摘要
泌尿外科腹腔镜手术的发展历史尚短，但因其创伤小、病人痛苦轻、恢复快的优点，使其得到了迅速的发展。从最初的较为简单的肾囊肿去顶术、精索静脉高位结扎术到今天已经到泌尿外科大部分的手术领域，包括难度较高的尿路重建手术，如肾盂成形术，输尿管膀胱再植术等。在国外，腹腔镜下输尿管膀胱再植术开展已有10余年的历史，特别是近5年，随着腹腔镜手术器械的发展及操作技术的进步，该手术有了迅猛的发展，并且形成了多种不同的术式，其中腹腔镜下膀胱壁瓣法输尿管膀胱再植术虽然手术相对复杂，但因其独特的抗返流效果，占据了重要地位。目前，在国内，仅有少数医疗机构有过少量的病例报道，并且没有开展与开放手术的对照研究。
我们从2002年3月开始开展腹腔镜下输尿管膀胱再植术，并从2004年1月开始至2006年6月，改进术式，进行了19例腹腔镜膀胱壁瓣法输尿管膀胱再植术。本研究旨在通过比较我们腹腔镜下膀胱壁瓣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数据，评价腹腔镜膀胱壁瓣法输尿管膀胱再植术的手术效果及临床意义，为该术式的普及和推广提供科学依据。
临床资料和研究方法
(一)临床资料
采用经腹腔途径施行腹腔镜下膀胱壁瓣法输尿管膀胱再植术治疗输尿管出口梗阻19例(A组)，男5例，女14例。年龄8—62岁，平均39岁。左侧5例，右侧13例，双侧1例。重度积水12例13侧，中度积水7例。
开放膀胱壁瓣法输尿管膀胱再植术治疗输尿管出口梗阻20例(B组)，男7例，女13例。年龄15—60岁，平均38岁。左侧8例，右侧12例。重度积水14侧，中度积水6例。
(二)病例的收录及排除标准
1．收录标准
各种原因引起的输尿管出口出梗阻，包括先天性输尿管出口发育畸形、输尿管膀胱再植术后再次出现输尿管出口出狭窄、盆腔手术后引起的输尿管出口梗阻。
2．排除标准
排除手术期间同时进行其他手术如胆囊切除术、妇科手术等的病例，以避免对统计数据的干扰。
(三)病例的收集
1．收集本院从2004年1月至2006年6月我们所做的共19例腹腔镜下膀胱壁瓣法输尿管膀胱再植术治疗输尿管出口梗阻的完整临床资料，详细记录患者的姓名、病历号、性别、年龄、联系地址及电话、主要诊断、合并疾病、临床表现、超声(Bus)和IVU或MRU结果、手术日期、手术时间、出血量、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、术后术后住院天数等。
2．收集本院从2004年1月至2006年6月我们所做的共20例开放膀胱壁瓣法输尿管膀胱再植术治疗输尿管出口梗阻的完整临床资料，详细记录患者的姓名、病历号、性别、年龄、联系地址及电话、主要诊断、合并疾病、临床表现、超声(Bus)和IVU或MRU结果、手术日期、手术时间、出血量、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、术后住院天数等。
(四)数据的处理
1．比较腹腔镜手术组及开放手术组在患者年龄、手术时间(min)、出血量(ml)、术后进流质时间(d)、术后抗生素使用时间(d)、术后引流引留置时间(d)、术后止痛药应用时间(d)、术后住院时间(d)、术后并发症发生率等方面的各项指标，研究腹腔镜组手术能否达到开放手术相同的效果以及能否达到微创的效果。
2．所有数据均通过SPSS 11.0 for windows专业统计软件，根据不同的数据情况选择T-test检验、非参数检验等统计学方法进行分析，以P＜0.05为差别具有统计学意义。
结果
1．腹腔镜组19例手术均获得成功，无1例中转开放手术，手术时间110-180min／侧，平均手术时间131.5min／侧。术中出血40-150ml，平均70ml。18例术后1.3d拔除膀胱外引流管下地活动，1例发生尿漏，术后5天拔出引流管。术后1周拔除导尿管，18例术后住院时间7-9d，1例因急性肾功能衰竭术后14天肾功能基本恢复后出院，平均8.4d。术后1个月拔除双J管。术后3-6个月膀胱造影2例双侧Ⅰ°输尿管返流，17例无反流。随访6-30个月，无明显腰部酸胀痛症状，肾积水均得到明显改善，B超和IVU、MRU复查无输尿管膀胱吻合口狭窄，中度肾积水3例，轻度肾积水6例，无明显肾积水10例。
2．开放手术组20例手术均获得成功，手术时间100-195min／侧，平均手术时间135.5min／侧。术中出血100-450ml，平均160ml。术后2-5d拔除膀胱外引流管下地活动，2例发生尿漏2d，引流管放置5d，2例发生切口感染，经换药及抗生素治疗2周后好转。术后1周拔除导尿管，术后住院时间9-17d，平均10.6d。术后1个月拔除双J管。术后3-6个月膀胱造影3例双侧Ⅰ°输尿管返流，17例无反流。随访6-30个月，无明显腰部酸胀痛症状，肾积水均得到明显改善，B超和IVU、MRU复查无输尿管膀胱吻合口狭窄，中度肾积水4例，轻度肾积水5例，无明显肾积水11例。
3．比较腹腔镜手术组和开放手术组，在患者年龄、手术时间方面，两组无统计学差别；在手术出血量、术后进流质时间、术后抗生素使用时间、术后引流引留置时间、术后止痛药应用时间、术后住院时间等方面，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
本研究结果表明，腹腔镜膀胱壁瓣法输尿管膀胱再植术安全、可行，与开放手术相比，创伤小、痛苦少、恢复快、术后并发症少，同时术后长期疗效相当，抗反流效果佳，是治疗输尿管出口病变的微创新途径。
Background and purpose:
Laparoscopy has been used in urologic surgery only more than ten years history, but it has developed rapidly. Laparoscopy has been used in most urologic surgery, including laparoscopic ureterovescial implantation. As compared with open operation, laparoscopy has the advantages of minimal invasion, less suffering, quicker recovery, less complication and same long-term outcome.
