后腹腔镜辅助小切口肾输尿管及膀胱袖套状切除术(附7例报告)

目的:探讨后腹腔镜辅助小切口肾输尿管及膀胱袖套状切除术的手术技巧。方法:用后腹腔镜辅助小切口为7例肾盂及输尿管肿瘤患者行肾输尿管及膀胱袖套状切除术,其中肾盂癌4例,输尿管癌3例。结果:7例手术均获成功,手术时间90~120min,平均108min,术中出血50~150ml,平均80ml。术后平均住院10d,无严重并发症发生。随访4~33个月,无肿瘤复发。结论:采用后腹腔镜辅助小切口肾输尿管及膀胱袖套状切除术治疗肾盂及输尿管肿瘤具有患者创伤小、出血少、手术时间短、并发症少、切除更完全等优点。     

经腹膜后入路机器人辅助单孔腹腔镜肾部分切除治疗孤立肾肾癌合并双肾盂双输尿管畸形一例报道

南京中医药大学附属医院泌尿外科2021年4月收治1例左侧孤立肾合并肾透明细胞癌患者,术前行MRI检查提示患者同时合并罕见的双肾盂双输尿管畸形变异。经术前充分评估,考虑患者解剖变异较大,为避免术中重复肾盂及输尿管损伤,笔者为患者行经腹膜后入路机器人辅助单孔腹腔镜手术。术中充分游离左肾动脉,精准阻断肾下极供应血管,行根治性肾部分切除术。手术进展顺利,手术时间为80min,术中出血量为30ml,无围手术期并发症发生,患者术后顺利出院。孤立肾双肾盂双输尿管重复畸形合并肾透明细胞癌病例罕见,需进行充分的术前影像学评估。经腹膜后入路的机器人辅助单孔腹腔镜手术中解剖精细,创伤小,术后恢复快,是临床可行的手术方式。     

机器人辅助腹腔镜“一步法”半尿路切除术(“大家泌尿网”观看手术视频)

根治性肾输尿管全长及膀胱袖套状切除术是上尿路尿路上皮癌的标准治疗方案,传统开放手术创伤较大、切口长、术后恢复时间长,腹腔镜肾切除术后采用下腹部切口取出标本并行膀胱袖状切除虽减少了手术创伤,但术中仍需要变换体位重新消毒,延长了手术时间。目前机器人辅助腹腔镜下根治性肾输尿管全长及膀胱袖状切除手术进一步提高了手术的精准度,我们采用单一体位一次性装机完成上尿路肿瘤的根治手术。本文就机器人辅助腹腔镜“一步法”半尿路切除术的手术步骤及技术要点等进行介绍。     

腹腔镜单一体位在膀胱气腔下行根治性肾、远端输尿管及膀胱壁袖套切除术

治疗高度恶性的上尿路移行细胞癌的手术金标准为根治性输尿管。肾、远端输尿管及膀胱壁内段袖套状切除术。传统的腹腔镜手术将上述手术过程分开，首先行腹腔镜下根治性输尿管肾切除术，再更换体位，行膀胱镜直视下腹腔镜辅助远端输尿管及膀胱壁内段袖套状切除术。Cheng等对传统的腹腔镜手术方式进行改良：使用膀胱气腔取代水腔，在分离远端输尿管时尽早夹闭输尿管括约肌，     

