TAP CHl Y Da<?C L A M S A N G 108 T i p 7 - S6 3/2012
Ket qua dieu tri phau thuat c^t u than rong rai qua noi soi sau phuc mac
The Results of Retroperitoneoscopic Radical Nephrectomy for Renal Tumor
Hoang Long B^nh vi4n Vi^t £>i«:
B^t vin di. Nam 1990, Clayman ap dgng ndi soi qua phuc mgc dd cSt u than l^n ddu tidn trSn thd gidi.
Nghien cdu danh gia tinh hi$u qua, muc dd an toan cua ph§u thuat cSt u than qua ndi soi sau phuc mac {NSSPM) va riit ra kmh nghi$m dd cd thd phat tridn k? thu$t nay trong didu tri cac b$nh ly than ac tinh. D6I tUQmg vi phuong phip. Bao cao 17 trudng hip-p u than dugc cat th$n rdng rai qua NSSPI^I t u 01/2007 ddn 01/2011 tai B$nh vi$n Vi$t Ouc bao gdm 10 nam va 7 nd vdi tudi trung binh la 41.5 ± 22.6 tudi (21 - 74 tudi). Kit qui. Chi d|nh md bao gdm; 25.3% u T l , 35.3% T2 va 29.4% T3a {khdng cd huydt khdi tTnh mach chu dudi). Chung tdi sd dung 3 trocars trong 58.8% va 4 trocar trong 41.2%. Thdi gian md trung binh la 92.6 ± 21.3 phiit (75 - 120 phiit), luang mau m^t trung binh la 88.9 ± 42.3 ml (30 - 200 ml). Kich thudc u trung binh la 4.5 ± 2.3 cm (3 - 7 cm). T^t ca ddu la ung thu te bao sang cua than (ROC). Cat than khd chiem 29.4% lien quan tinh trang xam lan quanh u, td chuc md day va tSng sinh mach quanh than nhung khdng phai chuydn md md. Ti le tai bidn chay mau trong md 5.9% va khong co bien chdng sau md. Thdi gian nSm vi&n trung binh la 4.2 ± 1.5 ngay (3 - 7 ngay). 100% BN duac theo doi sau md trung binh 36.41 ± 12.55 thang (12 - 54 thang), khdng phat hi§n I h l y tai phat tgi chd va di can u. Kit iu$n. Phiu thuat c^t u than NSSPM la phuong phap an toan, hieu qua va cd the ap dung rdng rai trong dilu trj cac benh Iy than ac tinh.
TCF khoi: Npi soi d bung, ung thu te bao than, c^t than tnet dd qua ndi sol sau phiic mac.
Summary
Introduction: The first laparoscopic nephrectomy (LPN) was done by Clayman in 1990 for the treatment of the renal tumor. The study evaluated the safety, efficacy and our experiences to expand the use of retroperitoneoscopic radical nephrectomy (RPRN) for the treatment of renal malignant tumor. Material and methods: 17 patients underwent RPRN between January 2007 and January 2011 at Viet Due University Hospital including 10 males and 7 females whose mean age was 41.5 ± 22.6 years (ranging from 21 to 74).
Results: RPRN indication included: T l , T2 and T3a (tumoral thombosis of inferior vena cava wasn't included).The mean size of tumor was 4.5 ± 2.3 cm (3 - 7 cm). We used 4 trocars for 58.8% of cases and 3 trocars for 41.2%. The average duration of operation was 92.6 ± 21.3 minutes (75 - 120 minutes). Mean volume blood loss occupies 88.9 ± 42.3 ml (30 - 200 ml). The RPRN was difficult in 29.4% relating to perirenal invasion and obese patients, no open conversion was necessary. 94.1% of RPRN was successful.
