输尿管口附近膀胱肿瘤的手术处理

目的　总结输尿管口附近膀胱肿瘤的手术治疗经验。　方法　需行输尿管再植的膀胱肿瘤患者 4 2例 ,随机分为两组 :A组 2 0例 ,绕输尿管口膀胱壁舌状切除结合改良Huctch Ⅱ输尿管移植 ;B组 2 2例 ,膀胱外寻找并离断输尿管 ,膀胱部分切除术后将输尿管再植于膀胱。对两组手术时间、手术失血量、术后引流量、近期并发症、膀胱输尿管返流、输尿管梗阻及肿瘤复发率进行对比分析。　结果　A组手术时间 (6 0 .5± 18.5 )min、手术失血量 (30 .7± 12 .4 )ml、术后引流量 (5 0 .6± 17.8)ml;B组手术时间 (15 0 .9± 2 2 .4 )min、手术失血量 (2 2 0 .5± 2 8.2 )ml、术后引流量 (2 80 .6± 5 8.9)ml;以上三项指标两组之间差异有显著性意义 (P <0 .0 0 1)。近期并发症A组 2例 ,B组 8例。两组间比较差异有显著性意义 (P <0 .0 5 ) ;膀胱输尿管返流、输尿管梗阻及肿瘤复发率两组比较差异无显著性 (P >0 .0 5 )。　结论　绕输尿管口膀胱舌状切除结合改良Huctch Ⅱ输尿管移植手术效果良好 ,手术并发症少 ,操作简单 ,值得推荐。     

经输尿管镜钬激光碎石术后留置双J管的临床研究

目的 探讨经输尿管镜钬激光治疗输尿管结石术后留置双J管的适应证及其必要性.方法 按病例纳入标准将270例输尿管结石患者随机分成A和B两组,经输尿管镜钬激光碎石术后,A组(135例)不留置双J管,B组(135例)放置双J管4周,比较两组之间的手术时间,术后腰腹部疼痛评分(VAS)、血尿、 尿路感染、膀胱刺激症状及远期输尿管狭窄发生率.结果 A组手术时间较B 组缩短(P<0.05),术后1、3d A组患者腰痛VAS评分与B组比较差异无统计学意义,而术后第7、14天 A组患者腰痛 VAS评分及血尿发生率均明显低于B 组(P<0.01).术后A组患者膀胱刺激症状明显低于B 组(P<0.01),两组尿路感染率差异无统计学意义.术后3个月两组均未出现输尿管狭窄并发症.结论 对于不复杂的输尿管结石,特别是单纯输尿管中下段结石常规放置双J管是不必要的.     

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.     

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。     

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。     

后腹腔镜联合膀胱电切镜对上尿路移行细胞癌根治性治疗的安全性研究

目的探讨后腹腔镜联合膀胱电切镜对肾盂、中上段输尿管移行细胞癌根治性治疗的手术及肿瘤学安全性。方法回顾性分析肾盂、中上段输尿管移行细胞癌患者58例临床资料,后腹腔镜联合膀胱电切镜肾输尿管全长切除组（A组）41例,开放肾输尿管切除组（B组）17例。对其手术效果、并发症及术后肿瘤复发情况进行对比。结果A组和B组手术出血量（98．4和165mL）、术后住院天数（7．1和8．0d）、术后应用止痛药时间（1．2和3．1d）比较,A组优于B组（P〈0．05）;两组手术时间（150和110min）、术后留置尿管时间（6．2和3．5d）比较,A组长于B组（P〈0．05）。A组1例因电切输尿管口出血,中转开放手术。A、B两组并发症发生率（7．3％和11．8％）及肿瘤复发率（14．6％,23．5％）差异均无统计学意义（P均〉O．05）。结论联合尿道电切镜、后腹腔镜肾输尿管切除术与开放手术相比,出血少、术后恢复快、并发症少,未增加术后肿瘤的复发。     

