P.R.E.S.S.技术膀胱袖套状切除术的操作要点和疗效

Surgical technique and efficacy of P.R.E.S.S.bladder cuff excision

目的:探讨完全后腹腔镜经膀胱外途径规范化直视下(P.R.E.S.S.)膀胱袖套状切除术的操作要点和疗效。方法:回顾性分析2017年8月至2020年12月收治的95例上尿路尿路上皮癌(UTUC)患者的病例资料,分别为海军军医大学长征医院30例,北京大学第一医院21例,烟台毓璜顶医院20例,大连医科大学附属第二医院21例,东部战区总医院3例。男57例,女38例。平均年龄(67.7±10.0)岁。中位肿瘤最大径3.0 cm。95例均行单次体位全程后腹腔镜肾输尿管全长切除联合P.R.E.S.S.技术膀胱袖套状切除术,根据术者手术习惯和经验分别采用四孔法(36例)和五孔法(59例)套管布局完成手术。四孔法组和五孔法组的年龄[(66.3±11.2)岁与(68.6±9.1)岁]、性别(男/女:25/11例与32/27例)、体质指数[(25.0±3.0)kg/m 2与(24.8±3.4)kg/m 2]、肿瘤最大径[2.8(1.6,3.5)cm与3.0(2.0,4.0)cm]、肿瘤侧别(左/右:19/17例与34/25例)、临床分期(T 1~2/T 3~4/Tis期:25/10/4例与49/10/0例)、多灶性肿瘤(3例与2例)比较差异均无统计学意义(P>0.05);术侧合并肾积水(13例与39例,P=0.004)、肿瘤位置(肾盂肾盏及上段输尿管/中段输尿管/下段输尿管:23/9/4例与35/4/20例,P=0.005)的差异均有统计学意义。术中行P.R.E.S.S.技术膀胱袖套状切除时,以脐动脉索为解剖标志,扩大输尿管周围的盆底侧方腹膜外间隙,切开膀胱壁后形成气膀胱效应,进行充分的膀胱袖套状切除和确切的膀胱袖口关闭。记录围手术期临床指标及随访结果。比较四孔法组和五孔法组的相关临床指标,分析套管布局方式对手术操作的影响。结果:本研究95例中,91例(95.8%)采用P.R.E.S.S.技术完成膀胱袖套状切除;1例(1.1%)因出血中转开放手术;3例(3.1%)因局部空间显露困难,仅以Hem-o-lok夹闭输尿管远端完成手术。手术时间中位值180(125,230)min。术中估计出血量中位值100(50,100)ml。总体并发症发生率10.5%(10/95),其中术中并发症2例(2.1%)均为出血,1例术中输血400 ml,1例中转开放手术,未输血;术后并发症8例(8.4%),其中Clavien-DindoⅡ级7例[继发出血3例,药物过敏、急性肾功能减退(血肌酐490μmol/L)、肺部感染及淋巴漏各1例],Ⅲa级1例(肠梗阻,局麻下置入肠梗阻导管),患者经对症治疗后均顺利出院。四孔法组和五孔法组在手术中转率[8.3%(3/36)与1.7%(1/59)]、术中估计出血量(100 ml与60 ml)、术中淋巴结清扫率[25.0%(9/36)与20.3%(12/59)]、P.R.E.S.S.技术膀胱袖套状切除成功率[91.7%(33/36)与98.3%(58/59)]、并发症发生率[13.8%(5/36)与8.5%(5/59)]、肿瘤病理分期(pT 1~2/pT 3~4/pTis期:22/11/3例与37/19/3例)以及复发转移比例[8.3%(3/36)与3.4%(2/59)]方面差异均无统计学意义(P>0.05);在手术时间(190 min与170 min,P=0.011)和术后住院时间(5 d与6 d,P=0.005)方面差异均有统计学意义。结论:P.R.E.S.S.技术通过建立扩大的盆底侧方腹膜外间隙和气膀胱效应,以脐动脉索为解剖标志,可直视下确切地行膀胱袖套状切除术,用于单次体位完全后腹腔镜肾输尿管全长切除术安全、可行。五孔法布局较四孔法布局更适用于下段输尿管肿瘤患者,但可能延长术后住院时间。

