经腹腔完全腔镜下肾输尿管膀胱袖状切除术中输尿管末段处理的经验总结
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摘要
目的:探讨完全腹腔镜下肾输尿管膀胱袖状切除术治疗上尿路肿瘤的手术技巧(尤其是末段输尿管的处理技术)及围手术期临床指标。方法:回顾性分析2012年1月～2017年7月在我院接受经完全腹腔下肾输尿管膀胱袖状切除术的87例上尿路尿路上皮癌(UTUC)患者的临床资料,其中男43例,女44例,平均年龄(67.25±9.90)岁;肾盂癌47例,肾盂癌合并输尿管癌10例,输尿管癌30例(输尿管上段癌12例,输尿管中段癌9例,输尿管下段癌11例);左侧49例,右侧38例;肿瘤平均直径(3.24±1.47)cm。87例患者均行全麻下经腹腔完全腹腔镜下肾、输尿管及膀胱袖状切除术,采用健侧卧位,术中无需改换体位。记录手术时间、术中出血量、术中输血情况、引流管留置时间、尿管留置时间、术后并发症。结果:87例手术顺利,无中转开放手术。平均手术时间(162.50±45.64)min,平均术中失血(113.33±59.74)ml,无围手术期输血。术后引流管平均留置(4.56±1.12)d,尿管平均留置(5.63±2.17)d。无术中并发症,术后出现并发症2例手术标本切缘均为阴性。术后病理分期T_1～T_4N_0M_0(T_1期24例,T_2期19例,T_3期37例,T_4期7例)。随访时间1～44个月,平均13个月,术后肿瘤复发8例。结论:经腹腔完全腹腔镜下肾输尿管膀胱袖状切除术对于UTUC的治疗安全有效,在处理下段输尿管时预先切断脐内侧襞可以增加操作空间,降低手术难度。
Objective:To verify the surgical skills of total transperitoneal laparoscopic nephroureterectomy(ttLNU)in the management of ureteral terminal and perioperative clinical indicators in the treatment of upper urinary tract urothelial carcinoma(UTUC).Method:From Jan.2012 to Jul.2017,there were 87 UTUC patients treated with ttLNU,including male 43 cases and female 44.The mean average age was(67.25±9.90)years old.Forty-seven cases were diagnosed with renal pelvis carcinoma,10 cases were diagnosed with renal pelvic and ureteral carcinoma,30 cases were diagnosed with ureteral carcinoma(12 for upper ureteral carcinoma,9 cases for middle ureteral carcinoma,11 cases for lower ureteral carcinoma).There were 49 in the left and 38 in the right.The mean diameter of the tumor was(3.24±1.47)cm.Patients were put on lateral position and the position was not changed during the operation.This group of cases was retrospectively summarized including operative time,blood loss,blood transfusion,drainage time,catheterizing days,postoperative complications and hospital stays.Result:The ttLNU procedures were successfully performed in all cases without conversion to open surgery.The mean operation time was(162.50±45.64)min.The median blood loss was(113.33±59.74)ml.No transfusions were needed.The mean drainage time was(4.56±1.12)d.The mean time with Foley catheter was(5.63±2.17)d.There was no complication during operation.Two cases had complications after operation.All the surgical margins were negative.Postoperative TNM stages were T1-T4 N0 M0(T124,T219,T337,T47).Eight patients were found tumor recurrence after the operation during the follow-up period of 1-44 months.Conclusion:Total transperitoneal laparoscopic nephroureterectomy is a safe and effective treatment of upper urinary tract urothelial carcinoma.Cutting off the medial umbilical fold can increase the operating space and reduce the difficulty of the operation before the management of ureteral terminal.