上尿路上皮癌手术中输尿管膀胱壁内段3种切除方法的疗效比较

目的比较开放式袖套状切除、经尿道电切以及经尿道铥激光切除输尿管膀胱壁内段治疗上尿路上皮癌的疗效。方法回顾性分析上海交通大学附属第一人民医院2004年5月至2009年5月利用3种不同方法切除输尿管膀胱壁内段治疗上尿路上皮癌的病例共49例。其中开放性输尿管膀胱壁内段袖套状切除术22例（A组）,经尿道电切镜切除输尿管膀胱壁内段15例（B组）,经尿道铥激光输尿管膀胱壁内段切除12例（C组）。比较3种方法的手术时间、术中失血量、导尿管留置时间、腹膜后引流管留置时间、术后住院时间以及肿瘤复发率。结果B、c两组与A组相比,手术时间明显缩短（平均分别为198、183、262rain,P〈0．05）;术中失血量明显减少（平均分别为140、135、363mL,P〈O．05）;术后住院时间明显缩短（平均10、8、12d,P〈o．05）;而B、C两组之间比较差异无统计学意义（P〉O．05）。3组术后腹膜后引流管与导尿管平均留置时间无明显差异（P〉O．05）。中位随访时间49个月（12～72个月）,其中A组术后膀胱肿瘤复发5例（2互7％）,腹膜后肿瘤复发1例（6．7％）;B组术后膀胱肿瘤复发4例（26．7％）;C组术后膀胱肿瘤复发2例（16．7％）。对比3组术后膀胱肿瘤复发率,差异无统计学意义（P=0．91）。结论与传统开放手术行输尿管膀胱壁内段袖套状切除术相比较,经尿道输尿管膀胱壁内段电切除术或激光切除术手术时间短、术后出血少、恢复快、不增加术后肿瘤种植及复发率。其中经尿道铥激光输尿管膀胱壁内段切除术更具有切割精确、手术安全性高等特点,有较好的临床应用前景。     

输尿管软镜手术中放置输尿管通道鞘引起输尿管壁损伤的研究分析

目的 评估输尿管软镜手术中放置输尿管通道鞘引起的输尿管壁损伤情况,并了解术前留置双J管能否减轻放置输尿管通道鞘引起的输尿管壁损伤.方法 112例进行输尿管软镜下碎石术的患者被随机分为两组,A组先留置双J管,2～3周后再进行输尿管软镜下碎石术,B组则术前不留置双J管而直接手术,比较两组患者输尿管壁损伤情况.结果 在A组患者中,出现低级别(0级+1级)的放置输尿管通道鞘引起的输尿管壁损伤共有53例,高级别(2级+3级+4级)的仅2例,而在B组患者中,出现低级别的放置输尿管通道鞘引起的输尿管壁损伤共有33例,高级别的共有24例,两组间比较有统计学差异(P＜0.05).结论 输尿管软镜术中放置输尿管通道鞘可引起不同程度的输尿管壁损伤,术前留置双J管可明显降低高级别的放置输尿管通道鞘引起的输尿管壁损伤的发生几率.     

后腹腔镜联合尿道电切镜根治性肾输尿管切除治疗上尿路移行细胞癌(附16例报告)

目的 探讨后腹腔镜联合尿道电切镜根治性肾输尿管切除治疗上尿路移行细胞癌的方法和临床疗效. 方法 对10例肾盂癌、6例输尿管上中段移行细胞癌先采用尿道电切镜行患侧输尿管口膀胱黏膜袖套状切除,而后行后腹腔镜根治性肾输尿管全切术. 结果 16例手术均获成功,平均手术时间120 min,术中出血平均80 ml,患者均于术后36～48 h下床活动,术后住院时间8～14 d(平均9.4 d),术后随访膀胱局部复发2例. 结论 后腹腔镜联合尿道电切镜根治性肾输尿管切除治疗上尿路肿瘤是一种安全、有效的微创手术方法,实用性较强,具有良好的应用前景.     

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。     

输尿管镜术中输尿管口丢失的应对策略

目的探讨输尿管镜术中输尿管口丢失的应对方法。方法报告输尿管镜术中因输尿管口丢失而进镜失败的14例患者的处理过程及结果。先采用斜仰卧截石位,实时超声定位下以G18穿刺针朝向肾盂输尿管连接部穿刺患肾中上盏,从针芯中顺行向输尿管内推置亲水导丝,如可见导丝进入膀胱,则沿导丝径路进镜;如导丝无法顺行进入膀胱,则换用经尿道电切镜,薄层电切患侧输尿管口对应部位,显露输尿管壁内段断端,置入亲水导丝后换用输尿管镜进镜。所有患者术后均留置F7双J管1~2根。结果11例肾穿刺顺行置入导丝可见进入膀胱,沿导丝成功进镜入输尿管;3例此法失败者采用输尿管口部位电切法成功进镜。所有患者肾穿刺针和导丝拔除后无大出血,无输尿管穿孔、撕脱等严重并发症,术后2~3个月拔除双J管后未发生输尿管口狭窄。结论输尿管镜术中发生输尿管口丢失,依次采用肾穿刺顺行导丝置入法和输尿管口部位电切法寻找输尿管口成功率高,创伤小,无严重并发症发生。     

Conversion of percutaneous ureteral stent to indwelling pigtail stent over guidewire

A ureteral stent placed percutaneously through a nephrostomy can be readily exchanged endoscopically for a ureteral indwelling pigtail stent over a percutaneous guide wire. Percutaneous antegrade stent placement can sometimes be accomplished when retrograde placement cannot. We report 10 successful conversions to indwelling stent in 11 cases. In 1 case the percutaneous guide wire could not be retrieved endoscopically because of a bleeding tumor in the bladder. No serious difficulties or complications were encountered. The percutaneous approach offers an alternative method of providing internal urinary diversion if retrograde ureteral indwelling stent placement has failed.     

