原发性醛固酮增多症的外科治疗-泌尿外科杂志(电子版)

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原发性醛固酮增多症的外科治疗

甄洪涛,
唐晓龙,
易强,
魏俊峰,
张超,
杜鹏,

收稿日期：2023-02-06 接受日期：2023-02-06 出版日期：2023-02-06 发布日期：2023-02-06

通讯作者： 甄洪涛,副主任医师,郑州市中心医院泌尿外科，郑州 450007

作者简介： 甄洪涛,男,郑州市中心医院泌尿外科，郑州 450007,副主任医师,熟练掌握泌尿外科常见病多发病诊治，对急危症患者能迅速依据原则妥善处理，规避医疗风险。熟练掌握泌尿外科手术，对前列腺疾患、尿路结石、泌尿肿瘤等疾病诊治有较高造诣。 . 唐晓龙 . 易强 . 魏俊峰 . 张超 . 杜鹏,男,北京大学肿瘤医院暨北京市肿瘤防治研究所泌尿外科，恶性肿瘤发病机制及转化研究教育部重点实验室，北京 100142,主任医师,汉族 .

基金资助：，项目负责人：甄洪涛

中图分类号：R699.3

文献标识码：A

文章编号：1674-7410(2022)03-018-05

DOI：10.20020/j.CNKI.1674-7410.2022.03.05

关键词： 原发性醛固酮增多症, 肾上腺切除术, 继发性高血压,

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近年来，原发性醛固酮增多症的精准外科诊治越来越受到关注。本文围绕原发性醛固酮增多症手术治疗相关内容进行探讨，对现有证据进行总结，从术前诊断分型的优化、术前检查及手术的适应症、手术效果的预判、手术过程细节优化、手术疗效评估5个方面展开总结分析，为临床工作提供参考。

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[1]甄洪涛,唐晓龙,易强,魏俊峰,张超,杜鹏.原发性醛固酮增多症的外科治疗[J].泌尿外科杂志(电子版),2022,14(03):20-24.DOI:10.20020/j.CNKI.1674-7410.2022.03.05

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前列腺癌（prostate cancer，PCa）是世界范围内男性最常见的恶性肿瘤之一，2020年发病数占男性所有恶性肿瘤的14.1%，位列第2，死亡数占6.8%，位列第 5 [1] ，我国 PCa发病率有逐年升高的趋势，但死亡率相对趋稳[2] ，这与前列腺特异性抗原（prostate specific antigen，PSA）在 PCa 筛查的逐渐普及有关，使得早期局限性 PCa的比例有明显提升[3] 。对于局限性 PCa，根治性手术和外放疗是常用的治愈性手段，预后相对较好，5 年生存率可达 100%，但无论是手术还是外放疗，都是针对全腺体的治疗方法，即将前列腺全部切除或对前列腺整体放疗。除了早期 PCa 患者比例升高，随着解剖、技术、设备等方面的改进，局部治疗的应用逐渐增多，随之而来的是全腺体治疗对性功能、尿控等方面的负面影响降低患者生活质量的问题更加突出[4] 。据统计，手术后平均 30%~90%的患者会出现勃起障碍、5%~20%的患者会出现尿失禁，放疗可能会造成 5%~20%的患者出现直肠毒性反应。考虑到大部分低危和预后良好的中危局限性 PCa 发展缓慢，观察等待或主动监测可以作为此类患者的治疗策略，等待PSA明显进展或出现症状时再进行抗肿瘤治疗[5-6] ，但对于穿刺国际泌尿病理学会（International Society of Urological Pathology，ISUP）分组≥3 的局限性 PCa，进展风险较高，期望对于此类局限性患者可以找到既可控制肿瘤、又可保留功能的治疗方法，局灶治疗（focal therapy，FT）便是其中之一。FT 是一种针对前列腺腺体内主要病灶（index lesion，IL）进行针对性治疗的的方法，包括冷冻消融、高频聚焦超声、光动力、射频消融等不同的能量平台[7] ，影像学、穿刺活检可以帮助确定 IL 是否可以涵盖全部或大部分具有临床意义的病灶（clinically significant prostate cancer，csPCa）。目前针对 FT 治疗 PCa的研究大部分为小样本、回顾性、非随机对照研究，受限于证据等级不高、设备仪器要求高等因素，指南并未做常规推荐。随着 PSA 筛查的进一步普及和影像技术的进展，FT 有机会扩展应用，本文将对应用于 PCa治疗的 FT进行简要综述。

1 PA 手术适应证及手术效果的预测

1.1 术前优势侧的判定和注意特殊群体

1.1.1 区分 PA 单侧或双侧优势

1.1.2 AVS 显示对侧抑制与否对手术治疗预后的判定

1.1.3 PA中的特殊类型

1.2 解剖方面

1.2.1 血管变异

1.2.2 腹腔镜切除双侧肾上腺的难度

1.2.3 梅奥粘连概率（MAP）评分

1.2.4 体位变化引起目标器官解剖变化

2 PA 手术策略选择及操作的优化

2.1 肾上腺单侧全切或部分切除

2.2 术中超声定位

2.3 肾脏去神经支配加肾上腺切除术治疗PA引起的顽固性高血压

2.4 腹腔镜肾上腺切除术后可不放置引流

3 术后患者评估

3.1 术后病理

3.2 术后效果评估

3.3 术后临床不缓解因素

3.4 PA 术后再入院

4 总结与展望

PA 患者术前行 CT 和 AVS 实现功能优势侧判定，手术切除功能优势侧肾上腺是 PA患者的主要外科治疗手段，AVS 导向下功能优势侧肾上腺切除术较 CT 导向有更好的临床获益。手术前 PA 亚型的准确判定（如老年PA患者，伴皮质醇功能分泌的PA），更精细的 AVS结果分类（对侧功能抑制与否），以及这些情况对手术后效果是目前研究热点。日本一项研究显示：通过超选择 AVS获得肾上腺内醛固酮活性图，反映 CYP11B2阳性病变的分布，优于传统的AVS[39] 。已经开展肾上腺功能影像学检测，以及对PA 患者行分泌功能优势侧更为精准的功能部分切除术，以减少术后皮质醇功能不全风险。针对 PA导致的顽固性高血压患者，腹腔镜下功能优势侧肾上腺切除联合同侧肾脏去神经支配较单纯肾上腺切除有更好的控制血压效果，期待更大样本和更多病例研究支持。手术后评估依据 PASO 国际共识，PA术后仍有部分患者达不到临床缓解，考虑原因有以下：①不适应的术前诊断分型；②合并长期高血压；③原发性高血压、慢性肾病、亚临床高皮质醇症的并发症；④男性，老年患者、KCNJ5 突变携带者。如何术前准确识别并在术后预防相关风险是将来研究的主要方向。

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