阶梯式手术培训模式在输尿管软镜教学中的应用

目的介绍我中心阶梯式手术培训模式在输尿管软镜教学的初步探索经验。 方法根据随机数字表的方式,将2015年5月至2018年5月期间,在南昌大学第四附属医院进修并接受输尿管软镜培训的泌尿外科医师随机分为阶梯式培训组和传统教学组,每组学员各20名。传统培训模式学员,直接进入临床培训阶段;阶梯式培训模式在学员进入临床培训前,需经过理论学习、体外训练、动物操作三个阶段。学员在前一阶段的学习后,经过考核方可进入下一阶段培训。 结果两组学员年龄、学历、职称及有无输尿管镜手术经验上差异无统计学意义。通过系统培训,两组共40名成员均可在导师指导下独立完成输尿管软镜手术。两组学员治疗结石患者年龄、性别及结石负荷差异无统计学意义。手术培训时间（月）、手术培训例数（例）,首例独立完成手术时间和学员评分四项指标差异有统计学意义。术中未发生结石移位,无输尿管穿孔,无结石残留。阶梯培训组,术后并发泌尿系感染1例,给与常规抗感染治疗后好转。 结论通过输尿管软镜碎石术的阶梯式培训模式,可以缩短手术培训时间,减少手术培训例数,降低首例手术时间,增加学员评分。     

输尿管镜在治疗输尿管疾病中的应用

应用输尿管硬镜和气压弹道式碎石机治疗输尿管结石和狭窄５８例，术中全部病例均放置内支架管或外支架管引流。结果５６例获得成功，２例失败，成功率达９６％，且均无术中并发症发生，认为输尿管镜和ＥＳＷＬ相互配合，可互相补充各自的不足，可以使大多数输尿管结石及狭窄患者免除手术创伤的痛苦，在泌尿外科有着广泛的应用前景。     

输尿管抓钳在输尿管镜手术中的应用

目的探讨输尿管抓钳在输尿管镜手术中的应用. 方法回顾分析我院2001年4月～2003年7月74例输尿管镜手术中输尿管抓钳的应用,包括摘除息肉再行气压弹道碎石25例,作为硬质导引通过输尿管扭曲部21例,扩张输尿管狭窄部通过输尿管镜再行碎石19例,输尿管完全性膜状闭塞3例,治疗术后双J管上移3例,术中活检2例,尿道狭窄拔除双J管4例,尿道结石气压弹道碎石2例. 结果 69例获成功.抓钳故障改开放手术1例,输尿管穿孔4例. 结论输尿管抓钳是输尿管镜手术中不可缺少的工具,灵活运用有利于手术的顺利进行.     

纤维输尿管镜的临床应用：附26例报告

报告用纤维输尿管镜治疗输尿管结石15例,行输尿管狭窄扩张术4例,行输尿管疾病检查7例。阐述了纤维输尿管镜的使用方法和取石效果,指出纤维输尿管镜与ESWL综合治疗输尿管结石能提高治疗效果。     

经尿道输尿管镜技术在泌尿外科的应用(附1100例报告)

目的探讨输尿管镜技术在泌尿外科疾病诊治中的临床应用价值。方法2003年1月至2005年6月应用经尿道输尿管镜技术诊断和治疗泌尿系疾病患者1100例。其中行输尿管镜治疗者1010例，包括输尿管结石945例1000侧，其中上段结石68例侧、中段360例370侧、下段517例562侧；输尿管狭窄20例侧；医原性双J管滞留28例；小儿后尿道狭窄2例、后尿道瓣膜症2例、下尿路结石3例、小儿逆行输尿管插管8例侧、内支架管置入2例侧。用于泌尿系疾病诊断90例侧。结果输尿管下段结石取石成功率为97．3％（547／562）；中段为93．0％（344／370）；上段为73．5％（50／68）。输尿管狭窄及小儿后尿道狭窄扩张、小儿后尿道瓣膜症等疾病疗效满意。用于诊断的90例患者中，发现肿瘤8例、阴性结石40例、息肉12例、腺性输尿管炎4例、输尿管狭窄12例、无阳性发现13例。手术失败12例。发生严重手术并发症30例，发生率2．7％（30／1100），其中输尿管高位横断拖出2例、穿孔10例、假道12例、黏膜撕脱3例、严重出血3例。结论只要熟练掌握，输尿管镜技术的并发症发生率较低，对输尿管下段结石可作为首选治疗措施，对其他疾病尤其是小儿患者有独特优势。     

