左分腎機能がGFR 36.2ml/minと保持されていることを確認し,5ヵ月後に経腹的右腎部分切除術を施行した.右腎腫瘍は腎門部に近く,出血と尿瘻のリスクが高いと想定された.選択的に動脈分枝の結紮切離を行ったが,動静脈温阻血28分を要した.尿管ステント留置を術中から行っていたにも関わらず術後8週目の時点で尿瘻の遷延を認めた.患者の苦痛軽減と安定したステント管理のため,経皮経膀胱的尿管ステント留置に変更し,術後12週で尿瘻は治癒した.病理診断は,左右共にclear cell renal cell carcinoma,pT1b,切除断端陰性であった.術後3年経過した現在,総腎機能はCre 1.01mg/dl,eGFR 59.8ml/min/1.73m2と温存され,癌の再発を認めていない.3D模型による術前シミュレーションは,腫瘍と腎血管・尿路との解剖学的関係の理解に基づいて,詳細な手術手順のリハーサルが可能で,難易度が高いと予想される腎部分切除症例に有用と思われる.経皮経膀胱的尿管ステント留置は,尿瘻が長期化した場合の患者の負担を軽減する対処法として有用と思われる.(著者抄録)A 54-year-old male presented with gross hematuria. Ultrasonography and computed tomography (CT) revealed a right kidney tumor of 68 mm and another left kidney tumor of 64 mm in diameter. Contrast-enhanced CT findings were suggestive of bilateral renal cell carcinoma (right cT1b/left cT1bN0M0). Their R.E.N.A.L. nephrometry scores were 10 and 9 points for the right and the left kidney, respectively. We developed three-dimensional (3D) kidney models to simulate open partial nephrectomy (PN) preopera- tively. According to the simulations, we planned two stage PNs with selective blood vessel dissection and urinary stenting due to the high possibility of postoperative urinary leakage. Firstly, we performed left PN with a 7-minute long renovascular clamping. After confirming renal function preservation, right PN was performed with a 28-minute long renovascular clamping. Due to long lasting postoperative urinary leakage of the right kidney, the transuretheral stent placed during the surgery was replaced by a percutaneous transvesical urinary stent 8 weeks postoperatively. The patient＇s burden was reduced by avoiding discomfort and catheter troubles. The urinary leakage was cured 12 weeks postoperatively. Pathological examinations revealed both tumors were clear cell renal cell carcinoma, pT1b with negative surgical margin. The estimated glomerular filtration rates 3 years after PN was well preserved at 59.8 ml/min/1.73m2. The patient has been doing well without cancer recurrence for 3 years. The three-dimensional kidney models facilitated us to understand the renal vascular anatomy as well as spatial relationships between the tumor and the urinary collecting system. We could rehearse the surgical procedure and take measures against conceivable complications. Preoperative simulations using 3D kidney models and percutaneous transvesical urinary stenting may help to complete partial nephrectomy in patients with highly complexed renal tumors. |
