摘要
目的：
比较我院腹腔镜粘膜下隧道法输尿管膀胱再植术和同期开展的开放输尿管膀胱再植术的各项临床数据,评价腹腔镜粘膜下隧道法输尿管膀胱再植术的手术效果及临床价值,为该术式的普及和推广提供科学依据。
资料与方法：
回顾性分析本院从2005年10月至2009年10月期间20例经腹腔途径行腹腔镜粘膜下隧道法输尿管膀胱再植术治疗输尿管末端梗阻患者(A组)及32例开放行粘膜下隧道法输尿管膀胱再植术治疗输尿管末端梗阻患者(B组)的完整临床资料。统计其姓名、性别、年龄、联系地址及电话、主要诊断、合并疾病、临床表现、B超(B-us)、IVU或CTU结果、手术日期、手术时间、出血量、切口长度、术后并发症、术后进流质时间、术后静脉抗生素天数、术后拔引流管时间、术后止痛药应用时间、术后住院天数、住院总费用和术后恢复正常生活时间等。并对其主要临床指标进行对比分析。评价腹腔镜粘膜下隧道法输尿管膀胱再植术的手术效果及临床价值。
结果：
腹腔镜组20例手术均获得成功,无1例中转开放手术。手术时间85-240min／侧,平均手术时间150.5min／侧。术中总出血量20-105ml,平均52ml。切口长度3-4 cm平均3.5cm。18例术后2-5天拔除膀胱外伤口引流管下地活动,20例平均引流管留置时间3.2天。2例发生尿漏,经局部换药,延迟1周无尿漏后拔除膀胱外伤口引流管后好转,无1例肾积水加重。术后1-3天进食流质,平均1.4天。术后14天拔除导尿管。术后应用抗生素2-8天,平均4.6天。术后应用止痛药0-2天,平均0.8天。术后住院时间5-12d,平均8d。住院总费用9-17千元,平均13.2千元。术后恢复正常生活时间16-35天,平均23.6天。术后3个月拔除双J管。随访2-38个月,均取得良好疗效,肾功能都保持稳定,无明显腰部胀痛症状,肾积水均得到明显改善,B超和IVP,CT复查无输尿管膀胱吻合口狭窄,中度肾积水1例,轻度肾积水6例,无明显肾积水13例,术后3-6个月膀胱造影1例输尿管返流,1年后返流消失；19例无返流。
开放组32例手术均获得成功。手术时间80-200min／侧,平均手术时间131.4min／侧。术中总出血量80-230ml,平均152.5ml。切口长度9-16cm平均12.7cm。27例术后2-6天拔除膀胱外伤口引流管下地活动,32例平均引流管留置时间4.2天。5例发生尿漏,经局部换药,延迟1周无尿漏后拔除膀胱外伤口引流管后好转,无1例肾积水加重。术后2-4天进食流质,平均2.8天。术后14天拔除导尿管。6例发生切口感染,经加强换药及抗生素治疗12天后好转。术后应用抗生素4-12天,平均7.2天。术后应用止痛药0-4天,平均2.2天。术后住院时间8-16d,平均11.7d。住院总费用8-17千元,平均12.9千元。术后恢复正常生活时间20-42天,平均30.1天。术后3个月拔除双J管。随访2-38个月,均取得良好疗效,肾功能都保持稳定,无明显腰部胀痛症状,肾积水均得到明显改善,B超和IVP,CT复查无输尿管膀胱吻合口狭窄,中度肾积水2例,轻度肾积水7例,无明显肾积水23例,术后3-6个月膀胱造影3例输尿管返流,1年后返流消失；29例无返流。
比较腹腔镜组和开放手术组,在患者年龄、性别、肾积水程度、肾积水改善程度及住院总费用方面,两组无统计学差别；在手术时间方面,两组差别具有统计学意义,开放手术优于腹腔镜手术；在手术出血量、切口长度、术后进流质时间、术后静脉抗生素使用时间、术后引流管留置时间、术后止痛药应用时间、术后住院时间、术后并发症和术后恢复正常生活时间等方面,两组差别具有统计学意义,腹腔镜手术均优于开放手术。
结论：
1.腹腔镜粘膜下隧道法输尿管膀胱再植术手术时间相对开放手术稍长,但是随着腹腔镜技术的不断发展和腹腔镜下操作的成熟,手术时间不断缩短并接近于开放手术。
2.腹腔镜粘膜下隧道法输尿管膀胱再植术与开放手术相比,不仅安全可行、创伤小、痛苦少、术后恢复快、住院时间短、术后并发症少和远期效果可期,而且在住院费用和手术疗效方面与开放手术无明显差异,有较高的临床应用价值,值得推广,是治疗输尿管末端病变的重要微创途径
Objective:In this study,Our researches focus on evaluating the clinical efficacy of transperitoneal laparoscopic extravesical ureterovesical implantation under submucosal tunnel versus the open surgery during the corresponding time period.Then we can provide scientific proof for the promotion of laparoscopic extravesical ureterovesical implantation under submucosal tunnel.
