术前三维影像重建在治疗肾盂输尿管连接部梗阻中的应用

Application of preoperative three-dimensional image reconstruction in the treatment of ureteropelvic junction obstruction

目的:探讨术前三维影像重建技术在治疗肾盂输尿管连接部梗阻(ureteropelvic junction obstruction,UPJO)中的应用价值。方法:选择2017年5月至2019年4月北京大学第一医院收治的UPJO患者病例资料进行回顾性分析,共收集病例40例,其中男性22例,女性18例,中位年龄26.5岁(四分位距23.25~38.75)岁。40例中11例合并异位血管,14例合并肾结石,3例合并马蹄肾,肾盂成形术后再梗阻6例。40例患者均在术前对泌尿系统增强CT进行三维影像模型重构,观察肾盂输尿管连接部梗阻位置,以及梗阻处与血管及周围组织器官的关系,依据三维重构影像结果制定手术计划。37例患者行腹腔镜下肾盂成形术(其中3例联合软膀胱镜取石,1例联合孙氏镜取石,1例联合输尿管切断再吻合术,3例联合马蹄肾成形术),2例行腹腔镜下舌黏膜补片法输尿管成形术,1例行机器人辅助腹腔镜下肾盂成形术。结果:术前泌尿系统增强CT图像经三维重建后,清晰显示了肾盂输尿管连接部梗阻处与血管及周围组织器官的关系,术者依据三维重建模型可于术前清晰地观察异位血管的类型、直径、位置及走形方向,评估肾结石或其他占位的数量、大小、位置和形态,累及的肾盏数,以及在肾盂、肾盏中的解剖分布,综合分析上述信息后,对所有患者施行个体化的手术方案,40例患者手术均顺利完成,无中转开放手术者。平均手术时间(129.91±37.90)min(75~273 min),平均出血量(48.1±78.0)mL(10~400 mL),平均住院时间(5.04±1.99)d(2~10 d),平均术后拔除引流时间(3.8±1.4)d(2~8 d)。结论:三维影像重建技术在UPJO治疗方面具有较高的临床应用价值,对辅助术者拟定手术方案具有指导意义,值得进一步临床推广及应用。

Objective:To investigate the value of preoperative three-dimensional image reconstruction in the treatment of ureteropelvic junction obstruction(UPJO).Methods:We reviewed data on 40 patients(22 male cases,and 18 female cases)diagnosed with UPJO in Peking University First Hospital from May 2017 to April 2019.The median age was 26.5 years(IQR 23.25-38.75)years.There were 11 patients complicated with ectopic vessels,14 patients with kidney stones,3 patients with horseshoe kidney,and 6 patients with obstruction after pyeloplasty.All the patients underwent preoperative enhanced CT scan,and the CT data were reconstructed into three-dimensional image models.The obstruction position of ureteropelvic junction and the relationship between ureteropelvic junction and blood vessels and organs were observed by three-dimensional models to assist planning surgery.Thirty-seven patients underwent laparoscopic pyeloplasty(including 3 cases combined with pyelolithotomy with flexible cystoscope,1 case combined with pyelolithotomy by sun-style cystoscope,1 case with laparoscopic ureter resection and anastomosis,3 cases of laparoscopic pyeloplasty of horseshoe kidney),2 patients underwent laparoscopic ventral onlay lingual mucosal graft ureteroplasty,and 1 patient underwent robot-assisted laparoscopic pyeloplasty.Results:Three-dimensional CT image clearly showed the relationship between the obstruction of ureteropelvic junction and blood vessels and organs after three-dimensional reconstruction.The type,diameter,position and direction of the ectopic vessels could be observed clearly before operation according to the three-dimensional reconstruction model,and the number,size,location and shape of renal calculi or other masses,the number of involved renal calyces and the anatomical distribution in the renal pelvis and calyces could be also evaluated preoperatively.After comprehensive analysis of the above information,individualized operation plans were performed on the patients,all the 40 cases were successfully completed with the surgery without any transfer to open surgery.The average operative time was(129.91±37.90)min(range:75 to 273),the average blood loss was(48.1±78.0)mL(range:10 to 400),the average hospitality was(5.04±1.99)d(range:2 to 10),and the average postoperative drainage time was(3.8±1.4)d(range:2 to 8).Conclusion:The preoperative three-dimensional image reconstruction has a high clinical value in the treatment of ureteropelvic junction obstruction,and it is of great help to assist surgery planning and is worthy of further clinical promotion and application.