机器人辅助腹腔镜肾部分切除术的学习曲线

目的:探讨机器人辅助腹腔镜肾部分切除术的学习曲线。方法:比较同一外科医生施行的早期20例机器人辅助腹腔镜肾部分切除术和最近20例腹腔镜肾部分切除术的围手术期结果。所有手术在2013年5月~2013年8月完成。既往该医生成功施行1 000余例腹腔镜肾部分切除术和300余例机器人辅助腹腔镜根治性前列腺切除术。比较2种术式的手术时间、热缺血时间、出血量、切缘阳性率、术后住院时间、围手术期并发症发生率。结果:2组患者术前临床资料和肿瘤病理学结果的比较差异无统计学意义(P0.05)。2组均无切缘阳性病例。2组手术出血量、术后住院时间、围手术期并发症发生率差异无统计学意义(P0.05)。在机器人辅助腹腔镜肾部分切除术的学习曲线中,手术时间和热缺血时间均呈下降趋势。经过早期9例手术后,机器人辅助腹腔镜肾部分切除术的平均手术时间即可接近最近20例腹腔镜肾部分切除术的平均手术时间。前9例机器人辅助腹腔镜肾部分切除术的平均手术时间是134min,热缺血时间是20min,远远长于后11例机器人辅助腹腔镜肾部分切除术平均手术时间107min,热缺血时间14min。结论:一个资深腹腔镜外科医生从腹腔镜肾部分切除术到机器人辅助腹腔镜肾部分切除术过渡是一个非常迅速的过程,经过前9例机器人辅助腹腔镜肾部分切除术后,行机器人辅助腹腔镜肾部分切除术和腹腔镜肾部分切除术的手术时间大致相同。2组热缺血时间、手术出血量、术后住院时间、手术出血量、术后住院时间、围手术期并发症发生率差异无统计学意义(P0.05)。     

机器人辅助经阴道多脏器切除治疗多发性尿路上皮癌一例报道

机器人辅助腹腔镜手术是尿路上皮癌最主要的微创治疗方式之一。甘肃省人民医院于2020年11月24日收治1例右侧输尿管恶性肿瘤合并膀胱恶性肿瘤患者,行机器人辅助腹腔镜膀胱根治性切除术+右侧肾、输尿管切除+子宫、附件切除+左侧输尿管皮肤造口术,手术多脏器标本经阴道取出,术后疗效满意,患者恢复可,美容效果佳。     

机器人辅助腹腔镜在泌尿外科手术中的临床应用(附500例报告)

目的:总结早期开展机器人辅助腹腔镜手术在泌尿外科应用的经验,探讨机器人辅助腹腔镜在泌尿外科中应用价值。方法:分析2007年10月~2013年11月行机器人辅助腹腔镜泌尿外科手术500例患者。结果:500例中497例成功完成手术,上尿路手术135例,占27.16%,包括肾上腺癌切除术2例(0.4%)、肾部分切除术60例(12.07%)、肾根治性切除术37例(7.44%)、肾输尿管全长切除术6例(1.21%)、肾囊肿去顶减压术3例(0.6%)、肾盂成形术11例(2.21%)、输尿管膀胱再植术14例(2.82%)、输尿管探查松解术1例(0.2%)、输尿管狭窄段切除及端端吻合1例(0.2%)。下尿路手术362例,占72.84%,包括前列腺癌根治术319例(64.19%)、膀胱根治性切除术及回肠膀胱术24例(4.83%)、原位新膀胱术7例(1.41%)、输尿管皮肤造瘘3例(0.6%)、盆腔肿物切除术3例(0.6%)、精囊肿物切除术4例(0.8%)、膀胱结石碎石术1例(0.2%)、骶骨加固术1例(0.2%)。中转开放手术3例,包括腹膜后纤维化松解术1例、前列腺癌根治术1例、膀胱全切1例,占0.6%。无显著并发症发生。结论:遵循开放手术及普通腹腔镜原则,机器人辅助腹腔镜手术在技术上是安全有效的,可取得满意的临床治疗效果。具有创伤小、术野清晰、失血少及学习曲线短等优点。     

