机器人全腹膜外肾输尿管全长及膀胱袖状切除术的初步临床应用

Complete retroperitoneal robotic nephroureterectomy： a preliminary report

目的探讨单次手术体位机器人全腹膜外肾输尿管全长及膀胱袖状切除术治疗上尿路尿路上皮癌的可行性和安全性，总结手术技巧和初步治疗经验。 方法2017年8—10月采用单次手术体位机器人全腹膜外肾输尿管全长及膀胱袖状切除术治疗上尿路尿路上皮癌患者3例。例1，男，年龄48岁，体重指数22.9 kg/m2，美国麻醉师协会（ASA）评分2分，Charlson合并症指数0，肿瘤位于左侧肾盂，肿瘤最大径3.2 cm；例2，女，年龄75岁，体重指数20.8 kg/m2，ASA评分2分，Charlson合并症指数3，有左肾结石、肾功能不全和糖尿病病史，肿瘤位于右输尿管上段，肿瘤最大径2.0 cm；例3，女，年龄68岁，体重指数21.3 kg/m2，ASA评分2分，Charlson合并症指数1，有糖尿病病史，肿瘤位于左输尿管下段，肿瘤最大径1.4 cm。3例患者术前均有肉眼血尿病史，术前均行腹部CT和CT尿路造影检查诊断为局限性上尿路恶性肿瘤。手术均采用全麻。患者取90°健侧卧位，于腋中线髂嵴上3 cm处放置12 mm套管，分别于腋后线肋缘下、腋前线肋缘下3 cm及髂前上棘内下方4 cm放置8 mm智能臂套管，于髂前上棘内上3 cm放置12 mm辅助孔套管，床旁操作系统进行头尾侧两次定泊，按常规后腹腔镜手术步骤切除肾脏，向下游离输尿管至膀胱壁内段，以Endo-GIA吻合器闭合或可吸收线缝合膀胱切口。 结果3例手术均顺利完成，未发生术中、术后并发症。手术时间分别为245 min、270 min和239 min，术中估计出血量均为100 ml，术中均无输血。术后第1天视觉疼痛模拟评分分别为5分、4分和4分，第2天为4分、3分和3分，第3天为2分、2分和1分。术后下床活动时间分别为术后24 h、32 h和32 h。术后禁食时间均为2 d。术后引流管留置时间分别为3 d、2 d和3 d。术后住院时间分别为3 d、2 d和4 d。术后24 h内均行膀胱灌注化疗1次。术后均留置尿管2周。病理诊断均为乳头状尿路上皮癌。 结论单次体位机器人全腹膜外肾输尿管全长及膀胱袖状切除术安全、可行，术后患者恢复快，但目前完成的病例数较少，仍需进一步临床经验积累。

ObjectiveThis study is to investigate the safety, feasibility and efficacy of the complete retroperitoneal robotic nephroureterectomy in treatment of upper urinary tract tumors. MethodsThree patients underwent complete retroperitoneal robotic nephroureterectomy due to the upper urinary epithelial tumor from August to October in 2017 in our institution. The 3 patients’ demographics and tumor characteristics, including age, gender, body mass index （kg/m2）, ASA score, Charlson comorbidity index, tumor laterality and diameter （cm）, were48/75/68 years old, male/female/female, 22.9/20.8/21.3, 2/2/2, 0/2/1, left/right/left, 3.2/2.0/1.4, respectively. All patients had complained about the hematuria and accepted the abdominal CT and CTU examination, preoperatively. All patients were diagnosed localized upper urinary tract malignant tumors based on these images. The tumor of case 1 located in the renal pelvis. The tumor of case 2 located in the upper segment of the ureter. The tumor of case 3 located in the lower segment of the ureter. The operations were performed under general anesthesia, and patients were positioned in full flank. A total of five ports were used in the procedure and placed in the following order. The initial port （Port 1） was a robotic camera port, which was placed 3 cm above the intersection of the mid axillary line and the iliac crest. The next three ports （Port 2 to Port 4） were all 8 mm robotic instrument ports and placed at the intersection of posterior axillary line and costal margin, 3 cm above the intersection of anterior axillary line and costal margin, and 4 cm medial and inferior to anterior superior iliac spine. The fifth port （Port 5） was a 12 mm assistant port and placed at 3 cm medial and superior to anterior superior iliac spine. Our completely robotic technique did not require patient repositioning and port reassignment, but redocking of the robotic arms was needed. Nephrectomy was performed according to the routine retroperitoneal laparoscopic procedure. Once the remainder of the kidney was mobilized, the dissection was directed down the pelvis to mobilize the distal segment of the ureter. The bladder defect was then closed by Endo-GIA stapler or absorbable sutures. ResultsAll procedures were successful and smooth, with no intraoperative or postoperative complications. Operative duration（min） and estimated blood loss（ml） was 245/270/239, 100/100/100, respectively. Postoperative pain measured by the visual analog pain scale（VASP） at day 1, day 2, day 3 was 5/4/4, 4/3/3, 2/2/1, respectively. Time off oral intake（d）, duration of drainage（d）, active time post-operation（h） and hospital stay（d） was 2/2/2, 3/2/3, 24/32/32, 3/2/4, respectively. Intravesical chemotherapy was performed within 24 h after the operation. Postoperatively, the urinary catheter was left in place for 2 weeks. Pathological examination confirmed papillary urothelial carcinoma in all cases. ConclusionsThe initial experience shows that the complete retroperitoneal robotic nephroureterectomy is a safe, feasible and efficacious procedure, but in this early stage the clinical indications should be strictly controlled.