输尿管镜在输尿管梗阻中的诊治价值

目的探讨输尿管镜在输尿管梗阻诊治中的价值.方法应用输尿管镜对52例非结石性输尿管梗阻进行诊治.结果输尿管狭窄35例(行输尿管镜硬性扩张19例,气囊扩张13例,腹腔镜下输尿管成形术3例),输尿管息肉13例行钬激光切除,输尿管癌3例改行开放手术,腔静脉后输尿管1例改行输尿管成形术.手术并发黏膜明显裂伤或黏膜下假道2例,输尿管穿孔1例,其它并发症.结论输尿管镜术能明确输尿管梗阻的病因,并能采取相应治疗.     

输尿管镜在原发性输尿管肿瘤诊断中的应用

近年来,原发性输尿管恶性肿瘤发病率有增高趋势,可能与发病者增多和诊断水平提高有关。其中移行细胞癌占绝大多数,其次为腺癌、鳞癌、未分化癌等。现将我们近年来诊治并经手术、病理证实的7例病例资料报告如下。     

虚拟模拟器在输尿管镜培训中应用的初步探讨

目的 评估虚拟模拟器UroMentorTM在输尿管镜培训中的应用价值. 方法 30名泌尿外科医师按单独完成输尿管镜例数＜ 20例和≥20例分成2组,分别为18名及12名.应用左输尿管下段取石模拟操作进行初评,包括:总操作时间、输尿管插管时间、损伤致出血点的数目、尝试插管次数以及综合总体评分(GRS),连续训练48 h后复评并与初评比较. 结果 经过模拟器训练后所有受试者总操作时间明显缩短[( 333±32)s及(228±18)s,P=0.001],GRS评分明显改善(24.4±2.1及28.1±1.2,P=0.010).少(无)经验组和有经验组初评总操作时间[(405±40)s及(262±22)s,P=0.014]、复评总操作时间[(276±12)s及(179±9)s,P=0.000]及初评GRS评分(19.6±2.5及29.2±1.3,P＝0.009)、复评GRS评分(25.0±1.1及31.2±0.7,P=0.002)差异均有统计学意义.独立完成的输尿管镜例数与GRS评分相关(初评r=0.705,复评r=0.756). 结论虚拟模拟器URO MentorTM可以成为输尿管镜技能培训及评估的有效工具.     

输尿管镜在580例输尿管疾病中的临床应用

目的　探讨输尿管镜处理输尿管疾病的临床价值。方法　回顾性分析 1997年 1月～ 2 0 0 4年 1月 5 80例输尿管结石、异物以及不明原因的血尿、肾积水采用输尿管镜诊治的临床资料。结果　输尿管镜用于诊断 79例 ,全部成功。治疗输尿管结石成功率为 92 .3 % ( 4 17/4 5 2 ) ,治疗输尿管狭窄 2 3例 ,取医源性输尿管双J管滞留 2 6例。其它疾病的疗效均满意。发生并发症 2 0例 ,占 3 .1%。结论　输尿管镜在输尿管疾病的诊治中具有重要临床应用价值。     

Training on bench models improves dexterity in ureteroscopy

INTRODUCTION: There is a need for alternative training in endourology. Computerised simulators have been introduced but have, so far, not been compared to real surgery. Bench models have proved to be comparable to real surgery when performing standard procedures in the upper urinary tract. OBJECTIVE: To validate training on bench models as a tool to improve dexterity in semi-rigid ureteroscopy. METHODS: Urology residents were tested when performing semi-rigid ureteroscopy on a bench model (Mediskills), before and after training. All standard equipment and instruments, including fluoroscopy, were available. For the test procedure we used a task-specific checklist and a global score (maximum score 10 + 9 = 19). After base line assessment, the participants practised under supervision. After training they were reassessed, using the same procedure as previously. RESULTS: The performance was significantly better after the training. Results before/after were: 5.1/9.2, 2.6/7.8 and 7.7/17.2 for task-specific checklist, global score and total score respectively. All residents felt more familiar with the instruments and the procedure after the training. CONCLUSION: Training on bench models for ureteroscopy enhanced the manual dexterity as well as familiarity with the method and is recommendable before operating on patients.     

Day-case rigid and flexible ureteroscopy

INTRODUCTION

The aim of this study was to evaluate the feasibility of rigid and flexible ureteroscopy as a day-surgery procedure.