Method:20 cases of laparoscopic extravesical ureterovesical implantation under submucosal tunnel and 32 cases of the open surgery which had been prformed for ureterovesical obstruction in our hospital from October 2005 to October 2009 were retrospectively analyzed.We gathered the detailed clinical data of these patients,including name,sex,age,total operation time,blood loss,length of incision, time to oral liquids,time of intravenous antibiotic,time of drainage, time of postoperative analgesia,postoperation hospital stay,postoperative complications, hospital costs and postoperative recovery time to normal life.Then we did a comparative study of the main clinical indicators and evaluated clinical significance of the Laparoscopic ureteral reimplantation.
Result:Laparoscopic ureteral reimplantation was completed in all 20 patients and no conversion to open conversion.The mean operative time (excluding anesthesia time) was 150.5minutes (range 85-240min).The mean drop in hemoglobin was 52mL(range 20-105mL) between preoperative and postoperative sampling.The mean length of incision was 3.5cm (range 3-4cm).The mean time of drainage was 3.2days.18 patients were discharged by pull out the drainage tube 2-5 days after surgery. However 2 patients with urine leakage were discharged by dressing change and pull out the drainage tube 7days after surgery.And no hydronephrosis aggravating. The mean time to oral liquids was 1.4days(range 1-3days) after surgery.The catheter was removed 14days later. Postoperative views in all patients was with a single dose of antibiotic after surgery for 4.6 days(range 2-8days).The mean time of postoperative analgesia was 0.8days (range 0-2days).The mean hospital costs was 13200yuan(range 9000-17000yuan).The mean hospital stay was 8days(range 5-12days) and the pig-tail catheter remained for an average of 3 months.The mean postoperative recovery time to normal life was 23.6days(range 16-35days).During 2-38 months'follow-up, Postoperative evaluation revealed good renal function and no ureteral stricture in all patients by B-US,IVU or CT examination.Postoperatively, ultrasonographic scanning in 13 patients showed no evidence of hydronephrosis, and in 6 patients, showed mild water of the pelvicaliceal collecting system,and in one patient,showed moderate water of the pelvicaliceal collecting system.3-6 months after surgery cystography showed urine reflux in one cases and no urine reflux in 19 cases.
Open surgery was completed in all 32 patients.The mean operative time (excluding anesthesia time) was 131.4minutes (range 80-200min).The mean drop in hemoglobin was 152.5mL(range 80-230mL) between preoperative and postoperative sampling.The mean length of incision was 12.7cm (range 9-16cm).The mean time of drainage was 4.2days.27 patients were discharged by pull out the drainage tube 2-6 days after surgery. However 5 patients with urine leakage were discharged by dressing change and pull out the drainage tube 7 days after surgery.And no hydronephrosis aggravating. The mean time to oral liquids was 2.8days(range 2-4days) after surgery.The catheter was removed 14days later. Postoperative views in all patients was with a single dose of antibiotic after surgery for 7.2days(range 4-12days).The mean time of postoperative analgesia was 2.2days (range 0-4days).The mean hospital costs was 12900yuan(range 8000-17000yuan).The mean hospital stay was 11.7days(range 8-16days) and the pig-tail catheter remained for an average of 3 months.The mean postoperative recovery time to normal life was 30.1days(range 20-42days).During 2-38 months'follow-up, Postoperative evaluation revealed good renal function and no ureteral stricture in all patients by B-us,IVU and CT examination.Postoperatively, ultrasonographic scanning in 23 patients showed no evidence of hydronephrosis, and in 7 patients, showed mild water of the pelvicaliceal collecting system,and in 2 patients,showed moderate water of the pelvicaliceal collecting system.3-6 months after surgery cystography showed urine reflux in 3 cases and no urine reflux in 29 cases.