The rate of per-operative haemorhage complication was 5.9%. The mean duration of hospitalization was 4.2
± 1.5 days (3 - 7 days). The postoperative pathology results showed Renal Cell Carcinoma, T1N0(23.5%), T2N0{35.3%) and T3aN0(29.4%). 100% of patients were followed up with the mean time of 36.41 ± 12.55 months (12 - 54 months). No local recurrent and tumoral metastasis were found. Conclusions: The RPRN for renal tumor is safe and an effective technique, which can be applied for the treatment of malignant tumors of the kidney.
Keywords: Laparoscopy, Renal cell carcinoma, Retroperitoneoscopic radical nephrectomy.
Phan bi^n khoa hoc: PGS. TS. NGUYEN THANH LONG
59
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY
I . D J t v i n d i
Ung thtf t t i j n \i b«nh IJ dCfng tiSng t h * 3 trong ung Ihu' tl4t nlOu sau ung t h u bSng quang vS t u y i n t i i n ll$t vii c h i i m l<hoang 3% ung thu' * ngu'dl I4n, Nam 1990, Clayman R.V Si Ap dgng nOI soi qua phijo mac (QPM) ai ci\ u th«n I4n d i u tISn tr«n t h i gifti.
Nam 1993, Gaur D. thg'c hi«n est t h j n nOI soi (CTNS) qua du'img sau phiSc mac (SPM). H i i n nay, CTNS Si au'(?c t r i i n khai rOng rSi trong v i i c d i i u Iri c4c b i n h lanh tinh vi ic tinh cOa du'dng t i i t n i i u [4|. Tai V i i t Nam, p h i u t h u i t (PT) c i t u t h i n nOi soi qua phiic mao du'QC thgc h i i n td' nam 2004 va xu hu'dng c h u y i n d i n sang dir(mg sau phuc mac. P h i u t h u i t n i y ducrc i p dgng tai B i n h v i i n V i i t Oii'c tu' nam 2005 cho d i n nay d4 dat du'O'c l<it qua t i t v i nh&ng kinh n g h i i m ban d i u . Qi tai nghiSn Cl>u cOa chung t i i n h i m mgc t i i u : Binh gii kit qui phiu thuft cit u thin r^ng rai qua nfyi sol sau phuc m^c.
2. o i l tiPQ'ng v i p h v a n g p h d p n g h i e n cipu 2.1. Bii tuvng nghiin ciru: 17 b i n h nhSn (BN) c h i n doan la u t i bao than t r i n chgp c i t top vi tinh va du'O'c p h i u thuat CTNS SPM tai khoa T i i t n i i u B i n h vian Viet Bi>c tu' 1 /2C07 d i n 1 /2011. Cac u du'dng bai tiet khong n i m trong nghidn ci>u.
2.2. Phuvng phap nghien cieu: Nghien ci>u m i ta t i i n CIHJ
BN CO cac tri^u chieng duvng tiit nl^u tren:
Gau that lu-ng, dai mau, kham thay than to du'gc iam 3. K i t qua n g h i e n cii'u
3.1. Chan doan u than: 17 BN gom 10 nam (58.8' ( 2 1 - 7 4 t u i i ) . e o tuoi t h u d n g gap n h i t la 41 - 60 c h i i m
Vol 7 • N'3l20n
s l i u i m va chup c i t Idp vi t(nh (CLVT) h i t i i t niSu, C h i n d o i n giai doan u theo p h i n loai TNM (1997) dg'a t r i n d i e d i i m v i kich thu'dc, vi tri, d i e tinh tanj sinh msoh, mi>c dO x i m 14" v i hach vOng. Xi\
n g h i i m chftc nSng t h i n v i danh g i i di can xa.
Cit u thin nfl sol sau phuc m ? c tft/^c cW dlnh cho u giai doan T l , T2 v i T3a chu'a c6 huyit k h i i tinh mach chii du'di (TMCD). PTNS c i t toSn t;}
t h i n , m d quanh t h i n , l4 chCrc hach c u i n g - r i n than v i c i t b i t u y i n thuo'ng t h i n cung thi d i i vdi u OK t r i n t h i n .
