3种腹腔镜输尿管切开取石术治疗L4平面以下输尿管嵌顿性巨大结石的疗效比较

Comparison among three laparoscopic ureterolithotomies for large impacted ureteral stones located in lower than fourth lumbar vertebra

目的:比较标准经腹途径腹腔镜(PL)、经脐单孔腹腔镜(U-LESS)、耻骨上辅助经脐双孔腹腔镜(SAU-LEDS)输尿管切开取石术治疗第4腰椎(L4)平面以下输尿管嵌顿性巨大结石的疗效,并探讨其临床应用价值。方法:采用前瞻性临床对照研究方法,选择L4平面以下输尿管嵌顿性巨大结石60例,随机分为PL组(20例)、U-LESS组(19例)和SAU-LEDS组(21例),比较三组手术时间、术中出血量、手术并发症、住院时间及患者瘢痕问卷评分(PSAQ)。结果:三组手术均顺利完成,术中术后未发生严重并发症,SAU-LEDS组与PL组手术时间比较差异无统计学意义(P>0.05),且SAU-LEDS组和PL组平均手术时间较U-LESS组明显缩短(P<0.01);SAU-LEDS组患者术后PSAQ评分低于PL组(P<0.05)和U-LESS组(P<0.01),U-LESS组患者术后PSAQ评分高于SAU-LEDS组(P<0.01)和PL组(P<0.05);三组术中出血、手术并发症发生率及住院时间比较差异无统计学意义(P>0.05)。随访25.6(11～48)个月,复查IVU显示输尿管通畅、无狭窄、无尿瘘,结石无复发,术后切口愈合良好。结论:PL、U-LESS和SAU-LEDS 3种腹腔镜输尿管切开取石术治疗L4平面以下输尿管嵌顿性巨大结石安全可行,SAU-LEDS技术可降低手术难度,且具有良好的美容效果,可作为治疗嵌顿性输尿管大结石的优选方法,值得临床推广应用。

Objective:To compare surgical outcomes among transperitoneal laparoscopic(PL)ureterolithotomy,transumbilical laparoendoscopic single-site surgery(U-LESS)and suprapubic-assisted umbilical laparoendoscopic dual-site surgery(SAU-LEDS)for large impacted ureteral stones located in lower than fourth lumbar vertebra(L4).Method:This is a prospective control trail.Sixty consecutive patients including 31 males and 29 females,with a mean age of 46(range 35-68)years old,underwent laparoscopic ureterolithotomy on 60 sides.They were divided into three groups randomly(PL,n=20;U-LESS,n=19;SAU-LEDS,n=21).Result:All the 60 procedures were all successfully performed without serious complications such as urinary fistula or abdominal infection.The operative time of SAU-LEDS and PL groups were shorter than that of U-LESS group(P<0.01).The postoperative patient scar assessment questionnaire(PSAQ)score of SAU-LEDS group was lower than that of PL group(P<0.05)and U-LESS group(P<0.01).The PSAQ score of U-LESS group was higher than that of PL group(P<0.05)and SAU-LEDS group(P<0.01).There was no statistically significant difference in intraoperative estimated blood loss,mean postoperative stay time or complication rates among the three groups(P>0.05).There were no cases of major complications,including recurrence of ureteral stone,urinary leakage or ureter obstruction on the basis of IVU evaluation during mean(range)follow-up 25.6(11-48)months postoperatively.Conclusion:PL,U-LESS and SAU-LEDS laparoscopic ureterolithotomy for large impacted ureteral stones located in lower than L4 are all safe and effective procedures.SAU-LEDS would not only lead to satisfied cosmetic results,but also decrease the difficulty of operation.It may be the first line choice for treatment of large impacted ureteral stones located in lower than L4,and is worth applying in clinic.