腹膜后腔镜肾盂成形术
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摘要
肾盂输尿管连接部(ureteropelvic junction，UPJ)梗阻是引起肾后性梗阻的常见原因之一。近几十年来，开放离断性肾盂成形术(Anderson-Hynes术)一直是治疗UPJ梗阻的标准治疗方法，其手术成功率超过90％。近年来随着微创外科的发展，腔镜技术治疗UPJ梗阻在临床上已逐渐成为主要的治疗手段，但无论是顺行经皮肾镜肾盂切开术还是逆行经输尿管镜肾盂切开术，其手术成功率为70％～89％，并有一定的并发症，治疗效果还达不到开放成形手术的效果，且不适于引起UPJ梗阻的外源性病变如异位血管、输尿管肾盂高位入口、巨大肾盂积水等。腹腔镜肾盂成形术作为90年代开展的治疗UPJ梗阻新技术，文献报道相对较少，随访时间也较短。但由于该术既可以达到开放手术的治疗效果，又具备了微创手术的创伤小、并发症少、恢复快等优点，是治疗UPJ梗阻的有效微创手术方法之一。
目的：介绍腹膜后腔镜Anderson-Hynes肾盂成形术新技术，探讨腹膜后腔镜在肾盂成形术的应用价值。
浙江大学硕士学位论文
方洁：对比分析腹膜后腔镜“例）和开放AnderSOn－HyncO肾盂成形术手
术u 例）两组手术时间、住院时间、术中出血及住院费用，术后症状变化
和B超、IVU复查结果。
结果：16例均成功地完成了手术。腹腔镜组无中转手术者，手术时间腹腔
组为（279土52）mh，开放手术组为（121土44）mh（P＜o．001）；而住院
时间、术后住院时间、术中出血均较开放手术组少（P＞0．05人 术后漏尿发
生率要高于开放手术组，但两组比较差别无显著意义。两组术后均未发生严
重的并发症。术后随访3个月，腰部疼痛缓解两组比较差别无显著意义，腹
腔镜组均恢复正常工作和生活，而开放手术组均仅5例恢复正常工作和生活。
结论：腹腔镜Anderson－Hyncs肾盂成形术可以达到开放手术的治疗效果，
又具备了微创手术的创伤小、并发症少、恢复快等优点，是治疗UPJ梗阻的
有效微创手术方法之一。
Ureteropelvic junction obstruction leads to progressive dilatation of the renal collecting system, and can result in pain and progressive deterioration of renal function. The gold standard therapy for repair of ureteropelvic junction obstruction has been open pyeloplasty with success rates greater than 90%. Endoscopic incision either in an antegrade or retrograde fashion provides an attractive minimally invasive alternative. However, these procedures have lower success rates of 70% to 89% evin in highly select patients. Patients at high risk for failure include those with a large redundant renal pelvis, crossing vessels or poor renal function (less than 20%). In such cases reconstructive pyeloplasty may provide an advantage. Since 1993, laparoscopic surgeons have continued to use the Anderson-Hynes pyeloplasty, the Foley Y-V advancement, and Fenger-plasty. Preliminary reports have
demonstrated the feasibility of laparoscopic procedures in experienced hands, with a lower morbidity and shorter convalescence, and operative success rates comparable with those of open techniques. In this study, we compared the outcome assessment of the pyeloplasty between retroperitoneal laparoscopic and open Anderson-Hynes.
Objective: To assess the feasibility and results of retroperitoneal laparoscopic pyeloplasty in the treatment of ureteropelvic junction obstruction.
Methods: From June 2001 to February 2002, 16 consecutive nonrandomized patients underwent 6 patients underwent retroperitoneal laparoscopic (laparoscopy group) and 10 patients underwent open Anderson-Hynes pyeloplasty (open surgery group). The decision between the two techniques depended on the patient's anesthetic ability to tolerate laparoscopic pyeloplasty, previous ureteropelvic junction surgery, and the surgeon's laparoscopic experience. Subjective outcomes as to postoperative pain and convalescence and objective findings on intravenous urography were assessed at 3 months postoperatively in both groups.
Results: All procedures were successfully completed. The mean operating time 279 minutes for laparoscopic pyeloplasty was much more longer than the time 121 minutes for open (p<0.001). The mean hospital stay time, operating bleeding volume, postoperative complication and hospital cost were same in the two groups. No severe postoperative complications were found. 3 months after the procedure the pain-free rates in flank pain were same between the two groups, but the open surgery group had much pain and
prolonged convalescence from a flank incision. The B type ultrasound and intravenous urography 3 months after the procedure showed good results.