Dinh gii trong m6: Thay d i i h u y i t d i n g , lugng mau m i t v i mau t r u y i n , n i n g d i Oi v i CO2 mdu qua theo dSi S p O i va PmCOz. c a c b i i n chdng trong mi:
C h i y mau do t i n thgcrng mach. t i n thuwng tang do p h i u tich. Ty l i va n g u y i n n h i n c h u y i n m i m d .
Dinh gii cic yiu td iiin quan den kit qua PT:
Phan tich cac y i u t i nguy c o g i y kho khan cho PT v i gay b i i n chi>ng trong. sau m i : BN b i o phi, khoing each b d su'dn - m i o c h j u n g i n , Idp m d quanh than day, tang sinh mach m i u quanh u, giai doan u, bk thifdng mach m i u c u i n g than, raeh phuc mac ton thu'o'ng tang va chay m i u trong m i .
Dinh gii sau mo: Tinh trang h u y i t d i n g , aau sau m i , so lu'dng n i f d c tieu, b i i n chdng sau m6:
C h i y mau, tran khi du'di da, tg dich sau phiic mac.
Thdi gian n i m v i i n , k i t qua giai p h i u b i n h . Theo doi xa phat hi^n b i i n c h d n g , tai phat tai cho v i di can xa sau m i .
%) va 7 BN nu' (41.2%) c6 tuoi trung binh la 41.5 ± 22.6 52.9%.
Bang 1. Lien quan giu'a t r l ^ u chu'ng va t h d i g i a n phat h l ^ n u Thdi gian
Oau that lu'ng Oai mau Sot. gay sut can S d t h i y than to T i n s u i t chan doan
s 6 thang 5 5 3 3 6(29.4%)
12thang 3 3 3 2 3(17.6%)
18 thang 2 2 0 0 2(11.8%)
2 2 nam 4 1 0 0 4(23.5%)
Tong - % 14(82.4%) 11(64.7%) 6(35.3%) 5(29.4%) 14(82.4%) 23.5% BN phat hign benh m u d " sau 2 nam ti> khi cd tn$u chung d^u tien. 3 BN ph^t hi§n tinh cd' khong c6 trieu chirng (17.6%) Dau that lu'ng vS ddi mau 1^ hai dau hi$u chinh chiem 82.4 va 64.7%. Ty 16 chan d o ^ du'ac tru'de 6 thang chi chiem 29.4%.
Chan doan sieu am va chyp CLVT cho thay 11 u than phai va 6 u th^n trai, kich thu-^c u trung binh la 5.5 ± 2.3 cm (4 - 7 cm). Khdng BN nao cd huyet khoi TMCD.
60
TAP CHl Y DLTOC LAM S A N G 108 Tap 7 - S 6 3/2012
B i n g 2,
D$c diim u liin quan dlin biin trong m i
€)$c tinh cua u
Vi tri u Vl tri u
Giai doan u
1/3 tran 1/3 gi&a 1/3 dudi Ludi trudc
Lu'di sau Tl T2 T3a
S6 BN - t j l i % (n=17) 4 (23.5%) 6 (35.3%) 5 (29.4%) 9 (62.9%) 8(47.1%) 4 (23.5%) 6 (35.3%) 6 (29.4%)
Cit thin khd 5/17(29.4%) 2(11.8%) 3(17.6%)
0 4 (23.5%)
1 (5.9%) 0 1 (6.9%) 4 (23.6%)
Chiy mau trong mi 1/17(5.9%)
1 (5.9%) 0 0 1 (5.9%)
0 0 0 1 (5.9%)
3.2. Kit qua phau thu$tDien bien trong mo: Chung tdi si> dyng 3 trocars trong 58.8% va 4 trocar trong 41.2%. 100%
cuong mgch th$n du'p'c bdc Id rieng bi$t va e$p clip rieng ddng mach thSn (DMT) vd tTnh mach th$n (TMT), 4 BN cd DMT phu cho c y c tren th$n vk 4 u nSm a eye tren cd c5t tuyen thu'o'ng th$n cung thi.
