经后腹腔镜治疗输尿管上段复杂性结石

Retroperitoneal laparoscopic ureterolithotomy for complicated upper ureteral calculi

目的探讨经后腹腔镜输尿管切开取石术治疗上段复杂性结石的适应证及临床应用价值。方法回顾性分析32例经后腹腔镜输尿管上段切开取石术患者的临床资料。本组体检发现21例,腰部胀痛就诊11例。经B超、静脉及逆行造影证实为单侧输尿管上段结石,结石直径1.2～2.6 cm。距肾门位置4～10 cm,停留时间1～24个月,18例行体外冲击波碎石术(ESWL)、17例行经输尿管镜碎石术(URL)不成功,其中11例合并远段输尿管扭曲。术中留置双J管并缝合输尿管切口。结果 32例结石均一次性完整取出,无中转开放手术及结石残留,同期处理输尿管扭曲。手术时间平均130 min。术中出血量平均30 mL。术后3例漏尿4～6 d。术后2、3个月均予随访,21例随访6～24个月,肾输尿管积水均明显好转,无输尿管狭窄及扭曲。结论经后腹腔镜输尿管上段切开取石术具有安全、有效、微创的优势,不仅可作为ESWL、URL治疗失败的补救措施,亦可作为有合并病变的复杂性输尿管结石的一线治疗方案。

【Objective】 To evaluate the indication selection,surgical techniques and clinical evaluation of retroperitonel laparoscopic ureterolithotomy on complicated upper ureteral calculi.【Methods】 The clinical data of 32 cases（23 males and 9 females） with mean age of 41 years,underwent retroperitonel laparoscopic ureterolithotomy were retrospectively analyzed.A total of 21 cases enrolled by physical examination with no symptom,and 11 cases complained with waist pain.All the upper ureteral calculi was confirmed with ultrasound,IVU,and retrograde urography.The stone size range was 1.2～2.6 cm,the distance from renal hilus was 4～10 cm,and the detention time was 1～24 months.Distal ureter twist was found in 11 cases.ESWL（extracorporeal shock-wave lithotripsy） or URL（ureteroscopic lithotripsy） had been performed but failed in 18 and 17 cases respectively.Double J tube insertion and ureter incision suture was routinely performed in the procedure.【Results】 The stone was taken out intact and the ureteral twist was treated successfully at the same time by retroperitonel laparoscopic ureterolithotomy in all the cases.The mean operation duration was 130 min,the mean intraoperative blood loss was 30 ml.Urinary leakage was occurred in 3 cases within 4~6 days.The follow-up period was 2~3 months for all the cases,and 6~24 months for 21 cases with ultrasound or IVU examination.Hydronephrosis or hydroureterosis was obviously relieved,and no ureteral stricture or twist was found.【Conclusions】 Retroperitonel laparoscopic ureterolithotomy is a safe and reliable minimally invasive procedure.It can not only be role as a salvage procedure for failed ESWL or URL,but can also be considered as the first-line treatment for complicated upper ureteral stone combined with ureter diseases.