机器人辅助腹腔镜手术治疗复杂肾盂输尿管连接部梗阻的双中心研究

Robot-assisted laparoscopic surgery in the management of complex ureteropelvic junction obstruction:bi-centre experience

目的:总结机器人辅助腹腔镜手术治疗复杂肾盂输尿管连接部梗阻(UPJO)的双中心经验。方法:收集2017年3月—2021年12月双中心收治37例复杂UPJO行机器人辅助腹腔镜手术患者的临床资料,并进行回顾性总结分析。复杂UPJO被定义为UPJO同时合并马蹄肾、重复肾输尿管畸形、肾盏结石、巨大肾积水伴肾功能不良及初次肾盂成形术后再狭窄。手术成功定义为症状消失或缓解且影像学检查提示肾积水较前缓解。结果:37例患者手术均在机器人辅助腹腔镜下完成,无术中并发症,无中转开放手术。其中行肾盂成形术22例,肾盂成形术+肾折叠术+肾固定术5例,口腔黏膜镶嵌输尿管成形术2例,阑尾镶嵌输尿管吻合术2例,肾盂成形术+软镜取石术2例,重复肾上肾盂与下输尿管吻合术2例,肾下盏输尿管吻合术1例,马蹄肾分离+双侧肾盂成形术1例。平均手术时间(168.9±42.5)min、术中中位失血量25(15~200)mL、平均术后住院时间(5.8±2.0)d、平均术后引流管留置时间(4.4±1.9)d;术后并发症ClavienⅠ~Ⅱ级发生率45.9%、ClavienⅢ级5.4%,中位随访19(6~60)个月,手术成功率为94.6%(35/37)。结论:机器人辅助腹腔镜手术治疗复杂UPJO是安全、可行的,短中期疗效满意,术前精确影像学检查、丰富的机器人手术经验团队及术中根据具体情况采取不同手术方法治疗是取得手术成功的关键。

Objective:To report bi-centre retrospective case series of outcomes after robot-assisted laparoscopic surgery(RALS)in patients with complex ureteropelvic junction obstruction(UPJO).Methods:We retrospectively collected clinical data of 37 patients with complex UPJO undergoing complex RALS from two medical centers between Mar.2017 and Dec.2021.Complex UPJO was defined in the following cases:anatomic variations including horseshoe,duplex kidney,calyceal stones,giant hydronephrosis with poorly function and recurrent UPJO after failed pyeloplasty.A successful surgery was defined as the absence or remission of subjective symptoms and remission of hydronephrosis indicated by imaging examinations.Results:Thirty-seven surgeries were successfully completed without open conversion,and no intraoperative complication was encountered.Twenty-two patients underwent dismembered pyeloplasty,five patients underwent pyeloplasty+nephroplication+nephropexy,two patients underwent oral mucosal graft ureteroplasty,two patients underwent on-lay appendiculoureteroplasty,two patients underwent pyeloplasty along with removal of stones using flexible nephroscopy,two patients underwent pyeloureterostomy,one ureterocalicostomy,one horseshoe kidney separation+bilateral pyeloplasties.The mean operative time was(168.9±42.5)min,and the median estimated blood loss was 25(15-200)mL.The abdominal drainage tubes were removed after a mean of(4.4±1.9)d,and the mean postoperative hospital stay was(5.8±2.0)d.The complications of ClavienⅠ-Ⅱand ClavienⅢwere 45.9%and 5.4%,respectively.The overall success rate was 94.6%(35/37)during a median follow-up period of 19(6-60)months.Conclusion:RALS was a safe and feasible method with good short-term and mid-term outcomes in complex UPJO.An accurate preoperative planning,an experienced surgical robotic team and taking different techniques according to different scenarios represented key points to successfully manage such complex cases.