Bdc Id va cat than khd gap d' 5 BN chiem ti 16 29.4%
gap chu yeu 6" nhdm u T3a v^ a \\.ta\ tru'd'c thgn chiem 80%. Gap 1 chay mau trong mo (5.9%) ti> Idp md' quanh u giai doan T 3 a eye a tren thSn xam l l n Idp md" xung quanh va tang sinh mach, cam mau du'p'c va khong phai chuyen mo md". Lu'O'ng mau mat trung binh la 88.9 ± 42.3 ml (30 - 200 ml), khong gap roi loan khi mau trong mo. Thdi gian mo trung binh la 92.6 ± 21.3 phiJt (75 - 1 2 0 phut).
Dien bien sau mo: Dung giam dau sau mo 2 - 3 ngay. Thdi gian nSm vien trung binh la 4.2 ± 1.5 (3 - 7 ngay). Khong cd bien chCpng sau mo. 9 4 . 1 % ket qua gan dat tot. 1 BN cd ket qua trung binh (5.9%) do dan lu'u ra cdn ra dich keo dai den ngky thu' 7 sau mo. Ket qua giai phau benh deu la ung t h y te bao sang va khong cd di can hach vung.
Theo doi xa sau mo: 100% BN du'p'c kham Igi vdi thiD'i gian trung binh sau mo la 36.41 ± 12.55 thang (12 - 54 thang). Tat ca BN deu khong cd bien chCpng xa sau mo va chua co BN nko phdt hien thay tai phat tai chd hoac di can xa.
4. Ban luan
U te bao sang cua than (Renal Cell Carcinoma - RCC) chiem khoang 9 0 % cac benh ly u than. D i l n bien am tham, tiem tang nen khi phat hiSn thay trieu chyng thi thydng u da CT giai doan ti6n trien gay anh hu'dng Idn d6n hinh thai, chifc nang than va phat trien sang cac to chLFc xung quanh. Nhdm BN trong nghien
ei>u eua chung tdi dyp'c ehSn dodn tu-crng d6i sdm vdi 29.4% BN phat hi^n t r y d c 6 thdng vk 17.6% phdt hi^n tinh c d khong bi^u hi$n tri^u chyng. 23.5% BN phat hi$n b$nh 2 nSm sau tri$u chieng dau tien deu da a giai dogn T3a nhyng c h y a cd huyet khoi TMCD nen van cdn chi dmh mo c^t than qua ndi soi. Nghien cuu eho thciy dd tuoi trung binh la 41.5, gap nhieu nhat la 41 - 60 tu6i chi6m 52.9%. ty Id BN nam nhidu hen nu', tuy nhien so lieu edn it nen khac biet khdng cd y nghia thong ke.
Cdc tac gia nhu' Abbou (1999), Matthew (2000), Bishoff (2007) deu thong nhdt la PTNS cat thSn cd yu diem hen han so vdi mo md- bieu hi^n hgu p h i u den gian, giam dau sau mo va tham my tdt hen eho BN. Viec dp dung PTNS de cat thgn khdng chi vdi benh ly lanh tinh ma ngay cang m d rdng doi vdi cdc benh ly dc tinh cua than. Qua PTNS v i n cd the thuc hien duac cat than rdng rai an toan nhu khi mo md [1], [3], [8]. liy ndm 1998, Rassweiler da long ket kinh nghiem cat than ndi soi cho 38 benh ly dc tinh va 444 benh ly lanh tinh cua than [10].
