后腹腔镜肾实质切开取石术治疗肾脏铸形结石(附23例报告)
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摘要
目的探讨后腹腔镜技术处理肾脏铸形结石的手术要点与临床应用价值。方法 2013年8月-2017年10月,对23例不适合经皮肾镜取石术(PCNL)的患者给予后腹腔镜肾实质切开取石,结石均为单侧,至少占据一个肾盏和全部肾盂,平均直径2.8(2.3~3.8)cm。术中阻断肾动脉后,经吸引器注入冰水给予肾表面降温,沿Brodel线切开肾实质取出结石,根据肾实质厚度以QuillTM双向倒刺线进行全层或分层连续缝合关闭创缘。结果 23例手术均获成功。手术时间75~135 min,中位数95 min;肾脏热缺血时间17~35 min,中位数25 min;术中估计失血量25~350 ml,中位数105 ml,术中术后均未输血。术后5例出现血尿,均在3.0 d后消失;另有3例出现漏尿,于术后3.0~5.0 d消失。术后复查无明显残石。术后平均随访10(2~18)个月,静脉尿路造影(IVU)显示患肾梗阻程度明显减轻。结论后腹腔镜肾实质切开取石术是一种安全、有效的微创手术方法,对于不适合行PCNL的患者,有望作为PCNL的替代治疗措施,但需进一步增加例数并观察远期疗效。
Objective To explore the key technical points and clinical value of retroperitoneal laparoscopic nephrolithotomy in the treatment of renal staghorn calculi. Methods From August 2013 to October 2017, 23 patients with unilateral staghorn calculi(occupying the whole pelvis and at least one caliceal group), who were unsuitable for percutaneous nephrolithotomy(PCNL), underwent retroperitoneal laparoscopic nephrolithotomy. The mean stone size was 2.8 cm(2.3 ~ 3.8 cm). After the blocking of renal artery, ice-cold saline was infused to reduce the kidney temperature via the suction. An incision on the Brodel line was made and the stone was removed, then the renal collecting system and parenchyma were closed by using bidirectional suture line(QuillTM SRS suture) for singlelayer or two-layer stitching according to the different thickness of the renal parenchyma. Results All the cases were successfully operated. There were no major intraoperative and postoperative complications. Median operative time was 95 min(75 ~ 135 min). Median warm ischemia time was 25 min(17 ~ 35 min). Median estimated blood loss was 105 ml(25 ~ 350 ml), no blood transfusion was needed during or after surgery. Gross hematuria occurred in 5 patients and disappeared three days later. Urine leakage occurred in 3 patients and disappeared three to five days later. No bleeding and residual stone occurred. Mean follow-up was 10 months(2 ~ 18), radiographic assessment by intravenous urography after surgery showed all renal units were completely functional, with significant relief of obstruction in all patients. Conclusion Retroperitoneal laparoscopic nephrolithotomy is a safe and effective procedure which could act as a promising alternative in treating staghorn renal calculi unsuitable for PCNL. Further investigation with a larger population group and longer follow up period are needed before this is suggested as the preferred method in selected patients in the future.
Objective To explore the key technical points and clinical value of retroperitoneal laparoscopic nephrolithotomy in the treatment of renal staghorn calculi. Methods From August 2013 to October 2017, 23 patients with unilateral staghorn calculi(occupying the whole pelvis and at least one caliceal group), who were unsuitable for percutaneous nephrolithotomy(PCNL), underwent retroperitoneal laparoscopic nephrolithotomy. The mean stone size was 2.8 cm(2.3 ~ 3.8 cm). After the blocking of renal artery, ice-cold saline was infused to reduce the kidney temperature via the suction. An incision on the Brodel line was made and the stone was removed, then the renal collecting system and parenchyma were closed by using bidirectional suture line(QuillTM SRS suture) for singlelayer or two-layer stitching according to the different thickness of the renal parenchyma. Results All the cases were successfully operated. There were no major intraoperative and postoperative complications. Median operative time was 95 min(75 ~ 135 min). Median warm ischemia time was 25 min(17 ~ 35 min). Median estimated blood loss was 105 ml(25 ~ 350 ml), no blood transfusion was needed during or after surgery. Gross hematuria occurred in 5 patients and disappeared three days later. Urine leakage occurred in 3 patients and disappeared three to five days later. No bleeding and residual stone occurred. Mean follow-up was 10 months(2 ~ 18), radiographic assessment by intravenous urography after surgery showed all renal units were completely functional, with significant relief of obstruction in all patients. Conclusion Retroperitoneal laparoscopic nephrolithotomy is a safe and effective procedure which could act as a promising alternative in treating staghorn renal calculi unsuitable for PCNL. Further investigation with a larger population group and longer follow up period are needed before this is suggested as the preferred method in selected patients in the future.