经尿道电切联合双J管置入术治疗输尿管口周围膀胱肿瘤的疗效分析

目的探讨经尿道等离子电切术(PKRBt)联合双J管置入在处理输尿管口周围膀胱肿瘤中的临床效果。 方法回顾性分析我院2011年9月至2017年5月41例输尿管口周围非肌层浸润性膀胱癌（NMIBC）患者的临床资料，其中2014年12月至2017年5月的23例患者作为试验组，手术方式采用PKRBt联合双J管置入术；2011年9月至2014年11月18例患者作为对照组，仅行常规PKRBt术。所有患者术前均经CTU证实无输尿管扩张、肾积水，无上尿路肿瘤，术后均坚持吡柔比星膀胱灌注化疗及膀胱镜定期随访。试验组留置双J管期间，嘱患者口服α受体阻滞剂（坦索罗辛）与M受体阻滞剂（索利那新）改善输尿管支架管相关症状，术后3个月拔除双J管。 结果所有手术均顺利完成，无中转开放，试验组患者在留置双J管期间，联合服用坦索罗辛与索利那新后其输尿管支架管相关性躯体疼痛症状得到明显改善，亦未出现持续的不可耐受的尿频尿急尿不尽等下尿路症状；所有患者在维持膀胱灌注化疗药物期间均无严重不良反应发生。经过4~79个月的随访，试验组均未发生输尿管狭窄或肾积水，膀胱镜下见输尿管口外观及喷尿均正常；对照组3例出现患侧输尿管口瘢痕狭窄，其中2例经行输尿管膀胱再植术，1例经行小儿输尿管镜下狭窄段输尿管扩张术。试验组膀胱肿瘤复发8例，对照组7例，复发部位均不在原电切创面，双J管置入后亦未发现上尿路有肿瘤的种植。 结论针对输尿管口周围的非肌层浸润性膀胱肿瘤，为了降低PKRBt术后输尿管口狭窄的发生率，常规于电切术前在患侧输尿管内留置双J管，此法不会增加肿瘤细胞逆行种植上尿路的风险，也不会严重影响患者的生活质量，值得临床上推广应用。     

Endoscopic management of ureteral complications following renal transplantation

Management of ureteral complications after kidney transplantation can be done with a surgical, percutaneous, or endoscopic approach. The aim of this study was to determine the success rate of the endoscopic retrograde approach for the management of these complications following renal transplantation. We reviewed the records of 25 patients who underwent endoscopic management of ureteral complications after renal transplant between 1995 and 2005. Variables examined included timing of event following transplant, type of ureteral complication, equipment implemented in the procedure, operating time, success in stent placement, and complications. Initial approach was via rigid cystoscopy followed by flexible cystoscopy if needed. Initial attempts to intubate the ureteral orifice were by a flexible-tipped guide wire, and occasionally an angiocatheter guide was used for ultimate wire placement. Stents were positioned with fluoroscopic and direct visual guidance. Of 25 patients evaluated, five had a ureteral anastomotic leak with a mean time of presentation of 16.8 days. The remaining 20 patients suffered from ureteral obstruction revealed by hydronephrosis on a renal ultrasound prompted by a rising creatinine. Mean time of onset was 48 months. Although each was initially approached with rigid cystoscopy, 12 were converted to flexible cystoscopy for easier access to the ureteral orifice. Twenty of the 25 patients had successful stent placement with three failures in the ureteral obstruction group and two failures in the leakage group. Average operative time was 42 minutes. No intraoperative complications were experienced. Resolution of hydronephrosis in those with preoperative obstruction was noted and all stented urinary leaks resolved.     