Nhieu nghien cuu cho thay khdng ed s y khac biet ve hieu qua cua phdu thudt CTNS trong va sau phiic mac nhy cua Mihir (2005), Jonathan (2005), Bishoff (2007) [3], [7], [9] Du'd'ng mo SPM co han che Id khd thyc hien d BN mo cu SPM, truo'ng hep mo hep hen do khoang SPM hep bi gidi han bdi to chye md gay khd khdn cho tiep can. bdc Id cudng than, giai phong u than. Doi vdi cdc benh ly u dudng bai tidt, u mat trudc than a giai doan phdt trien xam lan hay cd huyet khdi TMCD thi nhi6u nghien cuu lua chon dudng QPM de cd the cdt toan bp thgn nieu quan cung nhy kiem sodt va x y tri ton thyang mach mau dd dang va triet de hon [4], [9], [10]. Vdi BN chdn dodn u te bao than, u d mat sau than thi dudng mo SPM dup-c l y a chon. Chi djnh mo cua chung toi bao
61
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 7 - N°3;2012
g i m 23.5% u T 1 , 35,3% u T 2 , 29.4% u T 3 a k h i n g c i h u y i t k h i i TMCD.
G i i i p h i n g quanh t h i n di b i c 10 r i c i c t h i n h p h i n c u i n g mach t h i n i i th) m i quan trqng n h i t ciia CTNS SPM. N g u y i n t i c Chung khi PT ung Ihif t h j n l i p h i i b i c 10 va k i i m s o i t TMT t r d d c t i i n d i p h i t h i i n v i d i p h i n g sg' dl c h u y i n ciia m i m h u y i t k h i i ung thu' t d TMT v i o TMCD. Trong PT n i l soi n g u y i n t i c n i y cQng dutq/c tuan thii. Tuy n h i i n , v l i c bOc 10 v i c i p c i t d u v c OMT d i u t i i n , sau d i d i n TMT l i r i t c i n t h i i t giOp l i m g l i m Iddng m i u tdi t h i n , l i m xep TMT tao d i i u k i i n t h u i n lo'i cho c i p c i t v i sau, Khi TMT c i n cang s i iam tang nguy c c c h i y mau do d mau d than va cOng c i nghTa la c i n n h i n h OMT phu h o i c d i n g mach i ^ p m i u cho c i c cg'c than chu'a dUdC c i p c i t . Bay la m i t trong nh(/ng nguy Cd chinh gdy k h i khan cho cuOc m i , b i i n chdng chay m i u h o i c p h i i c h u y i n m i m d . Chung tOi si> dgng Clip Titanium d i kep DMT dam b i o an loan vdi It n h i t 3 clip cho m i l DMT. 2 clip d d i u trung t i m , 1 d d i u ngoai vi. Vdi TMT c6 t h i b u i c tang cu'dng b i n g chf Vicryl 2/0 hay 3/0 d i thu n h i du'dng kinh tru'de khi c i p clip. Trong n g h i i n c d u nay. c6 100% tru'dng hpp p h i u tich dudC ro c u i n g mach than chinh, bOc 10 v i c i p r i i n g OMT va TMT an toan b i n g Clip, khOng gap b i i n chdng.
MOt s i tac gia nhu' Bishotf, Matthew thu'dng s d dgng kep Endovascular GIA d i cap o i l TMT. Kavoiissi cho r i n g v i i c s d dgng Endovascular GIA d i x d ti i c u i n g mach CO t h i bi tuOt gay chay mau h o i c c6 b i i n chdng thong dOng - tTnh mach vdi ti 10 0.3% va 0.2%. MOt so tac gia khac lai s d dgng Hemo-lock d i kep DMT va TMT vi CO do an toan cao, gia thanh lai re hon nhieu so vdi Endovascular GIA [2], [3], (8].
