经腹入路一站式腹腔镜肾脏-输尿管-膀胱袖状切除术治疗上尿路尿路上皮癌的临床研究
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摘要
目的:探讨完全腹腔镜下经腹入路一站式肾脏-输尿管-膀胱袖状切除术治疗上尿路尿路上皮癌(UTUC)的手术技巧和临床效果。方法:2015年2月～2018年5月我院通过影像学检查或输尿管镜活检确诊的17例UTUC患者行完全腹腔镜下经腹入路一站式肾脏-输尿管-膀胱袖状切除手术。采取健侧60°卧位,放置5个Trocar,先行患侧根治性肾切除,然后沿输尿管向下游离至输尿管膀胱入口处,再将输尿管开口周围膀胱壁作袖状切除,缝闭膀胱切口。结果:17例手术均获成功,无中转开放,手术时间110～150min,平均125min;术中出血80～200ml,平均120ml;术后住院6～14d,平均8d;术后漏尿1例,引流后自愈。术后随访6～45个月,其中术后漏尿患者于术后9个月发现对侧输尿管口周围尿路上皮癌复发,行经尿道膀胱肿瘤电切术(TURBt),随访至今未见复发;失访3例,其余病例未见术中术后并发症,未见肿瘤复发及转移。结论:经腹入路一站式腹腔镜肾脏-输尿管-膀胱袖状切除术治疗UTUC安全可行,术中无需变换体位就能完成从肾脏到输尿管全段和膀胱袖状切除,是一种值得推广的手术方法。
Objective:To describe one-station technique of complete transperitoneal laparoscopic nephroureterectomy with bladder-cuff excision for treatment of upper tract urothelial cancer(UTUC).Method:Between February 2015 and May 2018,17 cases diagnosed with UTUC underwent complete transperitoneal laparoscopic nephroureterectomy with bladder-cuff excision.After finishing the transperitoneal laparoscopic nephrectomy in a60°recumbent position,an additional 5-mm(right side)or 12-mm trocar(left side)was inserted at the lower abdomen to continue dissecting the distal ureter and complete the bladder-cuff excision without repositioning the patient during the procedure.Result:All the operations were successful.The mean operative time was 125(range,110-150)min,the mean blood loss was 120(range,80-200)ml and the mean hospitalization time was 8(range,6-14)days.The postoperative follow-up time ranged from 6 to 45 months(3 cases lost to follow-up),one case suffered from urine leakage after surgery and had a bladder recurrence 9 months postoperatively.No serious complications occurred and no tumor recurrence or metastasis occurred in other cases.Conclusion:One-station complete transperitoneal laparoscopic nephroureterectomy with bladder-cuff excision is a safe and reliable operation for UTUC,with the advantages of no need repositioning during the procedure.
Objective:To describe one-station technique of complete transperitoneal laparoscopic nephroureterectomy with bladder-cuff excision for treatment of upper tract urothelial cancer(UTUC).Method:Between February 2015 and May 2018,17 cases diagnosed with UTUC underwent complete transperitoneal laparoscopic nephroureterectomy with bladder-cuff excision.After finishing the transperitoneal laparoscopic nephrectomy in a60°recumbent position,an additional 5-mm(right side)or 12-mm trocar(left side)was inserted at the lower abdomen to continue dissecting the distal ureter and complete the bladder-cuff excision without repositioning the patient during the procedure.Result:All the operations were successful.The mean operative time was 125(range,110-150)min,the mean blood loss was 120(range,80-200)ml and the mean hospitalization time was 8(range,6-14)days.The postoperative follow-up time ranged from 6 to 45 months(3 cases lost to follow-up),one case suffered from urine leakage after surgery and had a bladder recurrence 9 months postoperatively.No serious complications occurred and no tumor recurrence or metastasis occurred in other cases.Conclusion:One-station complete transperitoneal laparoscopic nephroureterectomy with bladder-cuff excision is a safe and reliable operation for UTUC,with the advantages of no need repositioning during the procedure.
引文
1 Kanno T,Kobori G,Kubota M,et al.Standardized and Simplified Retroperitoneal Lymph Node Dissection During Retroperitoneal Laparoscopic Radical Nephroureterectomy for Urothelial Carcinoma of the Upper Ureter or Renal Pelvis:En Bloc Resection Technique[J].Urology,2018,112:85-91.
2 王庆伟,张涛,文建国,等.上尿路尿路上皮癌预后多因素分析及术后再发膀胱癌危险因素分析[J].临床泌尿外科杂志,2018,33(5):385-389.
3 Lee C H,Ku J Y,Jeong C W,et al.Predictors for Intravesical Recurrence Following Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma:A National Multicenter Analysis[J].Clin Genitourin Cancer,2017,15(6):e1055-e1061.
4 Clayman R V,Kavoussi L R,Figenshau R S,et al.Laparoscopic nephroureterectomy:initial clinical case report[J].J Laparoendosc Surg,1991,1(6):343-349.
