后腹腔镜联合下腹部小切口手术治疗上尿路上皮癌52例分析

Retroperitoneal laparoscopy combined with lower abdominal incisions for the surgical treatment of upper urinary tract urothelial cell carcinoma in 52 patients

目的探讨后腹腔镜肾根治性切除联合下腹部小切口治疗上尿路上皮癌的可行性和临床应用效果。方法回顾性分析武警湖北省总队医院2005年4月至2016年12月采用后腹腔镜下肾根治性切除联合下腹部小切口治疗的肾盂癌和输尿管癌患者52例的临床资料。52例均为单侧发病, 患者均无淋巴结及远处转移。全身麻醉下先取健侧卧位, 行后腹腔镜下根治性肾切除术, 夹闭患侧输尿管但不离断。Hem-o-lock分别夹闭肾脏血管后, 切断肾动、静脉, 完全游离肾脏。缝合3个腹腔镜切口。改平卧位, 取患侧下腹部小切口, 长5.0~6.0 cm。继续游离下段输尿管至膀胱。袖套状切除输尿管开口处膀胱壁1.5 cm。从下腹部小切口完整取出患肾、输尿管。切口下端另取切口置入橡皮引流管。术后均按膀胱尿路上皮癌方案给予膀胱灌注。结果 52例手术均成功, 无一例中转开放手术, 无输血病例, 无二次手术病例。术后未出现尿漏、切口感染、大出血等并发症。术后病理报告为肾脏尿路上皮癌41例, 输尿管尿路上皮癌11例。术后随访48例, 失访4例。1例术后13个月死于心血管意外, 47例患者术后膀胱镜下均未见膀胱肿瘤, 无局部及远处转移。结论后腹腔镜联合下腹部小切口行肾盂癌或输尿管癌根治性切除术, 操作简便, 对手术器械要求低, 患者创伤小, 恢复快, 符合微创手术的要求。

Objective To investigate the feasibility and efficacy of retroperitoneal laparoscopy combined with lower abdominal incisions in the surgical treatment of upper urinary tract urothelial cell carcinoma.Methods The clinical data of 52 patients with renal pelvic and ureteral cancer,who received radical nephrectomy using the retroperitoneal laparoscopy combined with a lower abdomen incision approach in Hubei Provincial General Hospital of Armed Police Force from April 2005 to December 2016,were retrospectively analyzed.All 52 patients had unilateral renal pelvic and ureteral cancer but with no lymph nodes or distant metastasis.During general anesthesia in a healthy side-lying position,patients underwent retroperitoneal laparoscopic radical nephrectomy.The affected ureter was clamped but not disconnected.Renal blood vessels were clamped with Hem-o-lock clips.Renal arteries and veins were cut off.Then the kidney was completely isolated.Three laparoscopic incisions were sutured.After taking the patients to be in the supine position,a 5-6 cm-long incision was made in the lower abdomen on the affected side.The lower ureter was dissociated from the bladder.A 1.5 cm-long bladder wall was dissected in the sleeve manner.The affected kidney and ureter were completely removed from the lower abdomen through the made small incision.A rubber drainage tube was inserted in another incision made at the lower end of the prior incision.Results Operations were successful in all 52 cases.No cases were converted to open surgery,had blood transfused,or needed secondary surgery.There were no complications such as urinary leakage,incision infection,or massive bleeding.Postoperative pathology reported 41 cases of renal urothelial carcinoma and 11 cases of ureteral urothelial carcinoma.Forty-eight patients provided follow-up data,and four did not because of being lost.One patient died of a cardiovascular accident 13 months after surgery.Cystoscopy revealed that 47 cases had no bladder tumor,local or distant metastasis.Conclusion The retroperitoneal laparoscopy combined with lower abdominal incisions approach is suitable for radical resection of renal pelvic or ureteral cancer owing to ease in operation,few requirements for surgical instruments,minimal invasion,and rapid recovery.