V i i c p h i u tich vao r i n than la kho n h i t trong ky thuat mo nOi soi. Thu'ang tOn mach mau thi^dng x i y ra iam tang thdi gian mo, nguy OCT m i t mau va iam tang nguy Co t h i t bai ciia PTNS. P h i u tich vSo c u i n g than can tach biit DMT va TMT. Nhan xit trong m i cho thay nhdng u than giai doan phat t r i i n co tang sinh mach nen r i t kho p h i u tich c u i n g than tru'de tien. Khi do, can giai phong cac p h i n khac nhau ciia than CO u va vi§c tiep can vao cuong than se de dang hon. Thay doi t u the BN, dat them cac trocar cQng la cac biSn phap d u a c dat ra. N i u v i n con qua khO de b i c io cuong t h i n Ihi can can n h i c chuyen m i m d de dam bao an toan cho BN [8]. [9|. MOt yeu to lam tang nguy co chay mau trong mo. tang mdc dO kho cua phSu thuat la BN beo phi hay dai thao d u d n g . Ldp m d quanh than day kho p h i u tich tim du'tyc than. Mat khac, Sd tang sinh mach mau va mang bach huyet trong Idp m d quanh than cua b i n h canh ung thu' se lam giam tac dung cua cat va dot cam mau trong qua trinh p h i u ticti. Meraney va Gill da nhan manh cac nhanh mach bat thu'dng di vao cgc tren than ia nguon
g i c g i y c h i y m i u , VI v i y , khi p h i u tich quanh llijn p h i i chii i p h i t h i i n c i o D M T phg v i c i m mau kl mat d d d l t u y i n thdorng t h i n . N g o i i ra, c i c BN c i U l t h d d n g v i cOt s i n g , k h o i n g c i c h s d d n ldng hfp cDng la m i t y i u t i cang iam tSng mdc d i khd cua du'dng m i nOI sol SPM [2], [6].
Ti l i o i t t h i n k h i trong n g h i i n c d u n i y la 29.414.
Chiing l i i g i p 4 t r d d n g h d p c i D M T phg cho cgc trin v i 4 u CdC t r i n d m i t t r d d c t h i n d i u g i p k h i kh&i khi p h i u tich bOc 10 d i c i t t h i n rOng rai dl k i m cit t u y i n t h d d n g t h i n d 4 BN. Trong s i n i y 1 BN co c h i y mau trong m i t d d l i n p h i u tich u cgc trin da x i m I i n m d quanh t h i n d i c i m m i u d d o c qua nil sol. T i n t h d d n g mach trong CTNS xay ra b i t ky lOc n i o trong m i va c h i i m 1 - 3%, trong d i 0,5 - 1%U k h i n g k i i m s o i t d d d c qua nOi soi va p h i i chuyin m6 m d . Meraney g i p 7 t i n t h d o n g mach m i u trong 404 CTNS SPM c h i i m 1.7% g i m 2 raeh tinh macli thddng t h i n , 3 t i n t h d d n g TMT, 1 t i n Ihi/crng OMT va 1 t i n t h d d n g TMCD [1], (2]. c a c tac gia khi so sanh gida PTNS va m i m d thi d i u t h i y khOng c i s/
khac b i i t v i I d d n g m i u m i t trong m i tnjng binh &
100ml. Ldping mau m i t trung binh cua CTNS SPM thay d i i t d d n g dOi rOng t d 42 - 260ml [4], c i n trong n g h i i n c d u nay l i 88.9 ± 42.3 ml (30 - 200 ml). Khong c6 BN nao c i n t r u y i n mau trong m i .
