腹腔镜下经肠系膜途径行左侧肾盂成形术

Left transperitoneal laparoscopic pyeloplasty with direct access to the ureteropelvic junction

目的总结腹腔镜下经肠系膜途径行左侧肾盂成形术的经验和临床疗效。方法肾盂输尿管连接部（UPJ）狭窄患者12例。年龄9～49岁，平均33岁。均行腹腔镜下经肠系膜途径离断式肾盂成形术。常规制备气腹，进入腹腔后不游离结肠，透过肠系膜辨认扩张的肾盂和输尿管后，直接在降结肠系膜无血管区开窗，仔细游离出UPJ后行离断式肾盂成形术。记录患者手术时间、术中出血量、术后恢复饮食时间和下地活动时间、住院时间，术后症状改善以及B超和IVU复查结果。结果12例手术均获成功。平均手术时间（108±32）min，平均术中出血量（32±11）ml，平均恢复饮食和下床活动时间分别为18和29h。术后平均住院6．5d。随访8～42个月，平均24个月。术后3个月B超检查示，3例术前轻度肾积水者积水均消失，7例中度积水者中积水消失2例、转为轻度积水5例。2例重度积水者术后留置双J管2个月，6、8个月后复查磁共振水成像及肾图，提示肾外形与对侧相似，。肾盏仍有扩张，但肾盂不扩张，肾盂输尿管移行自然，分肾功能分别为67％和82％。10例术后1年复查IVU提示吻合口引流通畅，肾功能改善。结论对体形瘦、肾盂宽大、初次治疗的患者，经结肠系膜途径行左侧腹腔镜下肾盂成形术安全有效，可以减少创伤、缩短手术时间。

Objective To describe and evaluate the technique and outcome of transperitoneal left laporoscopic pyeloplasty with the transmesocolic approach to the ureteropelvic junction（UPJ）. Methods Twelve patients with UPJ obstruction were enrolled. After entering the peritoneal cavity, a window was made into the descending mesocolon in an avascular area with no left colon reflection. Ureter and UPJ were dissected through this window and a stented dismembered pyeloplasty was done. The operative time, blood loss, time to resumption of oral intake and complications, hospital stay were recorded. Results Operations were all successful in 12 patients, mean operative time was 108± 32 min and estimated blood loss was 32± 11 ml. There were no intraoperative or postoperative complications. The mean time to resumption of oral intake was 18 h and the time of ambulation was 29 h. The mean hospital stay was 6.5 d and the mean follow-up was 24 months. All the patients were assessed with physical examination, abdominal ultrasonography and IVU, they were demonstrated improved drainage with no evidence of obstruction and with no symptoms. Conclusions The transmesocolic approach to a dilated left pelvis enables a shorter operative time for transperitoneal left laporoscopic pyeloplasty without increasing morbidity, especially for slim patients or patients with a large renal pelvis.