后腹腔镜下肾固定术(附28例报告)(英文)

Retroperitoneal laparoscopic nephropexy: a report of 28 cases

目的：探讨后腹腔镜下肾固定术的手术方法和疗效。方法：采用后腹腔镜下手术治疗肾下垂28例。28例患者均为女性。年龄26-45岁,平均（34±2.5）岁。右侧15例,左侧12例,双侧1例。术前症状：腰区酸胀27例,腰区明显疼痛1例,频发尿路感染16例,血尿12例,其中肉眼血尿8例,镜下血尿4例。肾图显示患侧呈梗阻性表现12例。静脉肾盂造影提示肾下垂Ⅱ度10例,Ⅲ度14例,Ⅳ度4例。患侧轻度肾积水7例。1例双侧肾下垂采用经腹途径,其余27例均采用后腹腔途径。经后腹腔镜完整游离患侧肾脏,其中8例钳夹牵拉的肾下极血管。26例将下垂游离肾脏用腔镜内缝合技术固定于腰大肌,2例用外打结方法固定于患侧腰区皮下。结果：28例手术均获得成功。平均手术时间（125±9）min,平均住院时间（8±1.2）d,平均卧床时间（7±1.3）d。术后复查静脉肾盂造影提示患侧肾脏位于正常位置。27例腰区酸胀患者中24例症状消失,3例改善;1例腰区疼痛患者症状消失;16例频发尿路感染患者症状均消失;12例血尿患者中有10例症状消失。平均随访（24±4.2）个月,有一定的复发症状,包括血尿复发2例,1例复发尿路感染,4例复发患侧腰区酸胀。结论：后腹腔镜手术具有创伤小、疼痛轻、康复快等优点,有望成为理想的肾下垂手术方法之一。

Objective： To discuss the procedure and clinical effect of retroperitoneal laparoscopic nephropexy （RLN）. Methods： From August 2001 to June 2006, RLN was performed on 28 female patients aged 26-45 years old （mean, 34±2.5） with symptomatic nephroptosis, including 15 with the right kidney, 12 with the left, and 1 with both. The preoperative complaint of patients included subjective symptoms （constant and recurring pain in 28 patients） and objective symptoms （upper urinary infections in 16, hematuria in 12, and upper tract obstruction in 12）. One patient underwent nephropexy via the transperitoneal approach and the others underwent nephropexy via the retroperitoneal approach. A retroperitoneoscopic procedure was performed after positioning the patients in the flank position. Digital preparation of the retroperitoneal space was made and standardized trocar was placed. The key step of the surgery was complete exposure of the kidney within Gerota＇ fascia, which was aimed to separate the potential adhesions between the colon and kidney or between the inferior blood vessels of the kidney. Nephropexy was performed between the fibrous capsule at the lower pole of the kidney and the dissected psoas muscle, using three sutures placed by intracorporeal technique or the percutaneous needle both for introduction and removal of the suture; the sutures were separately tied over the sacrospinalis fascia. Results： The mean operative time was （125 ±9） min （ranging 115-240 min）; the mean postoperative hospital stay was （9±1.2） days, largely owing to the required 5-12 days＇ bed rest. During a mean followup of （24±4.2） months（ranging 3 to 70 months）, 3 patients had paresthesia, 5 had constant and recurrent ache, 20 were completely free of pain, and 4 had micro-hematuria. One patient had further episodes of pyelonephritis and upper tract obstruction after operation. Intravenous pyelogram（IVP） revealed that the ptosis incorporated into more than one vertebral body in 2 pa- tients. Postoperative renal function test showed an improvement in renal function. Conclusion： RLN is mini-invasive and has less complication. The procedure should be considered as one of the optimal therapy for nephroptosis.