Objective To explore the surgical technique and efficacy of pure retroperitoneoscopic extravesical standardized seeable(P.R.E.S.S.)technique for bladder cuff excision(BCE).Methods Ninety five patients with UTUC from five domestic centers(30 cases from Changzheng Hospital,21 cases from Peking University First Hospital,20 cases from Yuhuangding Hospital,21 cases from Dalian Medical University affiliated No.2 Hospital and 3 cases from General Hospital of Eastern Theater Command)between August 2017 and December 2020 were retrospectively analyzed.There were 57 males and 38 females with a mean age of(67.7±10.0)years and median tumor size of 3.0 cm.All patients underwent pure retroperitoneoscopic radical nephroureterectomy with a single surgical position and four(36 cases)or five(59 cases)trocar layout according to the surgeon’s prefer habit and experience.The demographics of the two groups were the age of[(66.3±11.2)years vs.(68.6±9.1)years],male/female ratio of(25/11 cases vs.32/27 cases),body mass index of[(25.0±3.0)kg/m2 vs.(24.8±3.4)kg/m2],tumor maximum diameter of[2.8(1.6,3.5)cm vs.3.0(2.0,4.0)cm],left/right side tumor of(19/17 cases vs.34/25 cases),T1-2/T3-4/Tis stage of(25/10/4 cases vs.49/10/0 cases),and multifocal tumors of(3 cases vs.2 cases),and the difference was not statistically significant(P>0.05).On the other hand,the differences of hydronephrosis of the operated kidney(13 cases vs.39 cases,P=0.004),and tumor location(in renal pelvis or calyx or upper/middle/lower ureter being 23/9/4 cases vs.35/4/20 cases,P=0.005),were statistically significant.The umbilical artery cord was used as anatomical landmark in the process of P.R.E.S.S.bladder cuff excision.The pelvic floor and extraperitoneal space around the ureter were expanded,the bladder wall was opened to form pneumovesicum,and a sufficient bladder cuff resection and exact bladder cuff closure was performed.Perioperative outcomes and follow-up data were analyzed,and the clinical outcomes between the four and five trocars were compared to evaluate the impact of trocar layout on the surgical outcomes.Results There were 91(95.8%)cases successfully undergoing P.R.E.S.S.BCE technique,with one case converted to open BCE due to bleeding and three cases converted to distal ureter Hem-o-lok clipping because of poor exposure.Median operative time was 180(125,230)min,and estimated blood loss was 100(50,100)ml.The overall complication rate was 10.5%(10/95),including 2 cases(2.1%)of intraoperative bleeding,with 1 case treated by transfusion(400 ml),the other case converted to open surgery without transfusion.There were 8 cases of postoperative complications(8.4%),including 7 cases of Clavien-Dindo gradeⅡ(3 cases of secondary hemorrhage,one case for each of drug allergy,acute renal insufficiency,blood creatinine increased to 490μmol/L,or lung infection with lymphatic leakage),1 case of gradeⅢa(intestinal obstruction treated with insertion of the intestinal obstruction catheter under local anesthesia),and all these patients were discharged smoothly.The difference between the four and five trocars was not statistically significant in the following variables,including the rate of surgical conversion(8.3%vs.1.7%),estimated intraoperative blood loss(100 ml vs.60 ml),ratio of intraoperative lymph node dissection(25.0%vs.20.3%),P.R.E.S.S.bladder cuff excision success rate(91.7%vs.98.3%),the incidence of intraoperative and postoperative complications(13.8%vs.8.5%),pT1-2/pT3-4/pTis stage(22/11/3 cases vs.37/19/3 cases)and the proportion of recurrence or metastasis(8.3%vs.3.4%)(all P>0.05).However,the differences in the operation time(190 min vs.170 min,P=0.011)and postoperative hospital stay(5 d vs.6 d,P=0.005)were statistically significant.Conclusions P.R.E.S.S.bladder cuff resection technique is safe and feasible during the procedure of pure retroperitoneoscopic radical nephroureterectomy by a single surgical position and facilitates seeable adequate bladder cuff excision by establishing an enlarged pelvic lateral extraperitoneal space and pneumovesicum.Five-trocar technique is more suitable for patients with lower ureteral tumors but may be associated with a longer postoperative hospital stay compared with the four-trocar technique.