腹腔镜黏膜下隧道法联合腰大肌悬吊输尿管膀胱再植术(附22例报道)

Laparoscopic submucosal tunneling ureteroneocystostomy with psoas hitch: 22 cases report

目的:探讨腹腔镜膀胱外黏膜下隧道法输尿管膀胱再植术联合腰大肌悬吊术治疗末段输尿管缺损的适应证、手术要点及术后疗效。方法:回顾性分析2012年1月-2019年3月行腹腔镜输尿管膀胱再植术联合腰大肌悬吊术的22例末段输尿管病变患者的临床资料,男10例,女12例,年龄21~55岁,平均(40.6±7.2)岁。其中内镜激光碎石术后狭窄7例;妇产科术后输尿管狭窄6例;输尿管子宫内膜异位症3例;原发性狭窄6例。术前影像学结果提示输尿管缺损长度4~8 cm,平均(5.0±1.6)cm;输尿管扩张直径0.7~2.5 cm,平均(1.3±0.7)cm;肾盂分离1.5~4.1 cm,平均(2.6±0.8)cm。术中均先充分游离末段病变输尿管及膀胱,离断输尿管后将膀胱悬吊于腰大肌或腰小肌肌腱;将病变段输尿管裁剪后,采用膀胱外黏膜下隧道法行输尿管膀胱的再植术。结果:22例手术均在腹腔镜下成功完成,手术时间130~230 min,平均(168±30.2)min;出血量15~120 mL,平均(60±30.2)mL;引流管留置时间4~8 d,平均(6±0.5)d;尿管留置时间7 d;术后住院8~11d,平均(9±1.2)d;术中留置双J管均于术后2~3个月拔除。随访5~80个月,平均(48.4±25.3)个月,患者均无尿瘘、吻合口瘘及吻合口狭窄;行B超、静脉肾盂造影、膀胱造影检查提示肾积水均明显减轻或消失,其中轻度肾积水8例,无明显肾积水14例,轻度膀胱输尿管反流1例。结论:腹腔镜膀胱外黏膜下隧道法联合腰大肌悬吊输尿管膀胱再植术治疗中等长度的末段输尿管缺损安全有效,损伤小,术后恢复快。腰大肌悬吊术能有效解决输尿管缺损较长的问题,使输尿管膀胱达到无张力吻合,黏膜下隧道法抗反流成功率高,降低了术后患者尿液反流导致逆行感染及慢性肾功能损害的发生率。

Objective:To investigate the surgery indications and describe the techniques and results of laparoscopic submucosal tunneling ureteroneocystostomy in combination with psoas hitch to restore urinary tract continuity in patients with medium-length distal ureteral defects.Methods:From January 2012 to March 2019,a total of 22 patients(10 males and 12 females)with age ranged from 21 to 55 years,(mean,40.6±7.2 years),suffering from distal ureteral diseases,were given the laparoscopic operation of ureteral submucosal tunneling reimplantation combined with psoas hitch.The perioperative data were retrospectively collected.The etiologies included ureteral strictures secondary to endoscopic laser lithotripsy in 7 patients,previous gynecological surgeries in 6 patients,infiltrative ureteral endometriosis in 3 patients,and ureteral strictures without obvious causes in the remaining 6 patients.The defective length ranged from 4 to 8 cm(mean,5±1.6 cm)and the diameter of upper ureter ranged from 0.7 to 2.5 cm(mean,1.3±0.7 cm).The anterior-posterior pelvic diameter ranged from 1.5 to 4.1 cm(mean,2.6±0.8 cm).During the operation,the distal ureter and the bladder were adequately mobilized.After the bladder was hitched to the musculus psoas major or psoas minor tendon,submucosal tunneling ureteroneocystostomy was performed.Results:In all patients,the laparoscopic procedure was successfully performed without conversion to open.The operating time ranged from 130 to 230 min(mean,168±30.2 min),the estimated blood loss ranged from 15 to 120 mL(mean,60±30.2 mL)and the drainage time ranged from 4 to 8 days(mean,6±0.5 days).The Foley catheter was removed on postoperative day 7.The length of postoperative hospital stay ranged from 8 to 11 days(mean,9±1.2 days).The double J ureteral stent was removed at 2nd-3rd month after the operation.All patients experienced symptomatic relief within a follow-up of 5 to 80 months(mean,48.4±25.3 months).No major complications defined as urine leak,fistula or ureteral stenosis,occurred during the follow-up period.Ultrasonography and IVU showed mild hydronephrosis in 8 cases and no obvious hydronephrosis in 14 cases.Voiding cystogram revealed mild reflux in 1 of the 22 cases.Conclusion:Extravesical submucosal tunneling ureteroneocystostomy combined with psoas hitch under laparoscopy is a feasible and effective option with little damage and quick recovery for medium-length distal ureteral defects in selected patients.Tension free anastomosis was achieved owing to the psoas hitch procedure.The submucosal tunneling ureteroneocystostomy efficiently improved the antireflux mechanism,reducing the chances of retrograde infection and chronic impairment to the kidney.