改良的肾盂癌肾输尿管全切术

目的：探讨经尿道输尿管口环切在肾输尿管全切术中的临床应用价值。方法：经尿道输尿管口环切后，作腰部斜切口行肾输尿管全切治疗肾盂移行细胞癌10例，并与传统的双切口肾输尿管全切术进行比较。结果：10例术后无一例出现尿漏，感染，出血等并发症，平均手术耗时2．5h，术后平均住院8d，与双切口术式相比差异有极显著性意义（P＜0．01），术后随访3－20个月，膀胱镜和CT检查未发现肿瘤复发，结论：本改良术式创伤小，并发症少，操作简单，疗效确切，较传统的双切口肾输尿管全切术有明显优点，值得推广应用。     

后腹腔镜联合经尿道输尿管口电切治疗上尿路尿路上皮癌

目的探讨后腹腔镜联合经尿道输尿管口电切行上尿路尿路上皮癌（upper urinary tract urothelial carcinoma,UUT—UC）根治性切除术的疗效。方法2009年4月～2012年1月,对21例UUT—UC采用后腹腔镜联合经尿道输尿管口电切行肾、输尿管、膀胱袖状切除术。先经尿道行输尿管口电切使输尿管与膀胱完全脱离,后腹腔镜下行肾及上段输尿管的游离和切除,取标本同时游离中下段输尿管以完成全程输尿管的切除。结果21例手术均成功,手术时间80～150min,平均110min,术中出血量60～180ml,平均100ml;无严重并发症发生。术后住院8～14d,平均9．5d。病理检查均为UUT—UC,其中肾盂癌15例,输尿管癌6例,20例T1-2N0M0,1例T3N0M0。21例随访4～36个月,平均20个月,均未见肿瘤复发及转移。结论后腹腔镜手术联合经尿道输尿管口电切治疗低级别肾盂癌和上段输尿管癌安全、有效。     

经尿道双极等离子电切镜在肾输尿管全切术中的应用

目的探讨经尿道双极等离子体电切镜行输尿管下段切除在肾盂输尿管癌根治中的应用价值。方法2003年6月～2005年3月，6例输尿管下段、同侧输尿管口及膀胱均未见肿瘤的肾盂输尿管癌，采用经尿道等离子电切镜联合腰部切口5例，后腹膜腹腔镜1例行肾输尿管全切术。结果6例手术顺利。手术时间120—210min，平均150min。术中尢一例发生闭孔神经反射。术后膀胱冲洗，未见出血。留置尿管7～9d。平均8d。1例术后5d拔尿管后出现患侧下腹疼痛、发热，证实少许尿外渗，再次留置尿管5d后，经尿道膀胱造影无渗漏，排尿恢复正常。术后病理结果输尿管残端均阴性。除1例术后3个月死于心肌梗死外，余5例术后随访7～21个月，平均16个月，未见肿瘤复发。结论输尿管下段切除术中应用经尿道双极等离子电切镜微创、无出血、并发症少，是辅助肾盂输尿管癌根治术中行之有效的方法。     

后腹腔镜联合经尿道电切镜治疗上尿路移行细胞癌(附83例报告)