引文
[1]ZHANG X, YE Z Q, CHEN Z, et al. Comparison of open surgery versus retroperitoneoscopic approach to chyluria[J]. J Urol, 2003,169(3):991-993.
[2]TüRK C, PET?íK A, SARICA K, et al. EAU guidelines on interventional treatment for urolithiasis.[J]. Eur Urol, 2016, 69(3):475-482.
[3]PREMINGER G M, ASSIMOS D G, LINGEMAN J E, et al.AUA guideline on management of staghorn calculi:diagnosis and treatment recommendations[J]. J Urol, 2005, 173(6):1991-2000.
[4]陈磊,马大东,聂欢,等.输尿管软镜联合经皮肾镜治疗复杂性肾结石的临床研究[J].微创泌尿外科杂志, 2017, 6(6):340-342.CHENL,MADD,NIEH,etal. Aclinicalstudyonflexible ureteroscopycombinedwithpercutaneousnephrolithotomy intreatmentofcomplexrenalstones[J].JournalofMinimally Invasive Urology, 2017, 6(6):340-342. Chinese
[5]黄苏溪,袁超英,袁杰,等.多镜联合治疗复杂性上尿路结石[J].中国内镜杂志, 2016, 22(4):100-103.HUANGSX, YUANC Y, YUANJ,etal.Multiendoscopein treatment of complex upper urinary tract calculi[J]. China Journal of Endoscopy, 2016, 22(4):100-103. Chinese
[6]WEN C C, NAKADA S Y. Treatment selection and outcomes:renal calculi[J]. Urol Clin North Am, 2007, 34(3):409-419.
[7]ANTONELLI J A, PEARLE M S. Advances in percutaneous nephrolithotomy[J]. Urol Clin North Am, 2013, 40(1):99-113.
[8]PRABHAKAR M. Retrograde ureteroscopic intrarenal surgery for large(1.6-3.5 cm)upper ureteric/renal calculus[J]. Indian Journal of Urology, 2010, 26(1):46-49.
[9]SANGUEDOLCE F, LIATSIKOS E,VERZE P, et al. Use of flexible ureteroscopyintheclinicalpracticeforthetreatmentofrenal stones:results from a large European survey conducted by the EAU Young Academic Urologists-Working Party on endourology and urolithiasis[J]. Urolithiasis. 2014, 42(4):329-334.
[10]魏世平,李辉明,陶维雄,等.经皮肾镜碎石术后并发全身炎症反应综合征的危险因素分析[J].中国内镜杂志, 2015, 21(8):878-880.WEI S P, LI H M, TAO W X, et al. Risk factors associated with systemicinflammatoryresponsesyndromeafterpercutaneous nephrolithotomy[J]. China Journal of Endoscopy, 2015, 21(8):878-880. Chinese
[11]李立宇,陶志兴,何昊阳,等.腹腔镜技术治疗上尿路结石的初步研究[J].中国内镜杂志, 2017, 23(11):56-62.LI L Y, TAO Z X, HE H Y, et al. Preliminary application of laparoscopic technique intreatment of upper urinary calculi[J].China Journal of Endoscopy, 2017, 23(11):56-62. Chinese
[12]AMINSHARIFIA,IRANID,MASOUMIM,etal.The managementoflargestaghornrenalstonesbypercutaneous versus laparoscopic versus open nephrolithotomy:a comparative analysisofclinicalefficacyandfunctionaloutcome[J].Urolithiasis, 2016, 44(6):551-557.
