后腹腔镜输尿管切开取石术的技术分析

Analysis of the surgical techniques in retroperitoneal laparoscopic ureterolithotomy

目的研究并改进后腹腔镜输尿管切开取石术的手术技术。方法结合手术录像和病历资料,分析和总结39例后腹腔镜输尿管切开取石术的技术细节,将镜下手术过程分解为四部分:结石定位、切开取石、留置支架管、镜下缝合,分析影响手术时间和效果的技术因素。结果 39例手术均顺利取净结石,手术时间33～23(6114.0±64.4)min,包括结石定位9～85 min;切开取石6～50 min;留置支架管4～105 min,其中单导丝法33例(35.2±30.4)min,双导丝法6例(5.3±2.0)min,P=0.018;镜下缝合9～60 min。以腰大肌和肾下极为参照寻找结石,自结石上方向下纵行切开扩张的输尿管,双导丝法置管,和使用合适长度的缝线镜下缝合,是快速完成手术的关键。术中出血微量,术中、术后无严重并发症。结论通过结合手术录像进行后腹腔镜输尿管切开取石术的技术分析,可以找到快速完成手术的方法。后腹腔镜输尿管切开取石术可作为输尿管中上段复杂性及较大结石的一线治疗方法。

Objective To investigate and improve the surgical techniques in retroperitoneal laparoscopic ureterolithotomy （RLUL）. Methods According the medical records and operation video, the surgical technique of RLUL with details of 39 cases were analyzed. The laparoscopic operative time was divided into 4 phases, as stone localization, stone retrieval, stent placing, and ureter incision suturing and ending. The factors which influence the operative time and outcomes were analyzed. Results The stone-free rate was 100%（39/39）.The operative time was （114±64.4） min （33-236 min）, including stone location（9-85 min）;stone retrieval（6-50 min）;stent placing（4-105 min）, it was （35.2±30.4） min in single wire method （n=33）, and （5.3±2.0） min in double wires method （n=6）, P=0.018; ureter incision suturing（9-60 min）. The key points of promptly completing the operation are：First, finding the ureteral stones with reference to the psoas muscle and the lower pole of kidney;Second, opening the dilated ureter longitudinally proximal to the stone and then down to it; Third, adopting two-wires method in stenting;Four, closing the ureter with suture of proper length. The blood loss was minimal. No major complication was found perioperatively. Conclusions The key points of surgical techniques in RLUL could be found through technical analysis with video review. Operative time and technical difficulty can be reduced following with technical improvements. RLUL could be the first line therapy for the complicated and large stones in proximal/middle ureter.