Cut-to-the-light technique and potassium titanyl phosphate laser ureterotomy for complete ureteral obstruction

We describe a case of complete ureteral obstruction managed by endoscopic recanalization using a 'cut-to-the-light' technique followed by potassium titanyl phosphate (KTP) laser ureterotomy. A 53-year-old man developed a ureteral obstruction following the transurethral resection of a bladder tumor (TUR-Bt) at the left ureteral orifice. The length of the obstructed segment was estimated at 1 cm based on combined antegrade and retrograde contrast studies. Histopathological analysis indicated that the obstruction was caused by fibrosis. The 'cut-to-the-light' technique was used for recanalization, and KTP laser ureterotomy was performed to obtain an adequate ureteral lumen. A 14 F/7 F endoureterotomy stent was removed 6 weeks after the operation. No significant complications and no signs of stenosis were observed 24 months after endoscopic repair. Endoscopic recanalization is a safe, effective technique for the management of a completely obliterated ureteral segment, especially in combination with subsequent KTP laser ureterotomy.     

Distal ureteral stenosis after early adjuvant intravesical mitomycin C application for superficial bladder cancer

We report a case of distal ureteral stenosis after transurethral resection of a small bladder tumor near the left ureteral orifice and early postoperative mitomycin C instillation for prevention of recurrence. The patient developed late recurrent stenosis of the ureteral orifice with histologic evidence of localized, severe benign inflammatory reaction. The recurrent stenosis was successfully managed by transurethral resection of the scar tissue and ureteric stenting. Although ureteral stenosis does occur after transurethral resection, the severity and time course of the stenosis in this case suggest an influence of the intravesical chemoprophylaxis used.     

SIMPLIFIED URETERAL STENT PLACEMENT WITH THE ASSISTANCE OF A URETERAL ACCESS SHEATH

PURPOSE: When using a ureteral access sheath following a ureteroscopic procedure, placement of an internal ureteral stent can be simplified by inserting the stent through the sheath without the need to reinsert the cystoscope. MATERIALS AND METHODS: An indwelling ureteral stent with the pull string attached is inserted over the guide wire into the access sheath followed by the pusher. The guide wire is partially withdrawn allowing the stent to form a coil in the renal pelvis, using the pull string to adjust the stent position. The fluoroscopy unit is then focused onto the bladder and the guide wire is slowly withdrawn until its tip is at the level of pubic symphysis. The pusher and guide wire are then removed and the pull string is cut at the urethral meatus. RESULTS: Among 71 cases studied 60 required ureteral stent placement. In 43 of the 60 cases (72%) the ureteral access sheath greatly facilitated ureteroscopy, and a stent was placed through the access sheath in 34 (79%). Stent placement through the access sheath was successful in all cases, with an average time saving of 2.3 minutes per case, compared to placing the stent by reinserting a cystoscope. CONCLUSIONS: If an access sheath has already been placed during a ureteroscopic procedure and stent insertion is deemed necessary, the stent can be easily placed through the access sheath under fluoroscopic guidance without the need to reinsert the cystoscope. Our experience suggests that all urologists who routinely perform ureteroscopic procedures can easily master this timesaving technique.     

经尿道电气化切除下段输尿管在上尿路肿瘤治疗中的应用

目的探讨经尿道电气化切除下段输尿管在上尿路肿瘤治疗中的应用价值。方法采用肾切除 经尿道电气化切除下段输尿管治疗上尿路移行细胞癌26例。结果26例手术时间1．5～2．5h，平均2h，腹膜后引流管留置24～48h，导尿管留置3～5d．术后未见出血、尿瘘、感染及切口肿瘤种植等。22例获得随访4～74个月．平均38个月，3例手术后6～9个月发生膀胱移行细胞癌并行膀胱部分切除或TUR—Bt术，患侧输尿管走行区及输尿管膀胱开口部未见肿瘤复发。结论该手术方法创伤小，术后并发症少．效果良好．是治疗上尿路肿瘤的有效手术方法。     

Epidural catheters can facilitate laparoscopic placement of ureteral stent: description of a technique

AIM: To introduce a novel technique for laparoscopic placement of ureteral stent and to investigate the safety and effectiveness of this new method. METHODS: Fourteen patients underwent laparoscopic placement of ureteral stents with the technique. The stent was indwelled with an epidural catheter, delivered to the operative field, and placed through the ureteral incision into the renal pelvis and bladder, respectively. The stent was then secured with pincers, while the epidural catheter was removed. RESULTS: With this method, the ureteral stent insertion is very convenient and time saving (the mean time for inserting a stent was 2.7 min). The stents were successfully inserted into 13 patients once. One patient underwent insertion of the stent twice intraoperatively. Thirty days after the operations, none of double-J stents had migrated out of the renal pelvis or bladder. CONCLUSIONS: This technique is reliable and effective in laparoscopic ureteral operations. Its use should be generalized in laparoscopic ureteral operations.