[13]王保军,王云鹏,李新涛,等.后腹腔镜肾实质切开肿瘤剜除术治疗肾窦部位完全内生型肾肿瘤[J].微创泌尿外科杂志,2016, 5(3):132-136.WANGBJ, WANG YP,LIX T,etal.Retroperitoneal laparoscopicparenchyma-incisedalongBrodellineandtumor enucleationforcompleteendophyticrenaltumorsaroundthe renaIsinus[J].JournalofMinimallyInvasiveUrology,2016,5(3):132-136. Chinese
[14]马鑫,黄庆波,刘启明,等.肾动脉低温灌注机器人辅助腹腔镜下肾部分切除术治疗完全内生型肾肿瘤的疗效分析[J].中华泌尿外科杂志, 2016, 37(10):721-725.MA X, HUANG Q B, LIU Q M, et al. Robot-assisted laparoscopic partialnephrectomyusingrenalarterycoldperfusionfor completely intraparenchymal tumors:the outcome and initial experience[J]. Chin J Urol, 2016, 37(10):721-725. Chinese
[15]SIMFOROOSH N, RADFAR M H, NOURALIZADEH A, et al.Laparoscopicanatrophicnephrolithotomyformanagementof staghorn renal calculi[J]. J Laparoendosc Adv Surg Tech A, 2013,23(4):306-310.
[16]ZHOU L, XUAN Q, WU B, et al. Retroperitoneal laparoscopic anatrophicnephrolithotomyforlargestaghorncalculi[J].IntJ Urol, 2011, 18(2):126-129.
[17]GIEDELMAN C, ARRIAGA J, CARMONA O, et al. Laparoscopic anatrophic nephrolithotomy:developments of the technique in the era of minimally invasive surgery[J]. J Endourol, 2012, 26(5):444-450.
[18]GILLIS, ABREUSC,DESAIMM,eta1.Laparoscopicice slush renal hypothermia for partial nephrectomy:the initial experience[J]. J Urol, 2003, 170(1):52-56.
[19]BECKER F, VAN POPPEL H, HAKENBERG O W, et al.Assessingtheimpactofisehaemiatimeduringpartial nephrectomy[J]. Eur Urol, 2009, 56(4):625-634.
[20]方烈奎,杨江根,黄建生,等.后腹腔镜下原位低温肾脏部分切除术的临床研究[J].中华实验外科杂志, 2014, 31(2):444-447.FANGLK, YANGJG,HUANGJS,etal.Clinicalresearch ofretroperitoneallaparoscopicpartialnephrectomywith hypothermic renal artery perfusion in situ[J]. Chin J Exp Surg,2014, 31(2):444-447. Chinese
[21]张旭,李宏召,马鑫,等.后腹腔镜保留肾脏手术治疗肾肿瘤[J].中华泌尿外科杂志, 2005, 26(3):160-162.ZHANG X, LI H Z, MA X, et al. Retroperitoneal laparoscopic nephron–sparing surgery for renal tumor[J]. Chin J Urol, 2005,26(3):160-162. Chinese
[22]王科,于胜强,林春华,等.双向倒刺可吸收线连续缝合在腹腔镜肾部分切除术中应用临床分析[J].现代泌尿生殖肿瘤杂志, 2014, 6(5):264-267.WANG K, YU S Q, LIN C H, et al. Clinical analysis of continuous kidneysuturewithbidirectionalbarbedabsorbablelinein retroperitoneoscopicpartialnephrectomy[J].JContempUrol Reprod Oncol, 2014, 6(5):264-267. Chinese
[23]ERDEM S, TEFIK T, MAMMADOV A, et al. The use of selfretaining barbed suture for inner layer renorrhaphy significantly reduces warm ischemia time in laparoscopic partial nephrectomy:outcomes of a matched-pair analysis[J]. J Endourol, 2013, 27(4):452-458.