目的 探讨后腹腔镜联合经尿道电切镜治疗上尿路移行细胞癌的效果和安全性. 方法 2003年3月～2006年7月,我院采用后腹腔镜联合经尿道电切镜治疗83例上尿路移行细胞癌.经尿道袖状电切患侧输尿管口周围1.5 cm范围膀胱壁达膀胱外脂肪组织,采用后腹腔镜切除肾及全长输尿管.术后留置导尿管7 d.11例术后辅助放疗. 结果 83例手术均成功.手术时间115～205 min,平均156 min.术中出血50～150 ml,平均80 ml.无术中并发症.术后住院7～11 d,平均8.5 d.病理报告：82例上尿路移行细胞癌,1例肾盂上皮中～重度不典型增生.术后随访3～38个月,平均10.8月.术后12个月内行膀胱镜检查发现膀胱肿瘤6例,其中5例行经尿道膀胱肿瘤电切,1例行腹腔镜根治性膀胱全切术、左侧输尿管皮肤造口术.2例肾盂肿瘤（pT3 G3和pT2 G3）于术后3个月肝转移.2例输尿管中段肿瘤（pT3 G3和pT3 G2～3）术后6个月原位复发并肺转移.1例输尿管下段肿瘤（pT3 G3）术后6个月骨转移.失访1例.其余71例均未发现肿瘤复发、切口转移及远处转移. 结论 对于上尿路移行细胞癌,采用后腹腔镜联合经尿道电切镜行肾、输尿管全切及膀胱袖套状切除具有创伤小、安全、恢复快等优点,值得临床推广应用.     

单切口联合经尿道输尿管袖套切除治疗肾盂、输尿管癌

目的：探讨改良肾盂、输尿管癌手术方式的效果。方法：1998年1月～2005年7月，我院收治肾盂、输尿管癌13例，均先采用腰部切口切除肾脏及大部分输尿管，然后顺输尿管残端插入双J管人膀胱，固定输尿管残端于双J管，再电切患侧输尿管开口及部分膀胱黏膜，袖套样拉下输尿管人膀胱。结果除1例袖套拉出失败改下腹部切口再手术以外，其余12例手术成功，手术时间60～90min，平均78min，术后留置尿管7～9d，平均7．6d，术后住院时间7～10d，平均7．9d。13例随访8～18个月，平均11．5月，均行尿脱落细胞、膀胱镜及B超检查，无肿瘤复发。结论：单一腰部切口联合经尿道输尿管袖套状切除，手术创伤小，术后并发症少，恢复快。     

输尿管镜经尿道电切术治疗输尿管口囊肿

目的 探索输尿管口囊肿的内镜治疗新方法，评价输尿管镜经尿道治疗的效果。方法 2003年11月～2006年11月，我院收治此类病例32例，全部行输尿管镜经尿道电切术，与我院前期的20例开放手术对比分析。结果 输尿管镜经尿道电切术的平均手术时间35min，平均住院时间5～6天，手术时间及住院时间小于开放手术，差异有显著性。输尿管镜经尿道电切术后平均随诊18个月，术后输尿管反流，输尿管末端窄及感染的发生率与开放性手术相比，差异无显著性。结论 输尿管镜经尿道电切术治疗输尿管口囊肿方法简单、损伤小、手术效果确切。     

后腹腔镜联合经尿道输尿管口电切术治疗肾盂输尿管肿瘤(附17例报告)

目的:评估后腹腔镜联合经尿道输尿管口电切术治疗肾盂、输尿管肿瘤的临床疗效。方法:2008年10月至2013年1月为17例肾盂或输尿管移行细胞癌患者行后腹腔镜根治性肾输尿管切除术,其中肾盂癌11例,输尿管癌6例。经尿道袖状电切患侧输尿管口周围1 cm范围膀胱壁,采用后腹腔镜切除肾及全长输尿管,完整取出切除的肾输尿管。术后常规吡柔比星膀胱灌注。结果:手术时间平均(186.9±30.2)min;术中出血量平均(110.1±38.6)ml;术中、术后未发生明显并发症。术后随访3～51个月,1例发生膀胱移行细胞癌。结论:后腹腔镜联合经尿道电切镜治疗肾盂癌、输尿管癌具有手术损伤小、康复快等优点,且不增加肿瘤种植风险,临床应用前景良好。     

