腹腔镜治疗复杂性输尿管中上段结石的疗效探讨

Transperitoneal laparoscopic ureterolithotomy for the treatment of upper or middle ureteral calculi

目的：探讨经腹腔途径腹腔镜下治疗复杂性输尿管中上段结石的临床技巧和疗效。方法：回顾性分析50例输尿管中上段结石患者的临床资料，均行彩超、CTU或MRU等影像学检查确诊，其中输尿管上段结石38例，输尿管中段结石12例。18例曾行1～4次ESWL治疗，9例曾行输尿管镜碎石治疗，3例曾行经皮肾镜（PCNL）碎石治疗失败。50例均行经腹腔途径腹腔镜下输尿管切开取石术。结果：50例手术均顺利完成，无中转开放手术者。取出结石大小1～3cm。21例伴有息肉，其中14例较小息肉给予电钩切除，7例较大、蒂宽息肉给予息肉段输尿管切除吻合。切除息肉术后病理检查均为输尿管炎性息肉，输尿管壁慢性炎症。平均手术时间70（50～105）min；平均术中出血量20（10-50）ml。2例出现漏尿者于术后2周和1个月漏尿停止。其余患者术后无明显外科并发症，3～5天拔除引流管，5～7天拔除尿管，术后6～8天顺利出院。术后6～8周拔除双J管。术后随访6个月～3年，2例双J管拔除后逐渐出现腰痛，彩超和IVU示原结石部位狭窄，狭窄段长0．5～1．0cm，行输尿管镜丝状电极内切开术后治愈。余48例彩超及IVU检查显示未见结石残留及吻合处输尿管狭窄发生。结论：经腹腔途径腹腔镜下输尿管切开取石术创伤小，恢复快，并发症少，是治疗复杂性输尿管中上段结石的理想方法。

Objective：To analyze the clinical technique and value of transperitoneal laparoscopic treatment for upper or middle ureteral calculi. Method.. The clinical data of 50 cases with upper or middle ureteral calculi were retrospectively reviewed. The diagnosis was set up by color ultrasonography, CTU or MRU. Thirty-eight cases suffered from upper ureteral calculi and 12 cases were found middle ureteral calculi. Eighteen cases received one to four times of ESWL, nine cases were performed ureteroscopy lithotripsy, and three patients underwent PCNL, but all the procedures failed. All of the 50 cases underwent transperitoneal laparoscopic ureterolithotomy. Result： All the operations were performed successfully, without conversion to open surgery. The size of stones ranged from 1 cm to 3 cm. Histopathologic examination demonstrated 21 cases suffered from ureteral polyps with inflam- matory change. The average operation time was 70 （range, 50-105） minutes, and the average blood loss was 20 （10-50） ml. The postoperative hospital stay was 6-8 days. Two eases were found urinary leakage and recovered 14 days and 30 days later respectively. All cases were followed-up for 6 to 36 months. The color ultrasonography and IVU showed two cases were found ureteral stenosis and cured by ureteroscopic needle electrode. No evidence Of stenosis or residual stones was found in the rest 48 cases. Conclusion：Transperitoneal laparoscopic Ureterolithoto- my could be a mini-invasive, effective, and easy-to-operate procedure for the treatment of upper or middle ureteral calculi.