改良体位经腹完全腹腔镜肾输尿管全长切除术20例报告

Report of 20 cases receiving pure laparoscopic radical nephroureterectomy under modified position

目的:谈讨改良体位经腹完全腹腔镜肾输尿管全长切除术在上尿路尿路上皮癌(UTUC)微创治疗方面的技术优势。方法:收集2017年1月~2018年6月在我院接受该术式20例患者的临床资料。先取30°健侧斜卧位并向患侧旋转手术床约15°头低脚高位。脐上2 cm正中放置观察通道,脐下2 cm左右侧腹直肌外缘放置操作通道,患侧麦氏点放置辅助通道,采用经膀胱途径完成袖套状切除。将手术床放平并向健侧旋转40°,形成70°斜卧位,患侧肋缘下锁骨中线处建立新操作通道,其余通道不变,完成根治性肾切除,术中同时完成盆腔或腹膜后淋巴清扫。术后给予局部灌注或全身化疗。结果:手术时间(178.2±29.0)min,术中出血量(155.4±46.6)mL,2例予以输血。3例术后出现淋巴漏,1例出现乳糜漏,给予持续负压引流后好转。无出血、感染、肠梗阻、漏尿发生。病理提示2例肿瘤侵犯局部淋巴结,所有标本输尿管切缘阴性。远期2例发生盆腔淋巴结转移,1例发生纵膈转移。结论:改良体位下经腹途径LRNU术操作简便、创伤小、并发症发生率低且控瘤效果满意,是一种适宜推广的UTUC微创处理新方法。

Objective:To evaluate the advantage of pure laparoscopic radical nephroureterectomy(LRNU)under modified positon on the surgical treatment of upper urinary tract urothelial carcinoma(UTUC).Method:The clinical data of 20 patients receiving LRNU in our department from Jan 2017 to Jun 2018 were retrospectively analyzed.The patients were laid in ipsilateral 30°flank position with operation table being rotated contralaterally at 15°before Trendelenburg position being applied.Observation port was placed supra-umbilicus and operating ports were bilaterally placed supra-umbilicus beside the lateral rectus muscle before the resection of distal ureter and bladder cuff being performed with intravesical technique.Afterwards,Trendelenburg position was cancelled with operation table being rotated ipsilaterally at 40°.Radical nephrectomy was performed after a sub-costal margin port being placed ipsilaterally.Regional lymphadenectomy was performed simultaneously.Intravesical and systemic chemotherapy were applied postoperatively.Result:The mean operation time was(178.2±29.0)min,with the mean bleeding of(155.4±46.6)mL,and 2 cases of transfusion.No severe complication was found except for 3 cases of lymphorrhagia and 1 case of chylous leakage.Pathology has showed 2 cases of lymphatic involvement and no positive margin of distal ureter.Postoperative metastasis has happened in 2 cases of pelvic lymph node and 1 case of mediastinum lymph node.Conclusion:Pure LRNU under modified position has the advantages of simple application,minimal invasiveness,favorable clinical safety as well as tumor-control,so it can be applied routinely for the treatment of UTUC.