五步骤法在经腹腹腔镜输尿管切开取石术中寻找输尿管结石的应用

Seeking ureteral calculi during transperitoneal laparoscopic ureterolithotomy by the five-step approach

目的：探讨经腹腹腔镜输尿管切开取石术（transperitoneal laparoscopic ureterolithotomy,TPLU）术中寻找输尿管结石的方法及技巧。方法：TPLU术中采用五步骤显露、处理输尿管结石：（1）大致位置;（2）解剖分离;（3）肌性管道;（4）局部膨隆;（5）硬物感。切开结石区输尿管,取出结石。结果：230例TPLU中,225例采用五步法准确找到输尿管结石,顺利完成手术,未发生结石残留或邻近肠管、血管损伤。结石寻找时间5～20 min,平均（11±8）min,结石最大径1.2～3.0 cm,平均（1.5±0.7）cm。寻找时间随操作熟练而逐步缩短。5例患者未能顺利按五步法找到结石,均发生于手术开展初期,其中因腹腔及输尿管周围严重粘连1例;腹腔镜下发生难以控制的出血1例;因解剖分离不当,结石上移进入肾盂或肾盏导致无硬物感3例,其中2例行腹腔镜肾盂切开取石术,1例仅行输尿管内D-J管引流,后期行经皮肾镜碎石术。结论：五步骤法寻找输尿管结石安全、有效,可减少邻近肠管、血管误伤,适合在临床上进一步推广。

Objective：To discuss the method and skill of seeking ureteral calculi during transperitoneal laparoscopic uret- erolithotomy （TPLU）. Methods：In this method, the ureteral calculi was exposed and managed by the five-step approach：approximate location,careful dissection, muscular tube, a bump on the wall, something feels hard. And then the stone was removed after the ureteral wall where the stone stayed was incised with a cold knife. Results： The five-step approach was used in a total of 230 cases. In 225 ea- ses ,the ureteral stones were successfully removed laparoscopically by using this method （97.8%）. There were no residual stone and no vascular or enteric injury in the neighborhood. Mean time for seeking ureteral stone was （11 ± 8） rain （range,5-20 rain）. Mean stone largest diameter was （1.5 ± 0.7 ）cm （range, 1.2-3.0 cm）. The time for seeking ureteral stone shortened with the increasing skills. In 5 cases that happened in the TPLU initial stage, the steps of seeking ureteral calculi were interrupted. The causes of failure included one severe conglutination （conversion to open surgery） ;one intractable bleeding （conversion to open surgery）,three lost the feeling of something hard, due to stone moving up into the renal pelvis or calyces because of improper dissection （2 conversion to laparoscopic pyelolithotomy, 1 conversion to placing a double-J stent only and the stone was finally removed by percutaneous nephrolithotomy）. Conclusions ： The five-step approach is a safe and effective method for seeking ureteral stone with reduced risk of vascular and enteric injury in the neighborhood. It is worth popularizing in the clinical practice.