Comparing the results of laparoscopic extravesical ureterovesical implantation under submucosal tunnel with open surgery,the age, the sex, the degree of hydronephrosis and the hospital costs were no significant differences,while the mean operative time were statistically significant different.The mean operative time of the laparoscopic approach was more than the open approach.But the mean volume of blood loss,length of incision, time to oral liquids,time of intravenous antibiotic,time of drainage,postoperation hospital stay,the postoperative complications and postoperative recovery time to normal life were statistically significant different.The laparoscopic approach was more minimally invasive than the open approach in the operation of b ladder-flag ureterovesical implantation.
Conclusion:The mean operative time of the laparoscopic extravesical ureterovesical implantation under submucosal tunnel is more than the open approach, but with the development of laparoscopic surgery and Laparoscopic procedure, the operative time was shortened little by little or even close to the open surgery.
Laparoscopic extravesical ureterovesical implantation under submucosal tunnel is not only a safe and feasible procedure with many operative indications,but has minimal invasion, less suffering and complications,shorter hospitalization and convalescence, excellent anti-urine reflux effect and expectant long-term outcomes.It has a clinical significance and expectant promotion comparable to open surgery about the postoperative complications and outcomes of the procedure. quicker recovery. It plays an important role in the treatment of ureterovesical junction obstruction.
引文
[1]Winfield HN, Donovan JF, See WA, et al. Urological laparoscopic surgery. J Urol.1991,146(4):941-948.
[2]Kamat N, Khandelwal P. Laparoscopic extravesical ureteral reimplantation in adults using intracorporeal freehand suturing:report of two cases. J Endourol. 2005,19(4):486-490.
[3]Yohannes P, Gershbaum D, Rotariu PE, et al. Management of ureteral stricture disease during laparoscopic ureteroneocystostomy. J Endourol.2001,15 (8):839-843.
[4]Gill IS, Ponsky LE, Desai M, et al. Laparoscopic cross-trigonal Cohen ureteroneocystostomy:novel technique. J Urol.2001,166(5):1811-1814.
[5]金讯波,夏庆华,赵勇.腹腔镜游离性输尿管膀胱再植术的临床应用.山东医药.2006,46(21)：4-5.
[6]Shu T, Cisek LJ, Jr., Moore RG. Laparoscopic extravesical reimplantation for postpubertal vesicoureteral reflux. J Endourol.2004,18(5):441-446.
[7]Ramalingam M, Senthil K, Venkatesh V. Laparoscopic repair of ureterovaginal fistula:successful outcome by laparoscopic ureteral reimplantation. J Endourol. 2005,19(10):1174-1176.
[8]Kutikov A, Guzzo TJ, Canter DJ, et al. Initial experience with laparoscopic transvesical ureteral reimplantation at the Children's Hospital of Philadelphia. J Urol.2006,176(5):2222-2225; discussion 2225-2226.
[9]Rassweiler JJ, Gozen AS, Erdogru T, et al. Ureteral reimplantation for management ofureteral strictures:a retrospective comparison oflaparoscopic and open mchniques. Eur Urol.2007; 51(2):512-23.
[10]Simmoms MN, Gill IS, Fergany AF,et al. Laparoscopic uretcral reconstruction for benign stricture disease. Urology.2007; 69(2):280-4.
[11]徐月敏.泌尿修复重建外科学.第一版.北京：人民卫生出版社,2007.12.
[12]黄健,李逊.微创泌尿外科学.第一版.武汉：湖北科学技术出版社,2005.9.
[13]李炎唐,臧美孚.泌尿外科手术并发症预防和处理.第一版.北京：人民卫生出版社,2004.10.
[14]Andou M, Yoshioka T, Ikuma K. Laparoscopic ureteroneocystostomy. Obstet Gynecol.2003,102(5 Pt2):1183-1185.
