经腹腔完全腔镜下肾输尿管膀胱袖状切除术中输尿管末段处理的经验总结

Experience of management of ureteral terminal in transperitoneal laparoscopic nephroureterectomy on cases with upper urinary tract urothelial carcinoma

目的:探讨完全腹腔镜下肾输尿管膀胱袖状切除术治疗上尿路肿瘤的手术技巧(尤其是末段输尿管的处理技术)及围手术期临床指标。方法:回顾性分析2012年1月～2017年7月在我院接受经完全腹腔下肾输尿管膀胱袖状切除术的87例上尿路尿路上皮癌(UTUC)患者的临床资料,其中男43例,女44例,平均年龄(67.25±9.90)岁;肾盂癌47例,肾盂癌合并输尿管癌10例,输尿管癌30例(输尿管上段癌12例,输尿管中段癌9例,输尿管下段癌11例);左侧49例,右侧38例;肿瘤平均直径(3.24±1.47)cm。87例患者均行全麻下经腹腔完全腹腔镜下肾、输尿管及膀胱袖状切除术,采用健侧卧位,术中无需改换体位。记录手术时间、术中出血量、术中输血情况、引流管留置时间、尿管留置时间、术后并发症。结果:87例手术顺利,无中转开放手术。平均手术时间(162.50±45.64)min,平均术中失血(113.33±59.74)ml,无围手术期输血。术后引流管平均留置(4.56±1.12)d,尿管平均留置(5.63±2.17)d。无术中并发症,术后出现并发症2例手术标本切缘均为阴性。术后病理分期T_1～T_4N_0M_0(T_1期24例,T_2期19例,T_3期37例,T_4期7例)。随访时间1～44个月,平均13个月,术后肿瘤复发8例。结论:经腹腔完全腹腔镜下肾输尿管膀胱袖状切除术对于UTUC的治疗安全有效,在处理下段输尿管时预先切断脐内侧襞可以增加操作空间,降低手术难度。

Objective:To verify the surgical skills of total transperitoneal laparoscopic nephroureterectomy(ttLNU)in the management of ureteral terminal and perioperative clinical indicators in the treatment of upper urinary tract urothelial carcinoma(UTUC).Method:From Jan.2012 to Jul.2017,there were 87 UTUC patients treated with ttLNU,including male 43 cases and female 44.The mean average age was(67.25±9.90)years old.Forty-seven cases were diagnosed with renal pelvis carcinoma,10 cases were diagnosed with renal pelvic and ureteral carcinoma,30 cases were diagnosed with ureteral carcinoma(12 for upper ureteral carcinoma,9 cases for middle ureteral carcinoma,11 cases for lower ureteral carcinoma).There were 49 in the left and 38 in the right.The mean diameter of the tumor was(3.24±1.47)cm.Patients were put on lateral position and the position was not changed during the operation.This group of cases was retrospectively summarized including operative time,blood loss,blood transfusion,drainage time,catheterizing days,postoperative complications and hospital stays.Result:The ttLNU procedures were successfully performed in all cases without conversion to open surgery.The mean operation time was(162.50±45.64)min.The median blood loss was(113.33±59.74)ml.No transfusions were needed.The mean drainage time was(4.56±1.12)d.The mean time with Foley catheter was(5.63±2.17)d.There was no complication during operation.Two cases had complications after operation.All the surgical margins were negative.Postoperative TNM stages were T1-T4 N0 M0(T124,T219,T337,T47).Eight patients were found tumor recurrence after the operation during the follow-up period of 1-44 months.Conclusion:Total transperitoneal laparoscopic nephroureterectomy is a safe and effective treatment of upper urinary tract urothelial carcinoma.Cutting off the medial umbilical fold can increase the operating space and reduce the difficulty of the operation before the management of ureteral terminal.