单一体位、原通道经腹入路RANU在治疗上尿路尿路上皮癌中的应用

Transperitoneal robot-assisted nephroureterectomy with a single body position and original ports:a simplified surgical technique for upper urinary tract urothelial carcinoma

目的探讨单一体位、原通道经腹入路机器人辅助腹腔镜肾输尿管全长切除术(RANU)在治疗上尿路尿路上皮癌(UTUC)中的疗效和安全性。方法回顾性分析2018年3月至2019年11月于郑州大学第一附属医院行单一体位、原通道经腹入路RANU 21例患者的临床资料。男14例,女7例;年龄(63.8±11.4)岁,体质指数(23.6±2.5)kg/m2。术前均诊断为局限性UTUC,肾盂癌8例,输尿管中段癌3例,输尿管下段癌10例;左侧11例,右侧10例;高危患者20例(95.2%)。手术均为同一术者完成,全麻下采用75°健侧卧位、整体15°头低足高位。穿刺套管布局:患侧脐旁两横指向下2 cm处为镜头套管C,患侧腹直肌外缘距C>8 cm近肋缘处、C与患侧髂嵴连线中点下2 cm处分别为1号、2号机械臂套管,腹中线脐上2 cm和脐下4 cm处分别为1号、2号辅助套管,右侧病变需在腹中线剑突下增加1个辅助套管用来挑起肝脏。游离输尿管至髂血管水平并于肿瘤远端用Hem-o-lok夹闭后,将患肾行根治性切除;无瘤原则下切除输尿管及距管口1 cm范围的膀胱壁全层后连续缝合膀胱。游离肾、输尿管同时行淋巴结清扫。术后拔除导尿管时行膀胱内灌注化疗。结果21例手术均顺利完成,无中转开放手术或更改体位,无围术期输血和术中并发症的发生。21例手术时间(205.2±57.3)min,中位术中出血量50 ml(20~120 ml)。术后中位引流管留置时间4 d(3~7 d),中位尿管留置时间7 d(5~8 d),中位术后住院时间7 d(6~12 d)。术后Clavien-DindoⅠ级并发症7例(33.3%),给予对症处理后均好转。21例术后病理诊断均为UTUC,切缘均提示阴性。术后中位随访时间为12个月(4~22个月),1例术后7个月死于车祸,3例(14.3%)分别于术后6、8、10个月出现复发,予肿瘤电切+膀胱灌注化疗、化疗栓塞等治疗后肿瘤无进展。结论单一体位、原通道经腹入路RANU安全、有效,术中无需更改患者体位、增加穿刺套管以及重新定泊和连接机械臂,节省手术时间,术中、术后并发症发生率低,术后患者恢复快,短期复发率低,控瘤效果佳。

Objective To investigate the efficacy and safety of transperitoneal robot-assisted nephroureterectomy(RANU)with a single body position and original ports for upper urinary tract urothelial carcinoma(UTUC).Methods Clinical data of 21 patients from March 2018 to November 2019 in the First Affiliated Hospital of Zhengzhou University was retrospectively analyzed,including 14 males and 7 females.The age was(63.8±11.4)years and the BMI was(23.6±2.5)kg/m2.Of the 21 localized UTUC patients,8 pelvic tumors,3 middle ureter tumors,10 lower ureter tumors;11 on the left,10 on the right;20 of 21 tumors(95.2%)were high risk.Surgery was done by the same urologist.Under general anesthesia,the patients were in 75°healthy side lying position and overall 15°head down and foot high position.Improved layout of ports:camera port C was located at two fingers lateral to the umbilicus,2 cm below the umbilicus;robotic arm port 1 and 2 were respectively located at pararestus line,close to costal margin and 2 cm below the midpoint between C and the affected iliac crest.Assistant port 1 and 2 were respectively located at 2 cm above the umbilicus and 4 cm below the umbilicus.The right cases need an additional assistant port under the xiphoid to provoke the liver.Hem-o-lok cliped the ureter distal to the tumor and the affected kidney was radically removed.Under the principle of tumor free,the ureter and the surrounding bladder wall within 1 cm were excised and the bladder was sutured.Lymphadenectomy was performed when the kidney and ureter were dissociated.Results All 21 procedures were successful without open surgery or position change and intraoperative complications.No patients required a blood transfusion.The operation time was(205.2±57.3)min.The median intraoperative blood loss was 50 ml(20-120 ml).The median drainage tube indwelling time was 4d(3-7 d)and the median urinary catheter indwelling time was 7 d(5-8 d),the median postoperative hospital stay was 7 d(6-12 d).7 cases(33.3%)of Clavien-Dindo gradeⅠcomplications after surgery and they all relieved after giving symptomatic treatment.All postoperative pathology showed UTUC and negative resection margins.The median follow-up time was 12 months(4-22 months),1 patient died of an accident 7 months after surgery and 3 patients had recurrence at 6,8,and 10 months after surgery,survival at the last follow-up after treatment.Conclusions The transperitoneal RANU with a single body position and original ports is safe and effective.The operation time is saved,the incidence of intraoperative and postoperative complications is low,the postoperative patients recover quickly.Short-term follow-up results prompt low recurrence rate and good tumor control effect.