In the past three years, we have performed less than twenty transperitoneal laparoscopic bladder-flap ureterovesical implantation for ureterovesical obstruction. Our researches focus on evaluating the clinical efficacy of transperitoneal laparoscopic bladder-flap ureterovesical implantation versus the open surgery during the correspongding time period.
Methods:
1. Including and excluding atandard
(1) Including standard
Choose the cases of uretrovesical obstruction incluing congenital ureterovesical stricture, secondum stricture after ureterovesical implantation, ureterovesical obstruction after pelvic surgery.
(2) Excluding standard
We rule out those cases operated concomitant with other surgery (such as
cholecystectomy,gynecological surgery, et al) in the case data was interfered.
2. Assemble the data
(1) Between January 2004 and June 2006 data were respectively obtained on our
19 consecutive cases of ureterovesical obstruction patients who were operated by laparoscopic bladder-flap ureterovesical implantation. We gathered the detailed clinical data of these patients, including age, total operation time, blood loss, time to oral liquids, time of intravenous antibiotic, time of drainage, time of postoperative analgesia, postoperation hospital stay, postoperative complications.
(2) Between January 2004 and June 2006 data were respectively obtained on our
20 consecutive cases of ureterovesical obstruction patients who were operated by open bladder-flap ureterovesical implantation. We gathered the detailed clinical data of these patients, including age, total operation time, blood loss, time to oral liquids, time of intravenous antibiotic, time of drainage, time of postoperative analgesia, postoperation hospital stay, postoperative complications.
3. Data analyzing:
(1) We evaluated the role of the laparoscopic bladder-flap ureterovesical implantation versus open surgery by analyzing the data of the age, total operation time, blood loss, time to oral liquids, time of intravenous antibiotic, time of drainage, time of postoperative analgesia, postoperation hospital stay, postoperative complications.
(2) All the data were analyzed by SPSS11.0 for windows. We chose different statistical method depended on the different data information.
Result:
1. Between January 2004 and June 2006, we treated 19 cases by laparoscopic bladder-flap ureterovesical implantation , all operations were successful and no conversion to open operation. Mean operative time was 131.5 minutes (110-180min), mean estimated blood loss was 70 ml (40-150ml), postoperative
hospital time was 8.4 d (7-14d).
