目的：根据术前三维影像重建建立肾窦内肿瘤手术难度评分系统，并评价其对手术策略的指导价值。方法：纳入2015 年7 月~2017 年4 月于解放军总医院泌尿外科就诊的55 例肾癌患者，其中男性37 例，女性18例，中位年龄54（32~67）岁。肿瘤位于左侧肾脏20 例，位于右侧肾脏35 例，肿瘤直径1.6~6.8cm，平均（3.9±1.3）cm。根据患者术前CT 或MRI 检查并行三维重建，综合考虑肾窦内肿瘤占肾窦体积的比率（Ratio），肾门血管及集合系统受肿瘤压迫程度（Oppress），肿瘤与血管和肾盂的位置关系（Association）、肿瘤直径（Diameter）及是否为孤立肾肿瘤（Solitary kidney），提出了肾窦内肿瘤手术难度评分系统（ROADS 评分系统）。ROADS 评分系统将肾窦内肿瘤手术复杂程度分为轻度（4~6 分）、中度（7~9 分）、高度（≥ 10 分），根据该评分系统对以上55例患者进行评分，分析评分对手术时间、出血量、肾脏缺血时间及手术策略的影响。结果：所有手术均顺利完成，其中15 例行根治性肾切除术，40 例行保留肾单位手术。根治性肾切除组中ROADS 评分中位分值10（8~15）分，保留肾单位组的手术方式分为常规术式和低温灌注冷缺血术式，其中常温组23 例，ROADS 评分中位分值5（4~8）分；低温组17 例，ROADS 评分中位分值7（5~9）分。手术难度为高度复杂组的患者均采用了根治性肾切除术。轻度复杂和中度复杂组中有40 例（85%）患者采用了保留肾单位手术，其中轻度复杂组中位手术时间120（55~230）min，中位出血量150（20~300）ml，中位缺血时间22（10~60）min，术后中位肌酐变化率7%（-7%~21%），术后中位eGFR 变化率-6%（-17%~6%）；中度复杂组中位手术时间157（105~225）min，中位出血量200（40~400）ml，中位缺血时间50（13~118）min，术后中位肌酐变化率22%（-18%~208%），术后中位eGFR 变化率-20%（-73%~19%）。中度复杂组中14 例考虑肾缺血时间较长，均采用肾动脉低温灌注技术，中位缺血时间为54（33~118）min，术后eGFR 平均降低12%（-25%~19%），术后肾功能保留满意。结论：基于三维影像重建建立的肾窦内肿瘤手术难度评分系统（ROADS 评分系统）可为术前手术策略的制定提供依据。但该评分系统仍需扩大样本量和长期随访进一步评估。

Objective: To develop an operation difficulty scoring system for renal tumors located on the renal sinus by making three-dimensional reconstruction before surgery. Then the guiding value of the novel scoring system on surgical decision making was investigated. Methods: 55 patients with renal carcinoma in our hospital from July 2015 to April 2017 were analyzed, including 37 males and 18 females with a median age of 54 (32 to 67) years old. The tumors were located on the left kidney in 20 cases and 35 cases on the right side. The average diameter of tumors was (3.9±1.3) (1.6 to 6.8)cm. Threedimensional reconstruction was made based on the computed tomography or MRI before surgery, the Ratio of tumor volume to the volume of renal sinus (R), the Oppression on vessels of renal hilus or collection system caused by the tumor (O), the Anteroposterior relation of tumor , vessels and pelvis (A), the tumor Diameter (D) and whether the tumor affects a Solitary kidney (S) (ROADS) were comprehensively considered and the ROADS scoring system was proposed. According to the ROADS scoring system, the operative complexity of the renal tumor was divided into low (4 to 6), moderate (7 to 9) and high level ( ≥ 10). The 55 patients were scored with the ROADS scoring system, the association of scores with operation approaches, operation complexity and intraoperative outcome was evaluated. Results: All the operations were performed successfully. 40 cases underwent nephron sparing surgery (NSS group) and 15 cases underwent radical nephrectomy (RN group). The median score of RN group was 10(8 to 15), the NSS group were divided into routine group and hypothermia perfusion group. The median score of the routine and hypothermia perfusion group were 5 (4 to 8) and 7 (5 to 9) respectively. All patients in the high complexity group underwent radical nephrectomy. Most patients in low- and moderate-complex groups received nephron sparing surgery. The median operation time was 120 (50 to 230)min, the median estimated blood loss was 150 (20 to 300)ml and the median ischemia time was 22 (10 to 60)min in low-complex group, with the median change rate of creatinine after operation 7% (-7% to 21%) and the median eGFR change rate -6% (-17% to 6%). In moderate-complex group, the median operation time was 157 (105 to 225)min, the median estimated blood loss was 40 (40 to 400)ml and the median ischemia time was 50 (13 to 118)min, with the median change rate of creatinine after operation 22% (-18% to 208%) and the median eGFR change rate -20% (-73% to 19%). In the moderate-complex group, 14 patients were performed with renal arterial hypothermia perfusion for longer ischemia time. The median ischemia time was 54 (33 to 118)min, the average eGFR change rate decreased by 12%(-25% to 19%) after surgery, with a satisfactory preservation of renal function after surgery. Conclusion: The ROADS scoring system provides a standardized, quantitative, 3-dimensional anatomic classification to guide surgical strategy in renal sinus tumors. However, further investigation with a larger sample and longer follow up were required. The scoring system needs to be further evaluated by expanding sample size and long-term follow-up.

收稿日期：2020-04-20 录用日期：2020-06-19

Received Date: 2020-04-20 Accepted Date: 2020-06-19

基金项目：北京市自然科学基金青年项目（7194319）

Foundation Item: Youth Project of Beijing Natural Science Foundation(7194319)

通讯作者：马鑫，Email：urologist@foxmail.com

Corresponding Author: Ma Xin, Email: urologist@foxmail. com

引用格式：彭程，黄庆波，朱捷，等. 基于三维影像重建的肾窦内肿瘤手术难度评分系统[J]. 机器人外科学杂志，2020，1（5）：345-354.

Citation: PENG C, HUANG Q B, ZHU J, et al. A novel operation difficulty scoring system for renal carcinoma in renal sinus based on three-dimensional image reconstruction [J]. Chinese Journal of Robotic Surgery, 2020, 1(5): 345-354.

注：彭程，黄庆波为共同第一作者

Co-first Author: PENG Cheng, HUANG Qingbo

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