Objective:To verify the surgical skills of total transperitoneal laparoscopic nephroureterectomy(ttLNU)in the management of ureteral terminal and perioperative clinical indicators in the treatment of upper urinary tract urothelial carcinoma(UTUC).Method:From Jan.2012 to Jul.2017,there were 87 UTUC patients treated with ttLNU,including male 43 cases and female 44.The mean average age was(67.25±9.90)years old.Forty-seven cases were diagnosed with renal pelvis carcinoma,10 cases were diagnosed with renal pelvic and ureteral carcinoma,30 cases were diagnosed with ureteral carcinoma(12 for upper ureteral carcinoma,9 cases for middle ureteral carcinoma,11 cases for lower ureteral carcinoma).There were 49 in the left and 38 in the right.The mean diameter of the tumor was(3.24±1.47)cm.Patients were put on lateral position and the position was not changed during the operation.This group of cases was retrospectively summarized including operative time,blood loss,blood transfusion,drainage time,catheterizing days,postoperative complications and hospital stays.Result:The ttLNU procedures were successfully performed in all cases without conversion to open surgery.The mean operation time was(162.50±45.64)min.The median blood loss was(113.33±59.74)ml.No transfusions were needed.The mean drainage time was(4.56±1.12)d.The mean time with Foley catheter was(5.63±2.17)d.There was no complication during operation.Two cases had complications after operation.All the surgical margins were negative.Postoperative TNM stages were T1-T4 N0 M0(T124,T219,T337,T47).Eight patients were found tumor recurrence after the operation during the follow-up period of 1-44 months.Conclusion:Total transperitoneal laparoscopic nephroureterectomy is a safe and effective treatment of upper urinary tract urothelial carcinoma.Cutting off the medial umbilical fold can increase the operating space and reduce the difficulty of the operation before the management of ureteral terminal.
引文
1 Rouprêt M,Zigeuner R,Palou J,et al.European guidelines for the diagnosis and management of upper urinary tract urothelial cell carcinomas:2011update[J].Eur Urol,2011,4(59):584-594.
2 Ristau B T,Tomaszewski J J,Ost M C.Upper tract urothelial carcinoma:current treatment and outcomes[J].Urology,2012,79(4):749-756.
3 Ni S,Tao W,Chen Q,et al.Laparoscopic Versus Open Nephroureterectomy for the Treatment of Upper Urinary Tract Urothelial Carcinoma:A Systematic Review and Cumulative Analysis of Comparative Studies[J].Eur Urol,2012,61(6):1142-1153.
4 Walton T J,Novara G,Matsumoto K,et al.Oncological outcomes after laparoscopic and open radical nephroureterectomy:results from an international cohort[J].BJUInt,2011,108(3):406-412.
5吕东,窦科,向颖,等.经腹腔与经后腹腔途径行腹腔镜上尿路尿路上皮癌根治性切除术的疗效比较[J].临床泌尿外科杂志,2016,31(11):979-981.
6柏宏伟,钱叶勇,石炳毅,等.全腹腔镜根治性肾输尿管全长切除术治疗肾移植术后上尿路肿瘤[J].临床泌尿外科杂志,2013,28(4):255-257.
7荣石,石冰冰,严维刚,等.后腹腔镜下肾盂、输尿管癌根治性切除术87例分析[J].中华外科杂志,2009,47(23):1834-1835.
8刘荣耀,赵鹏举,李学松,等.经腹腔完全腹腔镜肾输尿管全长切除术治疗上尿路尿路上皮癌[J].北京大学学报(医学版),2011,43(4):531-534.
9王鑫,高平生,朱刚,等.完全腹腔镜下肾、输尿管及膀胱袖状切除术治疗上尿路肿瘤的临床研究[J].中华泌尿外科杂志,2015,36(3):196-199.
10 Li C C,Chang T H,Wu W J,et al.Significant predictive factors for prognosis of primary upper urinary tract cancer after radical nephroureterectomy in Taiwanese patients[J].Eur Urol,2008,54(5):1127-1134.
11杨典东,高振利,林春华,等.腹腔镜手术治疗上尿路移行细胞癌不同路径的选择和应用[J].中华泌尿外科杂志,2008,29(11):759-762.
12周利群,杨昆霖,姚林,等.IUPU完全腹膜后镜肾输尿管全长切除术治疗上尿路上皮[J].泌尿外科杂志(电子版),2015,7(3):13-15.
13 Seisen T,Granger B,Colin P,et al.A Systematic Review and Meta-analysis of Clinicopathologic Factors Linked to Intravesical Recurrence After Radical Nephroureterectomy to Treat Upper Tract Urothelial Carcinoma[J].Eur Urol,2015,67:1122-1133.