[15]Fergany A, Gill IS, Abdel-Samee A, et al. Laparoscopic bladder flap ureteral reimplantation:survival porcine study. J Urol.2001,166(5):1920-1923.
[16]Lakshmanan Y, Fung LC. Laparoscopic extravesicular ureteral reimplantation for vesicoureteral reflux:recent technical advances. J Endourol. 2000,14(7):589-593; discussion 593-584.
[17]McDougall EM, Urban DA, Kerbl K, et al. Laparoscopic repair of vesicoureteral reflux utilizing the Lich-Gregoir technique in the pig model. J Urol. 1995,153(2):497-500.
[1]Winfield HN, Donovan JF, See WA, et al. Urological laparoscopic surgery. J Urol.1991,146(4):941-948.
[2]Yohannes P, Gershbaum D, Rotariu PE, et al. Management of ureteral stricture disease during laparoscopic ureteroneocystostomy. J Endourol. 2001,15(8):839-843.
[3]Gill IS, Ponsky LE, Desai M, et al. Laparoscopic cross-trigonal Cohen ureteroneocystostomy:novel technique. J Urol.2001,166(5):1811-1814.
[4]Andou M, Yoshioka T, Ikuma K. Laparoscopic ureteroneocystostomy. Obstet Gynecol.2003,102(5 Pt 2):1183-1185.
[5]Fergany A, Gill IS, Abdel-Samee A, et al. Laparoscopic bladder flap ureteral reimplantation:survival porcine study. J Urol.2001,166(5):1920-1923.
[6]McDougall EM, Urban DA, Kerbl K, et al. Laparoscopic repair of vesicoureteral reflux utilizing the Lich-Gregoir technique in the pig model. J Urol. 1995,153(2):497-500.
[7]Lakshmanan Y, Fung LC. Laparoscopic extravesicular ureteral reimplantation for vesicoureteral reflux:recent technical advances. J Endourol. 2000,14(7):589-593; discussion 593-584.
[8]Yohannes P, Chiou RK, Pelinkovic D. Pure robot-assisted laparoscopic ureteral reimplantation for ureteral stricture disease:case report. J Endourol.2003, 17:891-893.
[9]Elbadawi A. Anatomy and function of the ureteral sheath. J Urol. 1972,107(2):224-229.
[10]Politano VA. Ureterovesical junction. J Urol.1972,107(2):239-242.
[11]Symons S, Kurien A, Desai M. Laparoscopic ureteral reimplantation:a single center experience and literature review. J Endourol.2009,23(2):269-274.
[12]Rassweiler JJ, Gozen AS, Erdogru T, et al. Ureteral reimplantation for management of ureteral strictures:a retrospective comparison of laparoscopic and open techniques. Eur Urol.2007; 51(2):512-23.
[13]Simmons MN, Gill IS, Fergany AF,et al. Laparoscopic ureteral reconstruction for benign stricture disease. Urology.2007; 69(2):280-4.
[14]王勤章,丁国富,王新敏,等.经腹膜腹腔镜输尿管膀胱再植术.中国综合临床2006；22(2)：170-171.
[15]Massazza M. [The Casati-Boari method of ureteroneocystostomy.]. Minerva Ginecol.1962,14:74-86.
[16]张大宏,刘锋,丁国庆,等.腹腔镜膀胱壁瓣法输尿管膀胱再植术.中华泌尿外科杂志2006；27(9)：593-595.
[17]金讯波,夏庆华,赵勇.腹腔镜游离性输尿管膀胱再植术的临床应用.山东医药.2006,46(21)：4-5.
[18]徐月敏.泌尿修复重建外科学.第一版.北京：人民卫生出版社,2007.12.
[19]of a technique. J Urol,1959,82:573.
[20]Dinlenc CZ, Gerber E, Wagner JR. Ureteral reimplantation during robot assisted laparoscopic radical prostatectomy. J Urol.2004,172(3):905.
[21]Ratner LE, Ciseck LJ, Moore RG, et al. Laparoscopic live donor nephrectomy. Transplantation 60:1047,1995
[22]Casale P, Patel RP, Kolon TF. Nerve sparing robotic extravesical ureteral reimplantation. J Urol.2008,179(5):1987-1989; discussion 1990.