机器人辅助后腹腔镜改进“一体位”治疗上尿路上皮癌7例报告

Robot-assisted Posterior Laparoscopic Modified “Single-position” Treatment for Upper Tract Urothelial Carcinoma: Report of 7 Cases

目的探讨机器人辅助后腹腔镜改进“一体位”肾输尿管根治性切除术的可行性。方法2022年4月~2023年4月我科行机器人辅助后腹腔镜下单一体位肾输尿管根治性切除术7例。患者完全健侧卧位,建立人工气腹,于腋后线右肋缘、腋中线髂嵴上3~4 cm、腋前线肋缘下6~8 cm和腋中线髂嵴上3~4 cm水平线靠近腹直肌外缘处分别置入trocar,先切除肾脏后,向下游离输尿管至髂血管处,再将机器人主关节180°扭转进行重新对接后,向下游离输尿管至膀胱壁处,夹闭导尿管,膀胱注入吲哚菁绿及蒸馏水混合液后打开膀胱,洗净膀胱内液体,观察对侧输尿管口,袖套状切除患侧输尿管,V-LOCK 2-0缝合线分两层缝合膀胱切口,腋后线右肋缘下与腋中线髂嵴上3~4 cm连线方向延长切口取出标本。结果7例手术均顺利完成,手术操作时间155~263 min,平均247.0 min;术中出血20~100 ml,平均42.9 ml。术后肛门排气时间为14~24 h,平均22.6 h。1例术后出现吸收热,2例术后中度贫血(1例术后肌间动脉破裂导致大量出血和手术区域血肿形成,出血量约1000 ml,导致失血性贫血;1例术前后均中度贫血),2例术后切口脂肪液化。住院时间为8~16 d,平均11.6 d。7例病理均为高级别尿路上皮癌。7例术后随访3~9个月,平均为6.2月,均无膀胱肿瘤复发或远处转移。结论机器人辅助后腹腔镜改进“一体位”肾输尿管根治性切除术安全、可行。

Objective To evaluate the feasibitity of robot-assisted posterior laparoscopic modified“single-position”radical nephroureterectomy.Methods A retrospective analysis was made on 7 patients receiving robot-assisted posterior laparoscopic single-position radical nephroureterectomy between April 2022 and April 2023.The patients were in a fully healthy lateral position,and an artificial pneumoperitoneum was established.Trocars were placed at the right costal margin of the posterior axillary line,3-4 cm above the iliac crest of the midaxillary line,6-8 cm below the anterior axillary line,and 3-4 cm above the iliac crest of the midaxillary line near the outer edge of the musculus rectus abdominis,respectively.After the kidney was removed,the ureter was freed down to the iliac vessels,and then the main joint of the robot was reversed 180°for redocking.The ureter was continuously freed downwards to the bladder wall and the catheter was clamped.The bladder was opened after filling with indocyanine green and distilled water mixture.Then the fluid in the bladder was washed,the contralateral ureteral orifice was observed,the affected side of the ureter was resected,and the bladder incision was sutured by two layers with V-LOCK 2-0 sutures.The incision was extended under the right costal margin of the posterior axillary line and 3-4 cm above the iliac crest of the midaxillary line to remove the specimen.Results The operation was successfully completed in all the 7 cases.The surgical operation time was 155-263 min(mean,247.0 min)and the blood loss was 20-100 ml(mean,42.9 ml).The postoperative anal exhaust time was 14-24 h(mean,22.6 h).There were 1 case of postoperative absorption fever,2 cases of moderate anemia,and 2 cases of postoperative incision fat liquefaction.In the 2 patients with moderate anemia,one patient developed postoperative intramuscular artery rupture leading to massive bleeding and the formation of hematoma in the surgical area,with the amount of bleeding being approximately 1000 ml,and the other had moderate anemia before and after surgery.The hospital stay ranged 8-16 d(mean,11.6 d).Pathologic examinations showed high-grade uroepithelial carcer in all the patients.Postoperative follow-ups lasted 3-9 months,with a mean of 6.2 months.None had bladder tumor recurrence or distant metastasis.Conclusion Robot-assisted posterior laparoscopic modified“single-position”radical nephroureterectomy is safe and feasible.