泌尿外科单孔腹腔镜手术209例临床应用分析

Analysis of cumulative series of laparoendoscopic single-site surgery in urology ： with 209 consecutive cases report

目的报道单中心209例泌尿外科单孔多通道腹腔镜手术，并评价其临床应用特点和价值。方法前瞻性收集2008年12月至2012年7月209例泌尿外科单孔多通道腹腔镜手术患者的临床资料和围手术期数据。男121例，女88例。年龄（52．8±14．5）岁。体质指数（body massin．dex，BMI）（23．5±3．1）kg／m。。既往腹盆腔手术史42例（20．1％）。麻醉评分（american society of an—esthesiologists score，ASA）（2．0±0．3）分。合并高血压61例（29．2％），糖尿病27例（12．9％）。术前诊断为。肾肿瘤70例（33．5％），肾上腺占位42例（20．1％），肾囊肿22例（10．5％），输尿管上段结石22例（10．5％），无功能肾脏19例（9．1％），BPH10例（4．8％），其他24例（11．5％）。探讨总体手术适应证、手术并发症和手术中转情况等临床特点，并将所有手术按完成时间先后分为两个阶段，每个阶段各22个月，进行相关参数的比较分析。结果本组共完成手术209例，其中上尿路手术193例（92．3％），肿瘤相关手术116例（55．5％），术中需重建的手术34例（16．3％），经腹腔途径手术169例（80．9％），经膀胱途径手术11例（5．3％），经脐切口手术98例（46．9％）。总体手术中转率8．1％（17／209），其中增加一个5或10mm辅助孔9例（4．3％），中转普通腹腔镜手术4例（1．9％），中转开放手术4例（1．9％）。总手术并发症发生率16．3％（34／209），术中并发症发生率4．8％（10／209），术后并发症发生率11．5％（24／209）。两个阶段比较分析显示，手术总量从第一阶段的77例上升到第二阶段的132例，平均每月完成手术量分别为（3．5±3．0）和（6．0±3．5）例，两组比较差异有统计学意义（P〈0．05）。第二阶段中肿瘤相关手术、根治性肾切除术和肾上腺切除术比例增高，经脐切口手术、肾囊肿去顶减压术和经膀胱前列腺剜除术比例减少，与第一阶段比较差异均有统计学意义（P〈0．05）。结论对于具备丰富腹腔镜操作经验的术者，可用单孔腹腔镜技术成功完成各类泌尿外科手术，但仍有一定的手术并发症和手术中转风险，应严格把握手术适应证，尤其是初学者不宜开展需复杂重建或恶性肿瘤相关的单孔腹腔镜手术，应始终把手术安全和疗效放在首位。

Objective To report a 4-year cumulative series （209 cases） of laparoendoscopic single- site surgery （LESS） in urology and assess its clinical utilization. Methods Consecutive LESS eases done between December 2008 and July 2012 at our institution were prospectively recorded and retrospective ana- lyzed in this study. Demographic data, main perioperative outcomes, and information related to the surgical technique were collected and analyzed. There were 209 patients （ 121 males and 88 females） with a mean age of （ 52.8 ＋ 14.5 ） years, a mean BMI of （23.5 ＋ 3.12） kg/m2 and a mean ASA score of （2.0 ＋ 0.3 ）.20.1% （42 cases） of patients had previous abdominal or pelvic surgeries. 29.2% （61 cases） and 12.9% （27 cases） of patients had diabetes mellitus and hypertension. Indications were renal tumors （70 cases, 33.5% ） , adrenal tumors （42, 20. 1% ） , renal cyst （22 cases, 10.5% ） , ureteral calculi （22 cases, 10.5%）, nonfunctional kidneys （19 cases, 9. 1%）, BPH （10 cases, 4.8%）, and others （24 cases, 11.5% ）. Surgical conversions were evaluated, as well as intraoperative and postoperative complications. Two periods were arbitrarily defined： the first was from December 2008 to September 2010 （22 mon） and the second was from October 2010 to July 2012 （22 mon）. A comparative analysis between these two periods was conducted. Results There were 209 LESS surgeries included in this study. Most common procedures （92.3%） were done on the upper urinary tract, with 55.5% of the whole cohort being tumor-related indica- tions and only 16.3% being reconstructive procedures. The transperitoneal approaches were preferentially a- dopted in 80.9% cases, and transvesical access in 5.3% cases. The transumbilical access was used in 46.9% of cases. The overall conversion rate was 8. 1% , with 4.3% of cases converted to reduced -port laparoscopy, 1.9% to conventional laparoscopy, and 1.9% to open surgery. The intraoperativc complication rate was d. 8% （10/209） and postoperative complications, mostly low grade, were encountered in 11.5% （24/209） of cases. There was a significant increase in the number of LESS cases during the second study period ; the rate of some procedures （ ie, transumbilical LESS, renal cyst decortication and transvesical sin- gle-port enucleation of the prostate） was lower, whereas some other procedures were performed more fre- quently （ie, tumor-related LESS procedures, radical nephrectomy and adrenalectomy）. Conclusions A broad range of urological procedures can be finished with LESS technique in the experienced hands of a lapa- roscopic surgeons. However, LESS is still in its infancy with a certain risk of surgical complication and con- version. Stringent patient selection criteria should be applied, especially during the learning curve. Complex reconstructive procedures or malignant tumor related indications are not appropriate as the start of this kind of procedure. We need always put patient＇s safety and treatment efficacy first.