经腹腹腔镜经肠系膜入路复发性肾盂输尿管连接部狭窄再成型术的可行性分析(附5例报告)

Feasibility analysis of laparoscopic transperitoneal and transmesenteric pyeloplasty in recurrent ureteropelvic junction obstruction

目的:探讨经腹腹腔镜经肠系膜入路复发性肾盂输尿管连接部狭窄(ureteropelvic junction obstruction,UPJO)再成型术的可行性和安全性。方法:选取2006年5月至2008年6月北京大学第一医院泌尿外科收治的经腹膜后开放性肾盂输尿管连接部狭窄成型术后复发的患者5例,其中男性3例,女性2例,年龄19～32岁,平均24.5岁。狭窄复发发生于术后3～16年,平均7.8年。患者有不同程度的腰部酸胀不适,影像学检查显示为典型的UPJO,肾动态扫描示肾排空缓慢,注射呋塞米后有不同程度的排空。手术采用经腹腹腔镜经肠系膜入路,于小肠系膜根部患侧近肾蒂处纵向切开系膜及后腹膜,游离显露肾盂输尿管连接部(ureteropelvic junction,UPJ),注意避免损伤肠管和肠系膜血管。常规切除UPJO,并行Anderson-Hynes法2针连续缝合,吻合肾盂和输尿管。结果:手术时间105～230 min,平均为165 min;术中出血量为50～120 mL,平均为75 mL;术后第1日患者即可下地活动,术后第4～5日撤除引流管;术中和术后未发生副损伤和并发症。截止至2010年10月,随访33～49个月,平均37.5个月,影像学及利尿肾动态检查示UPJ排空通畅。结论:对于腹腔镜经验丰富的医师,经腹腹腔镜经肠系膜入路复发性肾盂输尿管连接部狭窄再成形术是可行和安全有效的,但对于初学腹腔镜者则需慎重选择此术式。

Objective： To discuss the feasibility and safety of laparoscopic transperitoneal and transme-senteric pyeloplasty for recurrent ureteropelvic junction obstruction（UPJO）.Methods： From May 2006 to June 2008,we admitted 5 cases of recurrent UPJO who had received open retroperitoneal pyeloplasty with 3 males and 2 females.They were 19 to 32 years old with the average of 24.5 years and suffered from recurrent UPJO 3 to 16 years with the average of 7.8 years after operation.They felt discomfort in the lumbar region to different extent and their intravenous pyelography（IVP） or computerized tomography for urinary system（CTU） showed typical UPJO.The nucleotide renal scan（NRS） revealed that the renal excretion was slow,even after intravenous injection of diuretics.The laparoscopic transperitoneal and transmesenteric pathway was done in such a way that the incision was longitudinal at the mesentery of small intestine near the affected ureteropelvic junction（UPJ）.The UPJ was isolated to avoid injuring the intestine and the mesenteric blood vessels.The UPJO was removed with the routine Anderson-Hynes technique and the anastomosis between pelvis and ureter was carried out by 2 separate and running sutures.Results： The operating time was 105-230 min with the average of 165 min and the estimated blood loss was 50 to 120 mL with the average of 75 mL.Patients left bed on the first day and the drainage tube was taken out on the 4^th to 5^th day after the operation.There were no other injuries and complications.By October of 2008,they had been followed up for 33 to 49 months with the average of 37.5 months and IVP or CTU and the diuretic NRS showed smooth excretion of the operated UPJ.Conclusion： As for experienced hands,the laparoscopic transperitoneal and transmesenteric pyeloplasty is feasible and safe for recurrent UPJO,but it＇s not recommended to the beginners of laparoscopic procedures.