后腹腔镜联合膀胱电切镜治疗上尿路移行细胞癌

目的 介绍后腹腔镜行肾输尿管全长及膀胱袖状电切治疗上尿路移行细胞癌的经验.方法 经后腹腔镜施行肾输尿管全长及膀胱袖状切除术32例.其中输尿管肿瘤20例,肾盂肿瘤12例.肿瘤位于右侧17例,左侧15例.2例输尿管肿瘤合并膀胱肿瘤.经尿道电切镜距输尿管口约0.5 cm环形切透膀胱全层,对输尿管末端电灼彻底封闭输尿管开口.输尿管末端电切结束退出电切镜后留置尿管.采用腰部3个穿刺套管针入路,行根治性肾切除,输尿管尽量向下游离,下腹部行5～9 cm切口,取出.肾标本,然后行下端输尿管及膀胱袖状切除.结果 31例手术顺利,1例术前有经皮肾镜术史,术中发生十二指肠瘘,手术中转开放修补十二指肠,术后恢复顺利.手术时间2.0～6.5 h,平均3.5 h.出血量25～1 500 ml,平均163 ml.术后随访2～36个月.29例患者无瘤存活;1例患者术后2个月发生膀胱、盆腔转移,目前带瘤存活;1例患者术后2年发生膀胱肿瘤,电切后无瘤存活;1例患者术后第3个月死于心脏疾病.结论 经后腹腔镜手术治疗肾盂和输尿管肿瘤,切口明显小于开放手术,术后恢复快.用电切镜环状切除输尿管末端可完整切除输尿管.     

经尿道电切治疗输尿管开口肿瘤65例报告

目的探讨经尿道电切治疗输尿管开口肿瘤的临床疗效。方法输尿管开口肿瘤65例，采用经尿道电切术，术后配合应用膀胱灌注化疗药物。结果手术时间5～90min，平均35min，术中出血量5～100ml，平均50ml。术中和术后无一例输血及死亡。65例中移行细胞瘤Ⅰ级43例，Ⅱ级10例，乳头状瘤12例。65例随访6～24个月，平均15个月，术后尿道狭窄4例，扩张治疗后治愈。肿瘤复发5例，复发部位均在膀胱三角区及侧壁，再次行经尿道电切术，术后更换灌注化疗药物，随访10～20个月，平均15个月，无复发。结论经尿道电切术治疗单纯输尿管开口肿瘤，疗效确切，值得推广应用。     

经尿道电切术治疗成人输尿管囊肿（附19例报告）

目的探讨经尿道电切术治疗成人输尿管囊肿的疗效。方法2000年9月～2008年10月采用经尿道电切治疗19例成人输尿管囊肿,其中单纯囊肿15例,合并结石4例。采用德国Storz膀胱电切镜,用电切环沿囊肿口切除囊壁1～1.5cm,再将电切环方向朝上,将囊肿下半部分切除,使残留的囊肿上半部分成为舌状壁瓣。4例合并囊内结石,切开囊壁后结石进入膀胱,导入钬激光光纤将结石击碎,用Ellik将结石碎末冲吸出。结果19例手术均一次成功,手术时间20～35min,平均28.6min。术后住院4～7d,平均4.5d。19例术后随访3～36个月,平均8.6月,临床症状均消失,静脉肾盂造影10例肾积水者积水消失,2例未显影的重度肾积水,12个月肾盂输尿管可见造影剂充盈,所有病例均未见输尿管返流。结论经尿道电切术治疗成人输尿管囊肿,创伤小,疗效满意。     