PATIENTS AND METHODS

All patients requiring elective ureteroscopy from March 2004 were considered for a day-surgery procedure. The standard day-surgery exclusions existed but there were no urological criteria for exclusion. A single consultant urologist performed or supervised all procedures.

RESULTS

A total of 64 patients underwent 50 rigid and 14 flexible procedures. Six diagnostic ureteroscopies were performed. There was a 96% stone clearance rate. Five patients required an unplanned admission within the first 2 weeks'' postoperatively. Three of these patients were admitted on the day of surgery, two for pain and one for social reasons. Two patients were admitted at 24 h and 48 h, respectively, for urinary retention.

CONCLUSIONS

Ureteroscopy, both rigid and flexible, is a safe procedure for the day-surgery setting. Routine use of prophylactic antibiotics, intravenous non-steroidal anti-inflammatory drugs resulted in an acceptable re-admission rate.     

Advances in ureteroscopy

Ureteroscopy (URS) is a procedure which has been constantly evolving since the development of first generation devices 40 years ago. Progress towards smaller and more sophisticated equipment has been particularly rapid in the last decade. We review the significant steps that have been made toward improving outcomes and limiting morbidity with this procedure which is central to the management of urolithiasis and other upper urinary tract pathology.     

对无管化输尿管镜碎石取石术的探讨

目的 探讨输尿管镜碎石取石术处理简单输尿管下段结石后不留置双J管与尿管的初步经验.方法 回顾性分析从2009年1月至2012年10月对64例简单输尿管下段结石患者行输尿管镜碎石取石术的临床资料,患者被分为两组:对照组32例(放置双J管);观察组32例(不放置双J管与尿管).结果 放置双J管组手术时间显著长于无管化组;无管化组术后患者腰痛、血尿、膀胱刺激征的发生率低于放置双J管组,两组之间有显著性差异(P＜0.05);术后1个月输尿管无石率无统计学差异(P＞0.05).结论 输尿管镜碎石取石术治疗简单输尿管下段结石,可不必常规留置双J管与尿管,创伤轻,痛苦少,恢复快.     

Comparing the reported burn conditions for different severity burns in porcine models: a systematic review

There are many porcine burn models that create burns using different materials (e.g. metal, water) and different burn conditions (e.g. temperature and duration of exposure). This review aims to determine whether a pooled analysis of these studies can provide insight into the burn materials and conditions required to create burns of a specific severity. A systematic review of 42 porcine burn studies describing the depth of burn injury with histological evaluation is presented. Inclusion criteria included thermal burns, burns created with a novel method or material, histological evaluation within 7 days post‐burn and method for depth of injury assessment specified. Conditions causing deep dermal scald burns compared to contact burns of equivalent severity were disparate, with lower temperatures and shorter durations reported for scald burns (83°C for 14 seconds) compared to contact burns (111°C for 23 seconds). A valuable archive of the different mechanisms and materials used for porcine burn models is presented to aid design and optimisation of future models. Significantly, this review demonstrates the effect of the mechanism of injury on burn severity and that caution is recommended when burn conditions established by porcine contact burn models are used by regulators to guide scald burn prevention strategies.     

输尿管镜手术上镜困难的原因与对策

目的：探讨输尿管镜手术时上镜困难的原因与对策。方法：报告在收治的182例输尿管镜手术患者中24例上镜困难者的临床资料。结果：10例是采用技巧性的旋转及变换角度才获入镜;14例有不同程度的狭窄或迂曲,经扩张或调整体位后有12例成功,1例中转开放,1例插管后行ESWL。结论：克服输尿管上镜困难的重要措施是熟悉输尿管解剖与熟练技巧性操作,术中防止输尿管穿孔及粘膜撕脱尤其重要。     

输尿管镜手术并发症分析与防治

目的：总结输尿管镜手术并发症及其防治措施。方法：：对250例应用输尿管镜手术患者临床资料进行回顾性分析，统计术中、术后发生的各种并发症及其处理方法。结果：术中输尿管穿孔3例（1．20％），1例改行开放手术，2例经留置双J管保守治疗；术后肉眼血尿173例（69．2％），应用止血药物对症治疗1～2天后血尿消失；术后腰痛41例（16．4％），其中肾绞痛5例（2．0％），针对引起腰痛的不同原因进行相应处理；感染9例（3．6％），经抗感染和拔除双J管等治疗后恢复；结石残留28例（占输尿管结石患者12．4％），子保留双J管行ESWL治疗后痊愈。结论：应用输尿管镜手术成功率高。严重并发症较少见，且绝大多数行保守治疗可得到解决；熟练的手术操作是减少输尿管镜手术并发症的关键。     