Thdi gian m i trung binh trong nghien cdu la 92.6 + 21.3 phiit va dao d i n g t d 75 - 120 phiit so sinh t h i y tifang d d d n g v i n g i n h e n m i l s i nghien cdu khac [4], [8|. (9) Chung toi nhan t h i y nhdng u giai doan T3a xSm I i n t i chdc m d quanh than, u d lirfli trddc than va u d cdC t r i n cd c i t t u y i n thi«?ng thSn khi CTNS SPM gap nhieu khd khan han va k i o dai thdi gian mo hdn so v d i nhdng u d mat sau hoac cue du'di than. Thdi gian mo phg thgOc v i o mdc dO phiic tap ciia t i n t h i f o n g , dO k h i ciia p h i u thuat va kinii nghiOm ciia ngu'di m i . So vdi CTNS QPM, thdi gian m i thu'dng dai hdn [7], 19],
P h i u t h u i t CTNS SPM co nguy Cd chay mau cao hon du'dng m i Q P M . Trong mo m d , chay mau it khOng gay anh hu'dng d i n qua trinh PT. Ngdoc lai trong PTNS, mOt lu'dng it mau chay cung da gay n h i i u can tro nhu' che l i p n g u i n chay mau, hipttiu anh sang lam giam dO c h i i u s i n g , viae s d dgng may hiit iam giam ap Igc hoi vung mo, mau d i b i n dinii vao camera va lam m d camera. Ben canh d i , CTNS SPM cung co nguy c d iam ton thu'dng tang, ton thuang mach mau, raeh thung phiic mac, raeh co hoanh va thiing mang p h i i khi dat trocar (3]. Racii phiic mac la 1 tai bien hay gap vdi nguyen nhSn cM yeu la do BN n d beo, Idp m d quanh than day, phijc mac rat mong. Tinh trang viem phan dng va tham n h i l m u quanh than d l lam raeh phije mac gSy kho khan khi phau tich. bOc Ip than. Raeh eo hoanh co ttiJ xay ra khi dat trocar sat b d s d d n , hudng trocar khong
62
TAP CHl Y Da<?C LAM S A N G 108 T$p 7 - S d 3/2012
dung. N 4 U phdt hi^n kjp thd'i khdu co" hoeinh qua nOi soi sau khi dd hilt h6t khf trong khoang m&ng phfii.
Bishoff (2007) da ghi nh$n 10 tryd-ng hgp thOng ca ho^nh, trong do 2 do dgt trocar v ^ 8 g$p trong qud trinh ph§u tich th$n [3]. Ngodi ra, c6 t h l g^p t6n thuo'ng td trdng dyp-c Meraney ghi nh$n hay rd tyy theo Rassweiler. Nghidn ei>u cua chOng tdi khdng g$p cac bien chu'ng ndy. TI 1$ tai b i l n trong m l ndi chung Id 1.27 - 26.2% vd cSn phdi c h u y i n m l md- 10- 0 - 14.3% [2], [10]. Bien chCpng toan mdu trong m6 CTNS SPM cd nguy co gdp phai n h i l u han CTNS QPM do khoang SPM Id 1 khoang 3o khdng c6 gi6i hgn rd rang, giau mgch mdu, n h i l u t6 chuc long l§o, md"
rdng dan theo lygng hai bam vdo, do dd s§ h i p thu COE nhilu han d l gdy toan mdu vd trdn kh( du-di da [4], Chiing tdi khdng gdp roi loan khi mdu trong vd sau mo. Cdc BN trong mo vd d giai dogn h i i tinh d i u c6 Sp02 va PaiC02 duy tri trong gidi hgn binh t h y d n g (SpOa 99% - 1 0 0 % , pBiCOa s 35mmHg).
T i t ca BN deu cd tien t r i l n sau m l thu$n Ip-i.
khdng co chay mdu sau m l . Chi cd 1 BN ra d|ch mdu keo ddi sau m l 7 ngdy d" BN cd chdy mdu trong m l nhung khdng thay d i i h u y l t dOng vd xet nghi$m mdu.Tren thyc te, b i l n chu'ng chay mdu sau mo Id do ton thuang mgch mdu thu'd'ng gdp 6 vung tuyen thu'o'ng thgn, tTnh mgch sinh dye vd mom cdt ni^u quan. Vdi vigc gidm dp lye bam hai vd quan sdt ky tru'de khi ket thuc phdu thudt co the phdi hi^n duac nhu'ng diem chay mdu Xiy cdc nguon khac nhau neu tren va cd cdc ddng mgch eye, Idp md' quanh thdn, ddc bi§t la cdc tTnh mach trudc do bi de ep do bam hai dp lye cao. Theo Henry (2006), CTNS SPM cd ti le b i l n chijng chay mdu sau mo la 3.3% [5]. Cdn theo nghien ci>u eua Rassweiler (1998) Id 4.6% vdi ti Ig phai mo lai sau CTNS la 3.4%, trong do 50% do chay mdu, 25% do dp xe sau mo [10].
