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改良经腹腹腔镜肾盂成形术联合孙氏镜治疗UPJO合并肾结石的初步经验

Initial experience of modified transperitoneal laparoscopic pyeloplasty combined with a rigid ureteroscope with a deflectable tip(Sun's ureteroscope) for the treatment of ureteropelvic junction obstruction with renal calculi

摘要:

目的 探讨改良经腹腹腔镜肾盂成形术联合末端可弯性输尿管肾镜(孙氏镜)治疗肾盂输尿管连接处梗阻合并肾结石的疗效和安全性.方法 回顾性分析2018年1-9月北京大学第一医院(7例)和海军军医大学长征医院(1例)收治的肾盂输尿管连接处梗阻合并肾结石患者的病例资料,男5例,女3例.年龄14~50岁,平均28岁.临床表现为腰痛4例,腰痛合并血尿1例,余3例无临床表现.体质指数16.8~26.2 kg/m2,平均22.0 kg/m2.病变位于左侧4例,右侧4例.肾盂多发结石1例,肾下盏多发结石4例,肾下盏单发结石3例.结石最大径2~10 mm,平均6.4 mm.轻度肾积水3例,中度肾积水5例.2例肾盂输尿管连接处梗阻合并异位血管.8例均采用IUPU改良经腹腹腔镜肾盂成形术联合孙氏镜治疗.(以左侧为例)取左锁骨中线肋缘下0.5 cm切开腹壁全层置入气腹针,建立气腹.于脐下3 cm、左腹直肌旁1 cm置入12 mm套管,置入腹腔镜.分别于脐上3 cm左腹直肌旁1 cm及左侧反麦氏点置入5 mm、12 mm操作套管,沿气腹针穿刺点处置入5 mm操作套管.于肾下极水平游离、显露肾盂及上段输尿管,于肾盂输尿管连接处梗阻部上方、肾盂下极处斜行剪开肾盂1.0 cm.由脐下12 mm套管置入孙氏镜至肾盂切口,寻找并用套石篮取出结石,然后行IUPU改良经腹腹腔镜肾盂成形术.输尿管内留置F6双J管.结果 本组8例手术均顺利完成,无中转开放手术.手术时间111~185 min,平均135 min.出血量10~ 50 ml,平均38.8 ml.住院时间3~7d,平均4d.术中结石清除率100% (8/8),围手术期未出现并发症.术后随访6~14个月,平均8.9个月.8例症状均缓解,影像学复查示肾积水缓解,末次随访时2例患侧结石复发.结论 改良经腹腹腔镜肾盂成形术联合孙氏镜取石在解除肾盂输尿管连接处梗阻的同时,可以充分取尽结石,易于操作,并发症少.

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abstracts:

Objective To evaluate the efficacy and safety of Institution Urology of Peking University modified technique for transperitoneal laparoscopic pyeloplasty combined with deflectable tip rigid ureteroscope(the Sun's ureteroscope) in ureteropelvic junction obstruction (UPJO) complicated with renal calculi.Methods From January 2018 to September 2018,eight patients,including five males and three females,were diagnosed as UPJO with coexistent ipsilateral renal calculi in Peking University First Hospital and Changzheng Hospital of Second Military Medical University.The age ranged from 14 to 50 years(mean 28 years).Four patients had flank pain and one patient had flank pain with hematuria,while the other three patients came without clinical symptom.The BMI ranged from 16.8 to 26.2 kg/m2 (mean 22.0 kg/m2).The lesion located on the left side in 4 cases and on the right side in 4 cases.One patient suffered with multiple pelvis stones.Four patients suffered with multiple lower calyceal stones,and 3 patients had solitary lower calyceal stone.The stone size ranged from 2 mm to 10 mm (mean 6.4 mm).3 cases had slight hydronephrosis and 5 cases had moderate hydronephrosis.Two patients combined with crossing vessels.All patients underwent modified transperotoneal laparoscopic dismembered pyeloplasty with pyelolithotomy.In cases with left lesion,an incision was made for the veress needle 5mm inferior to the costal margin in the left midclavicular line to establish pneumoperitoneum.A 12-mm camera port was placed 30 mm inferior to the umbilicus and 10 mm lateral to the border of left rectus muscle.Then,a 5 mm operative trocars was inserted at 30mm superior to the umbilicus 10 mm lateral to the border of left rectus muscle.Another 12 mm operative trocar was inserted at the opposite McBurney point.The last 5 mm operative trocar was placed at the veress needle point.After visualizing the pelvis and the proximal ureter at the lower pole of the kidney,a 1.0 cm transverse incision on the lower pole of the pelvis above the obstruction site was made.The Sun's ureteroscope was introduced into the renal pelvis through the 1.0 cm transverse incision via the 12-mm trocar below the umbilicus.Stones in the renal pelvis and calyces were extracted with basket catheters and removed via the port.After the pyelo-nephroscopy,a modified transperitoneal laparoscopic pyeloplasty was made.A F6 double-J stent was inserted into the ureter during the surgery.Result All surgeries were finished successfully without conversion.The surgical duration ranged from 111 to 185 min(mean 135 min).The estimated blood ranged from 10 to 50 ml(mean 38.8 ml).The hospital stay ranged from 3 to 7 days(mean 4 days).The intraoperative stone free rate was 100% (8/8).No perioperative complications occured.With the follow-up from 6 to 14.4 months(mean 8.9 months),there was no evidence of obstruction in all patients,as confirmed by symptoms or radiological improvement of hydronephrosis,and two patients found recurrence of renal calculi.Conclusions Our modified technique for transperitoneal laparoscopic pyeloplasty combined with deflectable tip rigid ureteroscope (the Sun's ureteroscope) is a safe,effective method to manage ureteropelvic junction obstruction with renal calculi.

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