输尿管镜在肾囊性病变治疗中的临床应用研究

Clinical utilization of ureteroscope in the management of kidney cystic lesions

目的：根据肾囊性病变特点建立差异性手术径路,使用输尿管镜钬激光内切开引流微创治疗肾囊肿；通过临床疗效评估研究,探讨输尿管镜在肾囊性病变治疗中的价值及临床应用前景.方法：2008年3月~2013年12月,对70例肾囊性病变患者采用输尿管镜钬激光内切开引流微创治疗.其中肾外周囊肿32例,15例囊肿位于肾盂前方靠腹侧,肾盂被囊肿推向背侧,选择经“皮→肾盂→囊肿”路径；17例囊肿位于肾盂后方靠背侧,肾盂被囊肿推向腹侧,选择经“皮→囊肿→肾盂”路径；肾盂旁囊肿38例,18例囊肿位于肾上极,选择经输尿管硬镜“尿道→肾盂→囊肿”路径；20例囊肿位于肾中、下极,选择经输尿管软镜“尿道→肾盂→囊肿”路径.所有病例囊肿直径4．5~7．0 c m,平均5．75 c m.49例患侧有腰背胀痛症状,21例为体检发现.术前均行B 超、I VU、CT 或 MRI 检查明确诊断为肾囊肿,术后留置双J 管.结果：70例患者手术均获成功,手术时间30~90 min ,平均60 min ,术中失血5~100 ml,平均52．5 ml.无中转开放手术及术中大血管损伤、误伤.术后2~3 d 拔出导尿管,住院时间5~9 d,平均7 d.经皮肾路径患者均无尿漏及尿外渗发生,术后2个月拔出双J 管.所有病例均获得随访3~24个月,经B 超或CT 检查68例未见囊肿复发.2例术后1年复发但直径均小于2．0 c m,输尿管镜检查证实囊肿内切开引流口再次闭合.结论：根据肾囊性病变的特点,制定差异性、个性化的手术路径,采取经输尿管镜钬激光内切开引流治疗是一种安全、有效、损伤小、复发率低的微创新术式,是输尿管镜在临床应用的拓展.与其他肾囊性病变的治疗方式对比,优势明显,具有良好的临床应用前景及推广使用价值.

Objective:To establish the individualized surgical approaches for hol miumlaser and incision drainage with ureteroscope according to the features of kidney cystic lesions ,and investigate the value and clinical application prospectofureteroscopeinthe managementofkidneycysticlesions.Methods:FromMar.2008toDec.2013,70ca-ses of kidneycysticlesions weresubjectedto minimallyinvasivetunnel byusingholmiumlaserandincisiondrainage. For32casesofperipheralrenalcysts,thecysts werelocatedinthefrontofandventraltotherenalpelvis whichwas pushedtothedorsalsurfacein15cases,andthesurgicalapproachfromskintorenalpelvisandthentocyst wascho-sen;and those behind and dorsal to the renal pelvis which was pushed to the ventral surface in 17 cases ,and the sur-gicalapproachfromskintocystandthentorenalpelviswaschosen.For38casesofparapelviccysts,therewere18 casesofcystslocatedintheupperpoleofthekidney,andthesurgicalapproachfromurethratorenalpelvisandthen tocyst withureteroscope waschosen;there were20casesofcystslocatedinthe middleandthebottomofthekid-ney,andthesurgicalapproachfromurethratorenalpelvisandthentocystwithflexibleureteroscopewaschosen. Thecysticdiameterswerefrom4.5to7.0cmwiththeaverageof5.75cm.Forty-ninecasescomplainedofpain symptomsontheloinandback.Twenty-onecaseshavingnosymptoms werepresentedinphysicalexamination.All the cases were diagnosed as renal cysts undergoing B ultrasound ,I UV,CT and MRI preoperatively .Double J stent was placed post-operation .Results:All the operations were successfully carried out .The operative ti me was fro m 30 to90 minwiththeaverageof60 min.Theintraoperativebloodloss was5to100 mLwiththeaverageof52.5 mL. There were no conversions to open surgery,vascular injury and accidental injury.Urethral catheter ,nephrostomy tube and double J tube were pulled out 2 days ,5 to 7 days and 2 months after the operation respectively .The nephr-ostomyhealedafter24handhadnourinaryfistulaandextravasation.Thehospitalstaywas5to9days withtheav-erageof7days.Duringthefollow-upperiodof3to24 months,BultrasoundorCTexaminationrevealedthat68ca-ses had no recurrence and only t wo patients had a recurrence with the cystic dia meter less than 2 .0 c m.Ureteroscopy confir med cystic incision drainage closed again .Conclusions:The individualized surgical approach according to the fea-turesofkidneycysticlesionsbyusingholmiumlaserandincisiondrainage withureteroscopeisanewminimallyinva-sive method withsafety,efficiency,lessinjury,andlowrecurrence.It'stheexpandof ureteroscopyandhas moread-vantages over other treat ments .