Theo ddi xa sau mo dat ket qua rat tot vdi 100%
BN dyp'c khdm Igi trung binh sau mo la 36.41 thang ( 1 2 - 5 4 thang). Tdt cd BN deu khdng dau thdt lu'ng vd khong cd roi loan tieu tien. Sieu am kiem tra khong thdy bat thyd'ng tai vung cdt thdn cO. Xet nghiem chuc ndng thdn trong gidi hgn binh thu'd'ng. Cd 7/17 BN (41.2%) dieu tri bo tra sau mo bdng lnte_rferon va khong BN nao phdt hi$n thay tai phat tgi chd hodc di can xa.
5. K i t luan
PTNS d y a e thyc hien qua dyd'ng sau phuc mac d 17 BN cdt u te bao thdn rdng rai da thu dup'c ket qua tot trong 9 4 . 1 % . Cdt than kho chiem 29.4% lien quan den giai dogn u T3a, vi tri u d ly&i t r y d c va eye tren thdn. Ti le chay mdu trong mo 5.9% va khong co b i l n chung sau mo. Tat ca BN deu dup'c theo doi xa sau mo t y 12 thdng den 54 thdng c h y a phat hien thay tdi phdt tgi eho va di cdn u. Phdu thugt CTNS SPM la
p h y a n g phdp an todn, h i | u qud vd cd t h l dp dgng r i n g rai trong d i l u trj cdc b | n h \)/ thdn dc tfnh.
Tdi ll$u t h a m khSo
1. Abbou C.C, CIssco A, Gasman D (1999).
Retroperitoneal laparoscopic versus open radical nephrectomy. The Journal of Urology. 161. 1776 - 1780.
2 Anoop M. Meraney, Inderbir S. Gill (2002). Vascular and bowel complications during retroperitoneal laparoscopic surgery. The Journal of Urology.168.1941-1944.
3. Bishoff Jay I, Louis R. Kavoussi (2007).
Laparoscopic surgery of the kidney. Campbell's Urology, sect 12, chap 51.1759-1809.
4. David C. Kerbl, Elspeth M. McDougall, Ralph V.
Clayman (2011). A history and evolution of laparoscopic nephrectomy: Perspectives from the past and future directions in the surgical management of renal tumors, The Journal of Urology. 185, pp. 1150-1154.
5. Henry M. Rosevear, Jeffrey S. Ivlontgomery, William W. Roberts (2006). Characterization and management of postoperative hemorrhage following upper retropentoneal laparoscopic surgery. The Journal of Urology. 176.1458-1462.
6. Jason W. Anast, Marshall L. Stoller, Maxwell V.
Meng (2004). Differences in complications and outcomes tor obese patients undergoing laparoscopic radical, partial or simple nephrectomy.
The Journal of Urology. 172. 2287-2291.
7. Jonathan L. Wright, James R. Porter (2005).
Laparoscopic partial nephrectomy comparison of transperitoneal and retroperitoneal approaches. The Journal of Urology, 174. 841-845.
8. Matthew D. Dunn, Andrew J. Portis, Arieh L.
Shaihav (2000). Laparoscopic versus open radical nephrectomy; A 9-year experience, The Journal of Urology, 164. 1153-1159.
9. Mihir M. Desai, Brenda Strzempkowski, Surena F.
Matin (2005). Prospective randomized comparison of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy, The Journal of Urology, 173.38-41.
10. Jens J. Rassweiler, Paolo Fornara, Mathias Weber (1998). Laparoscopic nephrectomy: the experience of the laparoscopy working group of the German Urologic Association, The Journal of Urology, 160.
18-21.