Conclusions: Laparoscopic pyeloplasty is a minimally invasive technique that provides durable clinical and radiographic results in a similar fashion as open pyeloplasty.
目的：介绍腹膜后腔镜Anderson-Hynes肾盂成形术新技术，探讨腹膜后腔镜在肾盂成形术的应用价值。
浙江大学硕士学位论文
方洁：对比分析腹膜后腔镜“例）和开放AnderSOn－HyncO肾盂成形术手
术u 例）两组手术时间、住院时间、术中出血及住院费用，术后症状变化
和B超、IVU复查结果。
结果：16例均成功地完成了手术。腹腔镜组无中转手术者，手术时间腹腔
组为（279土52）mh，开放手术组为（121土44）mh（P＜o．001）；而住院
时间、术后住院时间、术中出血均较开放手术组少（P＞0．05人 术后漏尿发
生率要高于开放手术组，但两组比较差别无显著意义。两组术后均未发生严
重的并发症。术后随访3个月，腰部疼痛缓解两组比较差别无显著意义，腹
腔镜组均恢复正常工作和生活，而开放手术组均仅5例恢复正常工作和生活。
结论：腹腔镜Anderson－Hyncs肾盂成形术可以达到开放手术的治疗效果，
又具备了微创手术的创伤小、并发症少、恢复快等优点，是治疗UPJ梗阻的
有效微创手术方法之一。
Ureteropelvic junction obstruction leads to progressive dilatation of the renal collecting system, and can result in pain and progressive deterioration of renal function. The gold standard therapy for repair of ureteropelvic junction obstruction has been open pyeloplasty with success rates greater than 90%. Endoscopic incision either in an antegrade or retrograde fashion provides an attractive minimally invasive alternative. However, these procedures have lower success rates of 70% to 89% evin in highly select patients. Patients at high risk for failure include those with a large redundant renal pelvis, crossing vessels or poor renal function (less than 20%). In such cases reconstructive pyeloplasty may provide an advantage. Since 1993, laparoscopic surgeons have continued to use the Anderson-Hynes pyeloplasty, the Foley Y-V advancement, and Fenger-plasty. Preliminary reports have
demonstrated the feasibility of laparoscopic procedures in experienced hands, with a lower morbidity and shorter convalescence, and operative success rates comparable with those of open techniques. In this study, we compared the outcome assessment of the pyeloplasty between retroperitoneal laparoscopic and open Anderson-Hynes.
Objective: To assess the feasibility and results of retroperitoneal laparoscopic pyeloplasty in the treatment of ureteropelvic junction obstruction.
Methods: From June 2001 to February 2002, 16 consecutive nonrandomized patients underwent 6 patients underwent retroperitoneal laparoscopic (laparoscopy group) and 10 patients underwent open Anderson-Hynes pyeloplasty (open surgery group). The decision between the two techniques depended on the patient's anesthetic ability to tolerate laparoscopic pyeloplasty, previous ureteropelvic junction surgery, and the surgeon's laparoscopic experience. Subjective outcomes as to postoperative pain and convalescence and objective findings on intravenous urography were assessed at 3 months postoperatively in both groups.
Results: All procedures were successfully completed. The mean operating time 279 minutes for laparoscopic pyeloplasty was much more longer than the time 121 minutes for open (p<0.001). The mean hospital stay time, operating bleeding volume, postoperative complication and hospital cost were same in the two groups. No severe postoperative complications were found. 3 months after the procedure the pain-free rates in flank pain were same between the two groups, but the open surgery group had much pain and
prolonged convalescence from a flank incision. The B type ultrasound and intravenous urography 3 months after the procedure showed good results.
Conclusions: Laparoscopic pyeloplasty is a minimally invasive technique that provides durable clinical and radiographic results in a similar fashion as open pyeloplasty.