后腹腔镜肾输尿管全长与膀胱袖状切除术的三种术式比较（附110例报告）

目的：探讨后腹腔镜肾输尿管全长与膀胱袖状切除的最佳手术方式.方法：对110例肾盂或输尿管癌伴膀胱癌患者采用三种不同术式行肾输尿管全长及膀胱袖状切除术：A术式即后腹腔镜肾输尿管全长切除＋下腹部切口膀胱壁内段袖状切除术,共行32例 B术式即后腹腔镜肾输尿管全长切除＋经尿道电切膀胱袖状切除＋经腹部切口取肾术,共行19例 C术式即经尿道电切膀胱袖状切除＋后腹腔镜肾输尿管全长切除＋经腹部切口取肾术,共行59例.结果：手术经过均顺利.三种术式的手术时间、术中出血量、平均住院时间差异无统计学意义.围手术期死亡3例.出院后获定期随访58例,随访8～85个月,平均38.3个月,46例失访.因肿瘤转移死亡4例,因气胸、脑血管病死亡各1例.三种术式术后早期并发症、对侧病变、膀胱痛复发情况差异无统计学意义 但C术式术后死亡及转移例数较少.结论：肾盂或输尿管癌伴膀胱癌者可优先选择经尿道电切膀胱袖状切除＋后腹腔镜肾输尿管全长切除＋经腹部切口取肾术,而仅有肾盂或输尿管癌者可考虑行后腹腔镜肾输尿管全长切除＋下腹部切口膀胱壁内段袖状切除术.     

Transurethral ureterocystostomy

Management of distal ureteric obstruction because of impacted stone, malignancy or scarred orifice using conventional methods may be cumbersome or may fail. Transurethral ureterocystostomy, performed by direct vision using resectoscope and Colling's knife in combination with fluoroscopic X-ray control, has solved the problem in seven patients with stones, two with prostatic cancer and one with scarred orifice. Thus, temporary or permanent transurethral ureterocystostomy can be recommended in selected cases of obstruction of the distal ureter by stone, malignancy or scar.     

后腹腔镜肾输尿管切除治疗肾盂癌22例

目的评价后腹腔镜肾输尿管切除术治疗肾盂癌的疗效。方法2002年12月-2005年11月，我院行后腹腔镜肾输尿管切除治疗肾盂癌22例。膀胱镜袖状切除患侧输尿管口，后腹腔镜切除患肾，并于下腹部做切口，将患肾、输尿管全部切除，取出。结果22例手术均获得成功。手术时间2～5h，平均4．3h。出血量50～600ml，平均187ml。引流量50～200ml/d，平均120ml/d，术后24-48h拔除引流管。住院时间8-13d，平均10d。22例均为肾盂移行细胞癌。22例随访1-24个月，平均14个月，均未复发。结论后腹腔镜肾输碌管切除治疗肾盂癌，可取得满意的效果，旦手术创伤小，恢复快，值得临床推广。     

A case of primary ureteral carcinoma in the duplicated renal pelvis and ureter diagnosed by transurethral uretero-renoscopy

We present a case of primary ureteral carcinoma in the duplicated renal pelvis and ureter diagnosed by transurethral uretero-renoscopy. The case was of a 78-year-old man with the complaint of sudden asymptomatic macrohematuria. An excretory urogram strongly suggested the presence of duplication of the right collecting system, and cystoscopy revealed a gross hematuria from the right ureteral orifice. A retrograde ureteropyelogram revealed incomplete duplication of the right renal pelvis and ureter fused at about the ureter crossing over the iliac vessels, and a polyp-like filling defect in the lower segment of duplicated ureter at about 4 cm from the fusion of the ureters. Transurethral uretero-renoscopy was employed to investigate the filling defect, and a papillary tumor extended into the lower segment of duplicated ureter was revealed. Tumor was resected by a rigid operating instrument under transurethral uretero-renoscopy. The pathological diagnosis was grade I-transitional cell carcinoma of the ureter, so that right total nephroureterectomy with partial cystectomy was carried out subsequently. Surgical specimen after right total nephroureterectomy with partial cystectomy showed no other tumor in the pelvis or ureter macroscopically, and histopathological studies of surgical specimens were no evidence of malignancy. We believe that transurethral uretero-renoscopy significantly increases the diagnostic accuracy in determining the nature of upper urinary tract lesions, and this procedure is indispensable in the diagnosis of ureteral tumors. The present case was the 7th case of primary ureteral carcinoma in the duplicated renal pelvis and ureter in the Japanese literature.     