2. Between January 2004 and June 2006, we treated 20 cases by open bladder-flap ureterovesical implantation , all operations were successful. Mean operative time was 135.5 minutes (100-195min), mean estimated blood loss was 160 ml (100-450ml), postoperative hospital time was 10.6 d (9-17d).
3. Comparing the results of laparoscopic bladder-flap ureterovesical implantation with open surgery, the age and the mean operative time was no significant differences, but the mean volume of blood loss, time to oral liquids, time of intravenous antibiotic, time of drainage, time of postoperative hospital time, and the postoperative complications were statistically significant different. The laparoscopic approach was more minimally invasive than the open approach in the operation of bladder-flag ureterovesical implantation.
Conclusion:
Compared with open surgery for ureterovesical obstruction, Transperitoneal laparoscopic bladder-flap ureterovesical implantation is a minimally invasive, less suffering, excellent anti-urine reflux effect; quicker recovery approach for treatment of ureterovesical obstruction.
引文
1. Winfield HN, Donovan JF, See WA, et al. Urological laparoscopics urology. J Urol, 1991, 146:941-948.
2. Reddy PK, Evans RM. Laparoscopic ureteroneocystostomy. J Urol 1994,152(6 pt 1):2057-2059.
3. Andou M, Yoshioka T, Ikuma K. Laparoscopic ureteroneocystostomy. Obstetrics & Gynecology, 2003, 102:1183-1185.
4. Gill IS, Ponsky LE, Desai M, et al. Laparoscopic cross-trigonal Cohen ureteroneocystostomy: novel technique. J Urol, 2001, 166: 1811-1814.
5. Fergany A, Gill IS, Abdel-Samee A, el al. Laparoscopic bladder flap ureteral reimplantion: survival porcine study. J Urol, 2001, 166: 1920-1923.
6. McDougall EM , Urban DA, Kerbl K, et al. Laparoscopic repair of vesieoureteral reflux utilizing the Lich-Gregoir technique in the pig model. J Urol, 1995, 153: 497-500.
7. Lakshmanan Y , Fung LC. Laparoscopic extravesicular ureteral reimplantation for vesicoureteral reflux: recent technical advances. J Endourol, 2000, 14: 589-594.
8. 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.
9. Simmons MN, Gill IS, Fergany AF, et al. Laparoscopic ureteral reconstruction for benign stricture disease. Urology. 2007; 69(2):280-4.
10．张大宏，陈岳兵，丁国庆，等。腹腔镜输尿管膀胱再植术(附17例报告)。中华泌尿外科杂志，2004，25：760-762。
11．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，2006，27：593-595。
1. Winfield HN, Donovan JF, See WA, et al. Urological laparoscopics urology. J Urol, 1991, 146: 941-948.
2. Reddy PK, Evans RM. Laparoscopic ureteroneocystostomy. J Urol 1994,152(6 pt 1):2057-2059.
3. Andou M, Yoshioka T, Ikuma K. Laparoscopic ureteroneocystostomy. Obstetrics & Gynecology, 2003, 102:1183-1185.
4. Gill IS, Ponsky LE, Desai M, et al. Laparoscopic cross-trigonal Cohen ureteroneocystostomy: novel technique. J Urol, 2001, 166: 1811-1814.
5. Fergany A, Gill IS, Abdel-Samee A, el al. Laparoscopic bladder flap ureteral reimplantion: survival porcine study. J Urol, 2001, 166: 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: 497-500.
7. Lakshmanan Y, Fung LC. Laparoscopic extravesicular ureteral reimplantation for vesicoureteral reflux: recent technical advances. J Endourol, 2000, 14: 589-594.
8. 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.
9. Simmons MN, Gill IS, Fergany AF, et al. Laparoscopic ureteral reconstruction for benign stricture disease. Urology. 2007; 69(2):280-4.
10．张大宏，陈岳兵，丁国庆，等。腹腔镜输尿管膀胱再植术(附17例报告)。中华泌尿外科杂志，2004，25：760-762。
11．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，2006，27：593-595。