摘要
研究目的
本课题旨在通过回顾性对比分析后腹腔镜与开放两种手术方式行重复肾上位半肾切除术术中、术后及随访的各项临床指标,评价后腹腔镜重复肾上位半肾切除术的临床疗效,探讨后腹腔镜重复肾上位半肾切除术的临床应用价值。
材料和方法
2004年11月至2009年12月期间,重复肾患者30例(腹腔镜组),男9例,女21例,平均年龄28.07±18.80岁(4-68岁)。因尿失禁就诊12例；因反复尿路感染就诊4例；因腰部胀痛就诊6例；因体查发现肾脏上极囊性占位病变8例。均行B超,IVU及CT检查,确诊为重复肾伴完全重复输尿管畸形。重复肾中上位肾重度积水或萎缩无功能,下位肾及对侧肾形态功能正常。有4例合并对侧重复肾输尿管畸形,但形态功能正常。该组患者均行后腹腔镜下重复肾上位半肾切除术。
1999年07月至2007年05月期间,重复肾患者32例(开放手术组),男11例,女21例。年龄24.25±16.87岁(2-54岁)。因腰部胀痛就诊9例；因体检发现患侧肾脏上极囊性病变10例；因尿失禁就诊10例；因反复尿路感染就诊3例。B超、IVU及CT检查确诊为重复肾伴完全重复输尿管畸形,上位肾重度积水或萎缩无功能,有手术切除指征。1例患者伴重复输尿管末端囊肿；2例患者合并对侧重复肾畸形,但形态功能正常。该组患者均行开放重复肾上位半肾切除术。
对两组患者年龄、性别、BMI、手术侧别、合并内科疾病情况、手术时间、术中估计失血量、术中输血例数、切口长度、术中并发症、术后并发症、术后肛门排气时间、术后进食流质时间、术后静脉应用抗生素天数、术后应用止痛药例数、术后体温恢复正常时间、术后留置腹膜后引流管时间、术后下床活动时间、术后住院时间及随访情况作回顾性分析和对照研究,对其结果进行统计学分析。
结果
两组手术均获成功,腹腔镜组术中无1例转开放。腹腔镜组平均手术时间155.17±29.73min,开放组平均手术时间148.59±21.90min；腹腔镜组术中平均估计失血量43.67±14.62ml,开放组术中平均估计失血量193.75±43.09ml；腹腔镜组平均手术切口长度4.91±0.51cm,开放组平均手术切口长度10.87±1.27cm,腹腔镜组术中无1例输血,开放组术中1例病人输血。腹腔镜组术后平均肛门排气时间1.73±0.52d,开放组术后平均肛门排气时间3.19±0.64d；腹腔镜组术后平均进食流质时间2.50±0.51d,开放组术后平均进食流质时间3.31±0.47d；腹腔镜组术后平均静脉抗生素应用天数5.13±0.68d,开放组术后平均静脉抗生素应用天数7.97±1.82d；腹腔镜组有3例病人术后应用止痛药,开放组有20例病人术后应用止痛药；腹腔镜组术后平均引流管留置时间4.63±0.77d,开放组术后平均引流管留置时间7.16±2.41d；腹腔镜组术后平均下床活动时间6.70±0.88d,开放组术后平均下床活动时间9.19±1.42d；腹腔镜组平均体温恢复正常时间33.13±8.59h,开放组平均体温恢复正常时间59.81±12.40h；腹腔镜组术后平均住院时间8.27±1.29d,开放组术后平均住院时间11.38±5.59d。腹腔镜组术中发生2例腹膜损伤,12例高碳酸血症,20例皮下气肿,随访2例远期切口不适,1例输尿管残端综合症；开放组术中发生1例下位肾损伤,2例胸膜损伤,术后2例尿漏,3例切口出血,5例切口不同程度感染,16例随访存在远期切口不适,1例随访重复肾切缘囊肿形成,1例随访输尿管残端综合症。
两组比较在年龄、性别、BMI、手术侧别、合并内科疾病情况方面无显著性差异(P>0.05)；两组在手术时间、术中输血例数、主要并发症(下位肾损伤、尿漏及尿性囊肿、下位肾功能缺失、输尿管残端综合症)发生率、腹膜损伤、胸膜损伤方面无显著性差异(P>0.05)；两组在手术切口长度、术中估计失血量、术后肛门排气时间、术后进流质时间、术后静脉应用抗生素时间、术后留置引流管时间、术后下床活动时间、术后住院时间、术后止痛药应用例数、气腹相关并发症发生率、切口相关并发症发生率方面有显著性差异(P<0.05)。腹腔镜组早期手术时间长于开放手术组,后期短于开放手术组；腹腔镜组手术时间随随时间、例数的增加有一定的下降趋势(r2=0.5411)。
结论
1.与传统开放手术相比,后腹腔镜下重复肾上位半肾切除术能达到开放手术的临床疗效,且具有术中出血少、手术创伤小、术后恢复快的优势,有极大的临床应用价值。
2.腹腔镜对上、下位肾血管的处理具有高选择性,可有效避免上位肾血管的漏扎及下位肾血管的误扎
3.腹腔镜对上、下位肾交界平面的判断及对残余肾盂粘膜与下位肾实质的分辨更为精细和准确,可有效避免下位肾实质及集合系统的损伤。
4.后腹腔镜重复肾上位半肾切除术虽然手术操作难度大,但随着术者操作经验的积累,手术时间逐渐缩短。
Objective
To evaluate the clinical efficacy and explore clinical value on retropritoneoscopic upper-pole heminephrectomy for duplex kidneys in retrospective comparision of open upper-pole heminephrectomy.