输尿管硬镜在治疗输尿管疾病中的应用(附58例报告)

应用输尿管硬镜和气压弹道式碎石机治疗输尿管结石和狭窄58例，术中全部病例均放置内支架管或外支架管引流。结果56例获得成功，2例失败，成功率达96％，且均无术中并发症发生。认为输尿管镜和ESWL相互配合，可互相补充各自的不足，可以使大多数输尿管结石及狭窄患者免除手术创伤的痛苦，在泌尿外科有着广泛的应用前景。     

Laparoscopic distal pancreatectomy in the porcine model

Our aim was to assess the feasibility and safety of laparoscopic distal pancreatectomy in an animate model. After developing the technique in acute animal experiments, laparoscopic distal pancreatectomy was performed in five young domestic pigs. Five trocars were used (2–10 mm, 2–12 mm, 1–11 mm) for video laparoscopic access to the peritoneal cavity. The operations were performed without complication in 62-95 min (mean±SEM, 77±7 min). Each animal tolerated oral feedings on the first postoperative day and subsequently gained 6–11 kg (10±2 kg) in the 4-7-week interval prior to sacrifice. Although there was a significant increase in serum amylase on the first postoperative day, this was associated with a comparable increase in hematocrit, possibly representing hemoconcentration. The weight of the laparoscopically resected pancreatic segment ranged from 16 to 36 g (19±2 g) while that of the pancreatic head at sacrifice was 13-29 g (21±3 g). At the time of sacrifice, there were few intraabdominal adhesions and no evidence of fluid collection or pancreatitis. The staple line across the body of the pancreas was grossly intact in all animals. We conclude that laparoscopic distal pancreatectomy in the porcine model is feasible and safe. It may therefore be possible to perform laparoscopic distal pancreatectomy in humans. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Phoenix, Arizona, USA, 3 April 1993     

逆行输尿管镜手术并发症(附2316例报告)

目的 总结分析逆行输尿管镜手术并发症的发生原因及防治措施.方法 对本院2004年10月-2010年10月2316例病人2468次逆行输尿管镜手术的临床资料进行回顾性分析.结果 总的并发症发生率7.1%(165/2316),操作失败78例(3.4%);结石移位至肾盂26例(1.1%);输尿管损伤30例(1.3%),其中膀胱壁内段穿孔形成输尿管黏膜下隧道9例(0.4%)、全层穿孔14例(0.6%)、部分断裂4例(0.2%)、黏膜撕脱3例(0.1%);输尿管内双J管移位10例(0.4%);16例(0.7%)出现早期术后并发症,包括严重感染5例(0.2%),持续较严重的血尿6例(0.3%),较严重的肾绞痛5例(0.2%);5例(0.2%)出现远期并发症,包括输尿管狭窄3例、持续存在膀胱输尿管返流2例.大部分的手术并发症(124例,75.2%)发生在操作者使用输尿管镜的最初2年中.结论 严格掌握手术适应证,提高术中操作技巧,采用正确的对应措施,能有效地减少并发症.

Abstract：

Objectives To summarize the complications of retrograde rigid ureteroscopy as well as their management. Methods A total of 2316 patients accepting retrograde rigid ureteroscopy from Oct 2006 to Oct 2010 were evaluated retropspectively. Results The rate of complications was 7. 1% (165/2316). The complications consisted of the ureteroscopy failure (78 cases, 3.4% ), migration of calcali (26 cases, 1. 1% ), ureteral injury (mucosal false passage [9 cases, 0.4% ], ureteral perforation [ 14 cases, 0.6% ], ureteral part fracture [4 cases,0. 2% ], ureteral avulsion [ 3 cases, 0. 1% ] ), migrated double-J stent ( 10 cases, 0. 4% ). Farly complications were described in 0.7% ( 16 cases): sepsis (5 cases, 0.2% ), serious persistent hematuria (6 cases, 0.3% ), serious renal colic ( 5 cases, 0.2% ). Late complications were ureteral stenosis ( 3 cases, 0. 1% ) and persistent vesicoureteral reflux (2 cases, 0. 1% ). Most (75.2%) of the complications occurred in the first 2 years of that operators used the ureteroscopy. Conclusions Strictly mastering surgical indications, strengthening preoperative training and mastering the surgical technique, taking correct measure is the key to reduce the failure rate and complications of ureteroscopy.