腹腔镜颊黏膜输尿管成形术治疗输尿管狭窄的临床应用

Laparosopic buccal mucosa graft ureteroplasty for ureteral stricture:clinical experience and outcome

目的探讨腹腔镜颊黏膜输尿管成形术治疗输尿管狭窄的可行性和临床疗效。方法回顾性分析2018年7月至2019年11月安徽医科大学第二附属医院收治的10例输尿管狭窄患者的临床资料,男7例,女3例。平均年龄(47.9±7.8)岁。病变位于左、右侧各5例。所有患者均有输尿管结石相关手术史。术前血肌酐中位值71(68~610)μmol/L,其中2例为孤立肾肾功能不全,血肌酐分别为206μmol/L和610μmol/L。术前行泌尿系B超、CTU和输尿管逆行造影等检查对肾积水和输尿管狭窄情况进行评估:患侧肾盂分离为(3.1±0.7)cm;上段狭窄7例,中段狭窄2例,多段狭窄1例;输尿管狭窄长度为(3.2±0.7)cm。10例均全麻下行腹腔镜颊黏膜输尿管成形术。术中游离并纵行切开狭窄段输尿管,根据狭窄情况切取长3.0~4.5 cm、宽1.0~1.5 cm的颊黏膜,修整后与狭窄段输尿管镶嵌吻合修复输尿管狭窄。结果本组10例手术均在腹腔镜下完成,无中转开放病例,无严重并发症。手术时间(199.2±27.4)min,术中出血量(101.5±54.7)ml,术后引流管留置时间中位值4.5(3.0~7.0)d,术后住院时间(7.9±1.9)d。术后1周患者发音吐字清晰,进食无障碍。术后1~2个月拔除双J管。术后随访(11.3±4.2)个月,影像学检查见患侧肾积水明显改善,患侧肾盂分离中位值1.8(0~2.2)cm。术后复查血肌酐中位值82(66~235)μmol/L,2例术前肾功能不全患者术后血肌酐明显下降。结论腹腔镜颊黏膜输尿管成形术治疗输尿管狭窄安全可行,具有创伤小、恢复快、并发症少等优点;远期疗效有待长期随访进行评估。

Objective To discuss the feasibility and clinical efficacy of laparoscopic ureteroplasty with buccal mucosa graft for ureteral stricture.Methods The clinical data of 10 patients with ureteral stricture admitted to the Second Affiliated Hospital of Anhui Medical University from July 2018 to November 2019 were retrospectively analyzed,including 7 males,3 females,5 cases on each side,with an average age of(47.9±7.8)years.All patients had a history of operation related to ureteral calculi.The median value of preoperative serum creatinine was 71(68~610)μmol/L.The status of hydronephrosis and ureteral stricture was evaluated by ultrasonography,CTU and ureteral retrograde angiography.The separation of the renal pelvis on the affected side was(3.1±0.7)cm.There were 7 cases of upper segment stenosis,2 cases of middle segment stenosis,and 1 case of multiple stenosis.The length of ureteral stenosis was(3.2±0.7)cm.Laparoscopic buccal mucosa ureteroplasty was performed in all 10 cases under general anesthesia.After the stricture ureter segment was separated during the operation,the ureteral stenosis segment was longitudinally cut.According to the stenosis,the buccal mucosa with a length of 3.0-4.5 cm and a width of 1.0-1.5 cm was cut.Buccal mucosa grafts were harvested and placed in the ureter as an anterior onlay with omental wrapping.Results Ureteral repair was performed laparoscopically in all cases,with no conversion to open and no serious complications.The operative time was(199.2±27.4)min,the blood loss was(101.5±54.7)ml,the median postoperative indwelling time of the drainage tube was 4.5(3.0-7.0)d,and the postoperative hospital stay was(7.9±1.9)days.The patients had clear pronunciation and barrier-free eating one week after the operation.The double J tube was removed one to two months after surgery.The patients were followed up for(11.3±4.2)months after the operation.Follow-up patients underwent imaging and other examinations,which showed significant improvement in hydronephrosis on the affected side,and the median value of renal pelvis separation on the affected side was 1.8(0-2.2)cm.The median value of serum creatinine was 82(66~235)μmol/L.The serum creatinine in 2 patients with renal insufficiency decreased significantly after operation.Conclusions Laparoscopic buccal mucosa graft ureteroplasty could be a safe and feasible option for the treatment of ureteral stricture with less trauma and rapid recovery.The results of the initial experience are encouraging.