[24]LIU W, CHEN M, ZU X, et al. The use of self-retaining barbed suturepreservessuperiorrenalfunctionduringlaparoscopic partial nephrectomy:a PADUA score matched comparison[J]. J Laparoendosc Adv Surg Tech A, 2015, 25(2):130-134.
[2]TüRK C, PET?íK A, SARICA K, et al. EAU guidelines on interventional treatment for urolithiasis.[J]. Eur Urol, 2016, 69(3):475-482.
[3]PREMINGER G M, ASSIMOS D G, LINGEMAN J E, et al.AUA guideline on management of staghorn calculi:diagnosis and treatment recommendations[J]. J Urol, 2005, 173(6):1991-2000.
[4]陈磊,马大东,聂欢,等.输尿管软镜联合经皮肾镜治疗复杂性肾结石的临床研究[J].微创泌尿外科杂志, 2017, 6(6):340-342.CHENL,MADD,NIEH,etal. Aclinicalstudyonflexible ureteroscopycombinedwithpercutaneousnephrolithotomy intreatmentofcomplexrenalstones[J].JournalofMinimally Invasive Urology, 2017, 6(6):340-342. Chinese
[5]黄苏溪,袁超英,袁杰,等.多镜联合治疗复杂性上尿路结石[J].中国内镜杂志, 2016, 22(4):100-103.HUANGSX, YUANC Y, YUANJ,etal.Multiendoscopein treatment of complex upper urinary tract calculi[J]. China Journal of Endoscopy, 2016, 22(4):100-103. Chinese
[6]WEN C C, NAKADA S Y. Treatment selection and outcomes:renal calculi[J]. Urol Clin North Am, 2007, 34(3):409-419.
[7]ANTONELLI J A, PEARLE M S. Advances in percutaneous nephrolithotomy[J]. Urol Clin North Am, 2013, 40(1):99-113.
[8]PRABHAKAR M. Retrograde ureteroscopic intrarenal surgery for large(1.6-3.5 cm)upper ureteric/renal calculus[J]. Indian Journal of Urology, 2010, 26(1):46-49.
[9]SANGUEDOLCE F, LIATSIKOS E,VERZE P, et al. Use of flexible ureteroscopyintheclinicalpracticeforthetreatmentofrenal stones:results from a large European survey conducted by the EAU Young Academic Urologists-Working Party on endourology and urolithiasis[J]. Urolithiasis. 2014, 42(4):329-334.
[10]魏世平,李辉明,陶维雄,等.经皮肾镜碎石术后并发全身炎症反应综合征的危险因素分析[J].中国内镜杂志, 2015, 21(8):878-880.WEI S P, LI H M, TAO W X, et al. Risk factors associated with systemicinflammatoryresponsesyndromeafterpercutaneous nephrolithotomy[J]. China Journal of Endoscopy, 2015, 21(8):878-880. Chinese
[11]李立宇,陶志兴,何昊阳,等.腹腔镜技术治疗上尿路结石的初步研究[J].中国内镜杂志, 2017, 23(11):56-62.LI L Y, TAO Z X, HE H Y, et al. Preliminary application of laparoscopic technique intreatment of upper urinary calculi[J].China Journal of Endoscopy, 2017, 23(11):56-62. Chinese
[12]AMINSHARIFIA,IRANID,MASOUMIM,etal.The managementoflargestaghornrenalstonesbypercutaneous versus laparoscopic versus open nephrolithotomy:a comparative analysisofclinicalefficacyandfunctionaloutcome[J].Urolithiasis, 2016, 44(6):551-557.