引文
1 O'Reilly PH, Brooman PJ, Mak S, et al. The long-term results of Anderson-Hynes pyeloplasty. BJU Int, 2001, 87:287
2 Gallucci M, Alpi G. Antegrade transpelvic endopyelotomy in primary obstruction of the ureteropelvic junction. J Endourol, 1996, 10:127
3 Tawfiek ER, Liu JB, Bagley DH, et al. Ureteroscopic treatment of ureteropelvic junction obstruction. J Urol, 1998, 160:1643
4 Thomas R, Monga M, Klein EW, et al. Ureteroscopic retrograde endopyelotomy for management of ureteropelvic junction obstruction. J Endourol, 1996, 10:141
5 Preminger GM, Clayman RV, Nakada SY, et al. A multicenter clinical trial investigating the use of a fluoroscopically controlled cutting balloon catheter for the management of ureteral and ureteropelvic junction obstruction. J Urol, 1997, 157:1625
6 Van Cangh PJ, Wilmart JF, Opsomer RJ, et al. Long-term results and late recurrence after endoureteropyelotomy: a critical analysis of prognostic factors. J Urol, 1994, 151:934
7 Bauer JJ, Bishoff JT, Moore RG, et al. Laparoscopic versus open pyeloplasty:assessment of objective and subjective outcome. J Urol,1999,162:692
8 Moore RG, Averch TD, Schulam PG, et al. Laparoscopic pyeloplasty:experience with the initial 30cases. J Urol, 1997,157:459
9 Janetschek G, Peschel R, Altarac S, et al. Laparascopic and retroperitoneoscopic repair of ureteroneoscopic repair of ureteropelvic junction obstruction. Urology, 1996,47:311
10 Ben Slama MR, Salomon L, Hoznek A, et al. Extraperitoneal laparoscopic repair of ureteropelvic junction obstruction: initial experience in 15 cases. Urology, 2000,56:45
11 Soulie M, Salomon L, Patard J J, et al. Extraperitoneal laparoscopic pyeloplasty :a multicenter study of 55 procedures. J Urol, 2001,166:48
12 Rehman J, Landman J, Sundaram C, et al. Missed anterior crossing vessels during open retroperitoneal pyeloplasty: laparoscopic transperitoneal discovery and repair. J Urol, 2001,166:593
13 Chen RN, Moore RG, Kavoussi LR. et al. Laparoscopic pyeloplasty:indications,technique,and long-term outcome. Urol Clin North Am, 1998,25:323
2 Gallucci M, Alpi G. Antegrade transpelvic endopyelotomy in primary obstruction of the ureteropelvic junction. J Endourol, 1996, 10:127
3 Tawfiek ER, Liu JB, Bagley DH, et al. Ureteroscopic treatment of ureteropelvic junction obstruction. J Urol, 1998, 160:1643
4 Thomas R, Monga M, Klein EW, et al. Ureteroscopic retrograde endopyelotomy for management of ureteropelvic junction obstruction. J Endourol, 1996, 10:141
5 Preminger GM, Clayman RV, Nakada SY, et al. A multicenter clinical trial investigating the use of a fluoroscopically controlled cutting balloon catheter for the management of ureteral and ureteropelvic junction obstruction. J Urol, 1997, 157:1625
6 Van Cangh PJ, Wilmart JF, Opsomer RJ, et al. Long-term results and late recurrence after endoureteropyelotomy: a critical analysis of prognostic factors. J Urol, 1994, 151:934
7 Bauer JJ, Bishoff JT, Moore RG, et al. Laparoscopic versus open pyeloplasty:assessment of objective and subjective outcome. J Urol,1999,162:692
8 Moore RG, Averch TD, Schulam PG, et al. Laparoscopic pyeloplasty:experience with the initial 30cases. J Urol, 1997,157:459
9 Janetschek G, Peschel R, Altarac S, et al. Laparascopic and retroperitoneoscopic repair of ureteroneoscopic repair of ureteropelvic junction obstruction. Urology, 1996,47:311
10 Ben Slama MR, Salomon L, Hoznek A, et al. Extraperitoneal laparoscopic repair of ureteropelvic junction obstruction: initial experience in 15 cases. Urology, 2000,56:45
11 Soulie M, Salomon L, Patard J J, et al. Extraperitoneal laparoscopic pyeloplasty :a multicenter study of 55 procedures. J Urol, 2001,166:48
12 Rehman J, Landman J, Sundaram C, et al. Missed anterior crossing vessels during open retroperitoneal pyeloplasty: laparoscopic transperitoneal discovery and repair. J Urol, 2001,166:593
13 Chen RN, Moore RG, Kavoussi LR. et al. Laparoscopic pyeloplasty:indications,technique,and long-term outcome. Urol Clin North Am, 1998,25:323