5 Xylinas E,Rink M,Cha E K,et al.Impact of distal ureter management on oncologic outcomes following radical nephroureterectomy for upper tract urothelial carcinoma[J].Eur Urol,2014,65(1):210-217.
6 Pai A,Hussain M,Hindley R,et al.Long-Term Outcomes of Laparoscopic Nephroureterectomy with Transurethral Circumferential Excision of the Ureteral Orifice for Urothelial Carcinoma[J].J Endourol,2017,31(7):651-654.
7 周利群,李学松,方冬,等.上尿路尿路上皮癌治疗方式的选择[J].临床泌尿外科杂志,2016,31(11):961-964.
8 Arango O,Bielsa O,Carles J,et al.Massive tumor implantation in the endoscopic resected area in modified nephroureterectomy[J].J Urol,1997,157(5):1839-1839.
9 Krabbe L M,Westerman M E,Bagrodia A,et al.Surgical management of the distal ureter during radical nephroureterectomy is an independent predictor of oncological outcomes:results of a current series and a review of the literature[J].Urol Oncol,2014,32(1):54e19-54e26.
10 Brown J A,Strup S E,Chenven E,et al.Hand-assisted laparoscopic nephroureterectomy:analysis of distal ureterectomy technique,margin status,and surgical outcomes[J].Urology,2005,66(6):1192-1196.
11 Kume H,Teramoto S,Tomita K,et al.Bladder recurrence of upper urinary tract cancer after laparoscopic surgery[J].J Surg Oncol,2006,93(4):318-322.
12 Liu P,Fang D,Xiong G,et al.A Novel and Simple Modification for Management of Distal Ureter During Laparoscopic Nephroureterectomy Without Patient Repositioning:A Bulldog Clamp Technique and Description of Modified Port Placement[J].J Endourol,2016,30(2):195-200.
13 Katz J E,Bivalacqua T J,Hahn N M,et al.Port Site Recurrence Following a Robotic Laparoscopic Radical Nephroureterectomy for Sarcomatoid Variant of Urothelial Carcinoma[J].Urol Case Rep,2017,13:82-84.
2 王庆伟,张涛,文建国,等.上尿路尿路上皮癌预后多因素分析及术后再发膀胱癌危险因素分析[J].临床泌尿外科杂志,2018,33(5):385-389.
3 Lee C H,Ku J Y,Jeong C W,et al.Predictors for Intravesical Recurrence Following Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma:A National Multicenter Analysis[J].Clin Genitourin Cancer,2017,15(6):e1055-e1061.
4 Clayman R V,Kavoussi L R,Figenshau R S,et al.Laparoscopic nephroureterectomy:initial clinical case report[J].J Laparoendosc Surg,1991,1(6):343-349.
5 Xylinas E,Rink M,Cha E K,et al.Impact of distal ureter management on oncologic outcomes following radical nephroureterectomy for upper tract urothelial carcinoma[J].Eur Urol,2014,65(1):210-217.
6 Pai A,Hussain M,Hindley R,et al.Long-Term Outcomes of Laparoscopic Nephroureterectomy with Transurethral Circumferential Excision of the Ureteral Orifice for Urothelial Carcinoma[J].J Endourol,2017,31(7):651-654.
7 周利群,李学松,方冬,等.上尿路尿路上皮癌治疗方式的选择[J].临床泌尿外科杂志,2016,31(11):961-964.
8 Arango O,Bielsa O,Carles J,et al.Massive tumor implantation in the endoscopic resected area in modified nephroureterectomy[J].J Urol,1997,157(5):1839-1839.
9 Krabbe L M,Westerman M E,Bagrodia A,et al.Surgical management of the distal ureter during radical nephroureterectomy is an independent predictor of oncological outcomes:results of a current series and a review of the literature[J].Urol Oncol,2014,32(1):54e19-54e26.
10 Brown J A,Strup S E,Chenven E,et al.Hand-assisted laparoscopic nephroureterectomy:analysis of distal ureterectomy technique,margin status,and surgical outcomes[J].Urology,2005,66(6):1192-1196.
11 Kume H,Teramoto S,Tomita K,et al.Bladder recurrence of upper urinary tract cancer after laparoscopic surgery[J].J Surg Oncol,2006,93(4):318-322.
12 Liu P,Fang D,Xiong G,et al.A Novel and Simple Modification for Management of Distal Ureter During Laparoscopic Nephroureterectomy Without Patient Repositioning:A Bulldog Clamp Technique and Description of Modified Port Placement[J].J Endourol,2016,30(2):195-200.
13 Katz J E,Bivalacqua T J,Hahn N M,et al.Port Site Recurrence Following a Robotic Laparoscopic Radical Nephroureterectomy for Sarcomatoid Variant of Urothelial Carcinoma[J].Urol Case Rep,2017,13:82-84.