[13]王保军,王云鹏,李新涛,等.后腹腔镜肾实质切开肿瘤剜除术治疗肾窦部位完全内生型肾肿瘤[J].微创泌尿外科杂志,2016, 5(3):132-136.WANGBJ, WANG YP,LIX T,etal.Retroperitoneal laparoscopicparenchyma-incisedalongBrodellineandtumor enucleationforcompleteendophyticrenaltumorsaroundthe renaIsinus[J].JournalofMinimallyInvasiveUrology,2016,5(3):132-136. Chinese
[14]马鑫,黄庆波,刘启明,等.肾动脉低温灌注机器人辅助腹腔镜下肾部分切除术治疗完全内生型肾肿瘤的疗效分析[J].中华泌尿外科杂志, 2016, 37(10):721-725.MA X, HUANG Q B, LIU Q M, et al. Robot-assisted laparoscopic partialnephrectomyusingrenalarterycoldperfusionfor completely intraparenchymal tumors:the outcome and initial experience[J]. Chin J Urol, 2016, 37(10):721-725. Chinese
[15]SIMFOROOSH N, RADFAR M H, NOURALIZADEH A, et al.Laparoscopicanatrophicnephrolithotomyformanagementof staghorn renal calculi[J]. J Laparoendosc Adv Surg Tech A, 2013,23(4):306-310.
[16]ZHOU L, XUAN Q, WU B, et al. Retroperitoneal laparoscopic anatrophicnephrolithotomyforlargestaghorncalculi[J].IntJ Urol, 2011, 18(2):126-129.
[17]GIEDELMAN C, ARRIAGA J, CARMONA O, et al. Laparoscopic anatrophic nephrolithotomy:developments of the technique in the era of minimally invasive surgery[J]. J Endourol, 2012, 26(5):444-450.
[18]GILLIS, ABREUSC,DESAIMM,eta1.Laparoscopicice slush renal hypothermia for partial nephrectomy:the initial experience[J]. J Urol, 2003, 170(1):52-56.
[19]BECKER F, VAN POPPEL H, HAKENBERG O W, et al.Assessingtheimpactofisehaemiatimeduringpartial nephrectomy[J]. Eur Urol, 2009, 56(4):625-634.
[20]方烈奎,杨江根,黄建生,等.后腹腔镜下原位低温肾脏部分切除术的临床研究[J].中华实验外科杂志, 2014, 31(2):444-447.FANGLK, YANGJG,HUANGJS,etal.Clinicalresearch ofretroperitoneallaparoscopicpartialnephrectomywith hypothermic renal artery perfusion in situ[J]. Chin J Exp Surg,2014, 31(2):444-447. Chinese
[21]张旭,李宏召,马鑫,等.后腹腔镜保留肾脏手术治疗肾肿瘤[J].中华泌尿外科杂志, 2005, 26(3):160-162.ZHANG X, LI H Z, MA X, et al. Retroperitoneal laparoscopic nephron–sparing surgery for renal tumor[J]. Chin J Urol, 2005,26(3):160-162. Chinese
[22]王科,于胜强,林春华,等.双向倒刺可吸收线连续缝合在腹腔镜肾部分切除术中应用临床分析[J].现代泌尿生殖肿瘤杂志, 2014, 6(5):264-267.WANG K, YU S Q, LIN C H, et al. Clinical analysis of continuous kidneysuturewithbidirectionalbarbedabsorbablelinein retroperitoneoscopicpartialnephrectomy[J].JContempUrol Reprod Oncol, 2014, 6(5):264-267. Chinese
[23]ERDEM S, TEFIK T, MAMMADOV A, et al. The use of selfretaining barbed suture for inner layer renorrhaphy significantly reduces warm ischemia time in laparoscopic partial nephrectomy:outcomes of a matched-pair analysis[J]. J Endourol, 2013, 27(4):452-458.
[24]LIU W, CHEN M, ZU X, et al. The use of self-retaining barbed suturepreservessuperiorrenalfunctionduringlaparoscopic partial nephrectomy:a PADUA score matched comparison[J]. J Laparoendosc Adv Surg Tech A, 2015, 25(2):130-134.