14 Fradet V,Mauermann J,Kassouf W,et al.Risk factors for bladder cancer recurrence after nephroureterectomy for upper tract urothelial tumors:results from the Canadian Upper Tract Collaboration[J].Urol Oncol,2014,32(6):839-845.
15 O'Brien T,Ray E,Singh R,et al.Prevention of bladder tumours after nephroureterectomy for primary upper urinary tract urothelial carcinoma:aprospective,multicentre,randomised clinical trial of a single postoperative intravesical dose of mitomycin C(the ODMIT-C Trial)[J].Eur Urol,2011,60(4):703-710.
16 Xylinas E,Kluth L A,Crivelli J J,et al.Impact of statin use on oncologic outcomes of patients with upper tract urothelial carcinoma treated with radical nephroureterectomy[J].Eur Urol,2013,63(6):1134-1135.
2 Ristau B T,Tomaszewski J J,Ost M C.Upper tract urothelial carcinoma:current treatment and outcomes[J].Urology,2012,79(4):749-756.
3 Ni S,Tao W,Chen Q,et al.Laparoscopic Versus Open Nephroureterectomy for the Treatment of Upper Urinary Tract Urothelial Carcinoma:A Systematic Review and Cumulative Analysis of Comparative Studies[J].Eur Urol,2012,61(6):1142-1153.
4 Walton T J,Novara G,Matsumoto K,et al.Oncological outcomes after laparoscopic and open radical nephroureterectomy:results from an international cohort[J].BJUInt,2011,108(3):406-412.
5吕东,窦科,向颖,等.经腹腔与经后腹腔途径行腹腔镜上尿路尿路上皮癌根治性切除术的疗效比较[J].临床泌尿外科杂志,2016,31(11):979-981.
6柏宏伟,钱叶勇,石炳毅,等.全腹腔镜根治性肾输尿管全长切除术治疗肾移植术后上尿路肿瘤[J].临床泌尿外科杂志,2013,28(4):255-257.
7荣石,石冰冰,严维刚,等.后腹腔镜下肾盂、输尿管癌根治性切除术87例分析[J].中华外科杂志,2009,47(23):1834-1835.
8刘荣耀,赵鹏举,李学松,等.经腹腔完全腹腔镜肾输尿管全长切除术治疗上尿路尿路上皮癌[J].北京大学学报(医学版),2011,43(4):531-534.
9王鑫,高平生,朱刚,等.完全腹腔镜下肾、输尿管及膀胱袖状切除术治疗上尿路肿瘤的临床研究[J].中华泌尿外科杂志,2015,36(3):196-199.
10 Li C C,Chang T H,Wu W J,et al.Significant predictive factors for prognosis of primary upper urinary tract cancer after radical nephroureterectomy in Taiwanese patients[J].Eur Urol,2008,54(5):1127-1134.
11杨典东,高振利,林春华,等.腹腔镜手术治疗上尿路移行细胞癌不同路径的选择和应用[J].中华泌尿外科杂志,2008,29(11):759-762.
12周利群,杨昆霖,姚林,等.IUPU完全腹膜后镜肾输尿管全长切除术治疗上尿路上皮[J].泌尿外科杂志(电子版),2015,7(3):13-15.
13 Seisen T,Granger B,Colin P,et al.A Systematic Review and Meta-analysis of Clinicopathologic Factors Linked to Intravesical Recurrence After Radical Nephroureterectomy to Treat Upper Tract Urothelial Carcinoma[J].Eur Urol,2015,67:1122-1133.
14 Fradet V,Mauermann J,Kassouf W,et al.Risk factors for bladder cancer recurrence after nephroureterectomy for upper tract urothelial tumors:results from the Canadian Upper Tract Collaboration[J].Urol Oncol,2014,32(6):839-845.
15 O'Brien T,Ray E,Singh R,et al.Prevention of bladder tumours after nephroureterectomy for primary upper urinary tract urothelial carcinoma:aprospective,multicentre,randomised clinical trial of a single postoperative intravesical dose of mitomycin C(the ODMIT-C Trial)[J].Eur Urol,2011,60(4):703-710.
16 Xylinas E,Kluth L A,Crivelli J J,et al.Impact of statin use on oncologic outcomes of patients with upper tract urothelial carcinoma treated with radical nephroureterectomy[J].Eur Urol,2013,63(6):1134-1135.