Objective: To explore the surgical strategy and experience of reoperation for pheochromocytoma and paraganglioma which is very challenging.
Methods: The clinical data of 7 patients with pheochromocytoma and paraganglioma who underwent reoperation in Department of Urology, Peking University Third Hospital from August 2016 to February 2021 were analyzed retrospectively. There were 4 males and 3 females, with an average age of (44.1±11.5) years (28-60 years), 6 cases on the right side and 1 case on the left side. The causes of the operations included: (1) 2 cases of tumor recurrence after resection; (2) The primary operations failed to completely remove the tumors in 3 cases, because the tumors were large and closely related to blood vessels. (3) Pheochromocytoma and paraganglioma wasn't diagnosed before primary operation, therefore, drug preparation wasn't prepared. Two cases were interrupted by severe blood pressure fluctuations during the primary operations. Imaging evaluation, catecholamine biochemical examination and adequate adrenergic α receptor blockers were administrated in all the cases. The surgical approaches included open transperitoneal surgery in 4 cases, robot-assisted laparoscopy in 1 case and retroperitoneal laparoscopy in 2 cases. The innovative techniques included mobilization of the liver, inferior vena cava transection and anastomosis, and transection of left renal vein.
Results: The average tumor size was (8.0±3.2) cm (3.6-13.9 cm). The median interval between the reoperation and the primary operation was 9 months (IQR: 6, 19 months). The median operation time was 407 min (IQR: 114, 430 min) and the median blood loss was 1 500 mL (IQR: 20, 3 800 mL). Operations of 5 cases were performed successfully, and 1 case failed only by exploration during the operation. One case died perioperatively. There were 5 cases of intraoperative blood transfusion, the median transfusion volume of red blood cells was 800 mL (IQR: 0, 2 000 mL). One case experienced postoperative lymphorrhagia, and recovered after conservative treatment. The renal function was normal in 2 cases after resection and anastomosis of inferior vena cava or transection of left renal vein. The average postoperative hospital stay was (7.2±3.3) d (4-13 d). The median follow-up time of 6 patients was 33.5 months (IQR: 4.8, 48.0 months). The case who failed in the reoperation still survived with tumor and there was no recurrence in the rest of the patients.
Conclusion: The reoperation of pheochromocytoma and paraganglioma, which can not be resected in the primary operation or recurred postoperatively, is difficult with high risk of hemorrhage, and there is a risk of failure and perioperative death. Different surgical approaches and strategies need to be adopted based on the different situation.
目的: 分析嗜铬细胞瘤和副神经节瘤二次手术的策略和总结经验教训。
方法: 回顾性分析2016年8月至2021年2月北京大学第三医院泌尿外科7例嗜铬细胞瘤和副神经节瘤实施二次手术的临床资料，其中男性4例、女性3例，平均(44.1±11.5)岁(28~60岁)，右侧6例, 左侧1例。二次手术的原因包括：(1)肿瘤切除后复发的病例2例; (2)肿瘤体积大并与血管关系密切，首次手术未能成功切除肿瘤的病例3例; (3)术前未诊断出嗜铬细胞瘤和副神经节瘤而没有进行药物准备，首次手术中出现血压剧烈波动而中止手术的病例2例。所有病例都进行了影像学评估、儿茶酚胺检查和充分肾上腺素能α受体阻滞剂的药物准备。手术方式包括经腹开放手术4例、机器人辅助腹腔镜手术1例、后腹腔镜手术2例。应用的创新技术包括翻肝技术、下腔静脉切断再吻合技术、左肾静脉切断技术。
结果: 肿瘤平均大小(8.0±3.2) cm (3.6~13.9 cm)。二次手术距首次手术的中位时间9个月(四分位数间距：6, 19个月)。二次手术中位手术时间407 min(四分位数间距：114, 430 min)，中位出血量1 500 mL(四分位数间距：20, 3 800 mL)。5例手术成功，1例术中仅做探查未能成功切除肿瘤，围手术期死亡1例。术中输血5例，中位输注悬浮红细胞800 mL(四分位数间距：0, 2 000 mL)，术后淋巴漏1例，保守治疗自愈。切断左肾静脉及下腔静脉切除再吻合病例，术后肾功能正常。术后平均住院天数(7.2±3.3) d (4~13 d)。存活6例患者中位随访33.5个月(四分位数间距：4.8, 48.0个月)，手术未成功病例仍带瘤生存，余病例尚无复发。
结论: 首次开放手术不能成功切除和复发的嗜铬细胞瘤和副神经节瘤二次手术难度大，出血多，手术风险高，存在手术失败和围手术期死亡风险，需要根据具体的情况采用不同的手术方式和策略。
Keywords: Paraganglioma; Pheochromocytoma; Recurrence; Reoperation.