耻骨上辅助经脐单孔腹腔镜上尿路全切除术(附8例报告)

Suprapubic-assisted laparoendoscopic single-site surgery for nephroureterectomy:Report of 8 cases

目的：探讨耻骨上辅助经脐单孔腹腔镜（SA—LESS）上尿路全切除术的可行性、有效性和技术要点。方法：对2例肾盂癌，2例输尿管癌，1例肾盂癌合并输尿管癌，2例肾结核，1例巨输尿管症并积脓、肾萎缩患者施行SA—LESS上尿路全切除术。患者全麻，取健侧70°卧位，于脐缘内侧置人两个Trocar，自患侧耻骨联合上方置人一个Trocar，分别置入远端可弯曲腹腔镜及操作器械。先游离患侧输尿管下段，予Hem—0—lok夹闭；向上游离肾脏并离断。肾动静脉，切除肾脏；向下行袖套状切除输尿管末端周围膀胱壁，缝合膀胱切口；标本装袋，延长耻骨上切口取出。结果：8例手术均顺利完成。中位手术时间165（115～220）min，术中中位失血量140（50～200）ml。均未输血，术中未出现肠管、实质性器官和大血管损伤等并发症。均于术后第1天下床活动，第2～3天拔除腹腔和盆腔引流管，第6～7天拔除导尿管（肿瘤患者行膀胱灌注后），第8天出院。结论：SA-LESS上尿路全切除术安全可行，术后恢复快，住院时间短，美容优势明显，值得临床应用。

Objective;To evaluate the feasibility and efficacy of suprapubic-assisted laparoendoscopic single-site surgery（SA-LESS） for nephroureterectomy, and to discuss its key technique issues. Methods.. Eight patients （two of them with renal pelvic carcinoma, two with ureteral carcinoma, one with renal pelvic carcinoma combined with ureteral carcinoma, two with renal tuberculosis, and one with megaureter and empyema） were subjected to SA- LESS nephroureterectomy. The patient was administrated general endotracheal anesthesia and secured on the oper- ating table in lateral decubitus with affected side elevated 70~. Two trocars were inserted at the medial margin of umbilicus, and one was inserted into abdominal cavity below the pubic hairline. The operation was performed u- sing conventional operating instruments, under direct vision achieved by a 5 mm flexible-tip 0° laparoscope. Firstly, the distal ureter was isolated completely and blocked by a Hem-o-lok clip. Then, the nephrectomy was per-formed according to the method of the standard laparoscopy. Finally, the bladder cuff excision was performed and the incision was sutured. The specimen was removed after the incisions below the pubic hairline was enlarged transversely and the rectus abdominis muscle sheath was incised vertically. Results;All the procedures were succe-ssfully performed. The median operative time was 165 （range 115 to 220） minutes, and the median estimated blood loss was 140 （range 50 to 200）ml. There was no major perioperative complication occurred. All the patients resumed ambulation on postoperative day 1. The abdominal and pelvic drainage tube was removed on postoperative day 2-3. Urethral catheter was removed on postoperative day 6-7 （the tumor patients underwent irrigation of blad- der with Pirarubicin）. The patients were discharged on postoperative day 8. Conclusions..SA-LESS nephroureterec-tomy appears to be feasible and effective with faster postoperative recovery, shorter hospitalization time and better cosmetic results.