Methods
Between November 2004 and December 2009,a total of 30 paients (9 males and 21 females)of duplex kidney with nonfunc- tioning upper-pole moiedties were involved. The mean age was 28.07±18.80 years (range 4 to 68).12 patients came to our hospital for urinary incontinence; 4 patients with recurrent urinary tract infection; 6 patients complained of flank pain;8 patients were misdiagnosised as renal cyst during health examination.All of patients were diagnosed duplex kidney and ureter by utrasonagraphy,IVU and or CT befor operation.Of all patients,the upper-pole moieties were found sever hydronephrosis or atrophy,and have no reservation value.4 patients were accompanied with contralateral duplex kidney, which were showed normal renal function by IVU,CT and so on. Of 30 patients the lower moieties and contralateral kidney were normal in morphology and function.Retoperitoneoscopic Upper-pole Heminephrectomy was performed in all of them.
Between July 1999 and May 2007,32 patients (12 males and 20 females)of duplex kidney with nonfunctioning upper-pole moiedties were involved. The mean age was 24.25±16.87 years (range 2 to 54).9 patients complained of flank pain; 10 patients were misdiagnosised as renal cyst during health examination; 10 patients came to our hospital for urinary incontinence.Of all patients,the upper-pole moieties were found serious hydronephrosis or atrophy with indications of dissection.1 patient was diagnosed ureterocele;2 patients were accompanied with contralateral duplex kidney and ureter,which was nomal in function. All of patients underwent open upper-pole heminephrectomy.
Age,gender,BMI,the sides of operation, cases with chronic medical diseases,the duration of operation, intraoperative estimated blood loss,cases of intraoperative blood transfusion, length of incision, intraoperative and postoperative complications, time to anal exsufflation, time to oral liquids,time of postoperative intravenous antibiotic,cases of postoperation analgesia, temperature recovery time,time of postoperative drainage,time to ambulation,postoperative hospital stay, follow-up information were compared between the two groups retrospectively.
Results
All operations of the two groups were performed successfully. None of Laparoscopic Group experienced conversion to open surgery.In Laparoscopic Group and Open Group,mean operating time was 155.17±29.73min vs 148.59±21.90min,mean estimated blood loss was 43.67±14.62ml vs 193.75±43.09ml,mean length of incision was 4.91±0.51cm vs 10.87±1.27cm,no patient vs 1 patient need intraoperative blood transfusion,mean time to anal exsufflation was 1.73±0.52d vs 3.19±0.64d,time to oral liquids was 2.50±0.51d vs 3.31±0.47d, time of postoperative intravenous antibiotic was 5.13±0.68d vs 7.97±1.82d,3 patients vs 20 patients used postoperation analgesia,mean time of postoperative drainage was 4.63±0.77d vs 7.16±2.41d, time to ambulation was 6.70±0.88d vs 9.19±1.42d,temperature recovery time was 33.13±8.59h vs59.81±12.40h,postoperative hospital stay was 8.27±1.29d vs 11.38±5.59d.In Laparoscopic Group,2 patients with injured peritoneum,12 ones with hypercapnia,20 ones subcutaneous emphysema, 2 ones with discomfort in surgical position,1 with urinary tract infection were observed. In Open Group,1 patient with injured lower moiety,2 ones with injured pleura,2 ones with urine leakage,3 ones with incision hemorrhage,5 ones with incision infection,16 ones with incision discomfort were observed.
Results showed that there were no significant differences between the 2 groups in terms of age,gender,BMI,the sides of operation, cases with chronic medical diseases(P> 0.05); there were no significant differences between the 2 groups in terms of the duration of operation, cases of intraoperative blood transfusion,the main complication(injured lower moiety, urine leakage, urinoma, functional loss of the remaining moiety, recurrent urinary tract infection related to ureteral stump), injured peritoneum, injured pleura(P>0.05); there were significant differences between the 2 groups in terms of length of incision, intraoperative estimated blood loss, time to anal exsufflation, time to oral liquids,time of postoperative intravenous antibiotic,cases of postoperation analgesia, temperature recovery time,time of postoperative drainage,time to ambulation,postoperative hospital stay(P<0.05);Early operative time in Laparoscopic Group is longer than that in Open Group,but late operative time is shorter than that in Open Group. We observed a slight tendency for the duration of the procedure to decrease with experience.
Conclusions
1. In comparision of traditional open heminephrectomy, retoperitoneoscopic upper-pole heminephrectomy is safe and effective technique with minimal invasion and quicker postoperative recovery,and should be offered as the treatment modality of choice to patients with duplication kidney.
2. Retoperitoneoscopic upper-pole heminephrectomy is to clearly define the duplex polar vascular anatomy,thus avoid omitting vascular of the upper moiety and mistaking that of the lower moiety.
3. Retoperitoneoscopic upper-pole heminephrectomy is to clearly judge the junction of upper and lower moiety,and to clearly define residual renal pelvis and the lower moiety,thus predict injury from renal parenchyma and collecting system of the lower moiety.
4. There is a slight tendency for the duration of the laparoscopic procedure to decrease with experience.
引文
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