Modified nephroureterectomy: a risk of tumour implantation

The standard surgical management of patients presenting with transitional cell carcinoma of the upper urinary tract is nephroureterectomy with excision of a cuff of bladder around the ureteric orifice. Recently a modified technique of resecting the lower ureter endoscopically and completing the nephroureterectomy through a single loin incision has been advocated as a safe and simple procedure. We consider that this technique may have a risk of tumour implantation at the site of the resected lower ureter. We report our experience of this operation in five patients, two of whom developed invasive tumour at the site of the ureteric orifice after only a short follow-up.     

Hand-assisted laparoscopic nephroureterectomy with open cystotomy for removal of the distal ureter and bladder cuff

BACKGROUND AND PURPOSE: While performing laparoscopic nephroureterectomy, different techniques are used for removal of the distal ureter and bladder cuff. We present a series of patients with urothelial carcinoma of the renal pelvis or ureter who underwent hand-assisted laparoscopic nephroureterectomy (HALNU) with open cystotomy for removal of the distal ureter and bladder cuff. PATIENTS AND METHODS: From January 2000 to August 2004, 34 patients underwent HALNU. The hand-port device was placed in a lower-midline infraumbilical incision in all cases. After laparoscopic removal of the kidney and ureter down to the bladder, the hand port incision was extended caudally to allow open cystotomy. Intravesical dissection was performed at the ureteral orifice, and the bladder cuff and distal ureter were removed in a traditional open fashion. RESULTS: The mean operative time was 317 +/- 150 (SD) minutes, but the median operative time was 247 minutes. The mean estimated blood loss was 252 +/- 146 mL. The mean length of stay was 7.6 +/- 6.0 days, but the median stay was 5 days postoperatively (range 3-25). The mean morphine equivalent required postoperatively was 33 +/- 22 mg. The time of Foley catheter removal ranged from 3 to 15 days (mean 6.1 +/- 3.8 days), with no cases of extravasation by cystography at removal. Within a mean follow-up of 13.9 months, no recurrence of urothelial carcinoma was seen at the site of the excised ureteral orifice. CONCLUSION: A HALNU utilizing an open cystotomy for removal of the entire distal ureter with a bladder cuff provides excellent oncologic control while not adding significantly to the operative time or the morbidity of the procedure.     

腹腔镜膀胱壁瓣法输尿管膀胱再植术

目的 探讨腹腔镜膀胱壁瓣法输尿管膀胱再植术的可行性和临床疗效。方法 采用经腹腔途径施行腹腔镜膀胱壁瓣法输尿管膀胱再植术治疗输尿管出口梗阻9例。左侧1例，右侧7例，双侧1例。4例为单纯性输尿管出口狭窄，1例输尿管出口狭窄伴对侧输尿管结石，1例输尿管出口狭窄者经尿道钬激光切开术后1年出现再次狭窄，1例为开放输尿管膀胱再植术后再发输尿管出口狭窄，1例为泌尿系结核左肾切除术后右侧输尿管出口狭窄，1例为右卵巢囊肿术后双侧输尿管出口梗阻伴发急性肾衰竭2周。B超和IVU检查示重度肾积水6例7侧，中度肾积水3例。结果 9例手术均顺利。手术耗时115～180min/侧，平均132min／侧。术中出血40～150ml，平均62ml。术后1～3d拔除膀胱外引流管下地活动，无一例漏尿。术后1周拔除导尿管，7—14d出院，平均住院时间8d。术后1个月拔除双J管。术后3～6个月膀胱造影显示I度双侧输尿管返流1例，无返流8例。随访3～16个月，B超和IVU、MRU复查无吻合口狭窄，肾积水均得到明显改善，中度肾积水者2例，轻度肾积水者4例，无明显肾积水者3例。结论 腹腔镜膀胱壁瓣法输尿管膀胱再植术手术效果好，抗返流效果佳，刨伤小，是治疗输尿管出口病变的微创新途径。