从腹腔镜到机器人辅助肾部分切除术的过渡:一个资深腹腔镜外科医生的学习曲线

背景腹腔镜肾部分切除术的高难度和挑战性使许多腹腔镜外科医生采用机器人辅助肾部分切除术治疗肾脏小肿瘤。从腹腔镜肾部分切除术到机器人辅助肾部分切除术的过渡期我们评估一个资深腹腔镜外科医生的学习曲线。方法我们比较同一外科医生施行的早期20例机器人辅助肾部分切除术和最近18例腹腔镜肾部分切除术的围术期结果。所有手术是在2005年4月～2009年7月间完成的。既往该医生成功施行100余例腹腔镜肾部分切除术和100余例机器人辅助手术。2组手术步骤相同,在镜下充分游离肾动静脉后,完整游离肿瘤表面,利用术中超声来界定肿瘤边界,哈巴狗血管阻断钳控制肾动脉,在热缺血状态下切除肿瘤,2-0可吸收线连续缝合肾实质,如果集合系统切开后也予以缝合。学习曲线的定义指能熟练地在较短的手术时间和热缺血时间内完成机器人辅助肾部分切除术的例数。利用散点图显示机器人辅助肾部分切除术的学习曲线,用以比较2种术式的手术时间和热缺血时间。结果 2组患者术前临床资料和肿瘤病理学结果的比较无统计学差异。2组均无切缘阳性病例。2组手术并发症也无统计学差异。在机器人辅助肾部分切除术的学习曲线(图1)中,手术时间和热缺血时间均呈下降趋势。经过早期5例手术后,机器人辅助肾部分切除术的平均手术时间即可接近最近18例腹腔镜肾部分切除术的平均手术时间。前5例机器人辅助肾部分切除术的平均手术时间是242.8 min,远远长于后15例机器人辅助肾部分切除术平均手术时间171.3 min(P=0.011)。结论 一个资深腹腔镜外科医生从腹腔镜到机器人辅助肾部分切除术过渡是一个非常迅速的过程。2组热缺血时间、术中估计出血量和住院时间均无统计学差异。经过前5例机器人辅助肾部分切除术后,一个资深腔镜外科医生行机器人辅助和腹腔镜肾部分切除术的手术时间大致相同。     

机器人辅助腹腔镜泌尿外科手术中的早期应用体会*(附28例报告)

目的:探究机器人辅助腹腔镜在泌尿外科手术的应用前景及疗效。方法:回顾性分析我院2016年8~12月使用达芬奇机器人手术辅助系统进行泌尿外科手术28例患者的临床资料。结果:28例手术中,上尿路手术包括10例肾上腺肿瘤切除术,4例肾癌根治性切除术,4例肾部分切除术,2例肾输尿管全长切除术,1例肾盂输尿管成形术;下尿路手术包括4例根治性前列腺切除术,1例输尿管膀胱再植术,2例盆腔肿物切除术。其中1例输尿管膀胱再植术患者术中因心功能不全中转开放,1例左侧巨大嗜铬细胞瘤手术因操作不当损伤脾脏后及时止血并顺利完成余下手术,其余26例手术均顺利完成。术后28例患者均无并发症。结论:机器人辅助手术系统可以应用于几乎所有泌尿系统的腹腔镜手术中,其优越性在泌尿系修复重建、泌尿系巨大占位和盆腔内占位等手术中体现更为明显。     

机器人辅助肾部分切除会成为金标准吗?

<正>微创手术是外科医生的不懈追求,达芬奇机器人手术系统(Da Vinci robotic surgery system,DVSS)在外科领域的广泛应用和发展是当今世界临床医学发展的里程碑。泌尿外科是DVSS应用的主要阵地之一,开展范围较广,技术日益成熟。肾部分切除手术是治疗T1(≤7cm)期肾细胞癌的首推方法,主要包括开放性肾部分切除术、腹腔镜肾部分切除术和机器人辅助腹腔镜肾部分切除术。     

Robot-assisted laparoscopic nephroureterectomy for upper tract urothelial carcinoma (UT-UC)

Upper tract urothelial carcinoma (UT-UC), including tumors evolving from the renal pelvis and ureter, accounts for around 5% of all UCs and 10% of all renal tumor cases. In Taiwan, the incidence of UT-UC is higher than the western countries especially in the female and patients at renal replacement therapy. The standard care of UT-UC is nephroureterectomy with bladder cuff excision. In the past decades, minimally invasive surgery is proved to achieve comparable oncological results as conventional open procedure. Though laparoscopic nephroureterectomy with bladder cuff excision including pure laparoscopic or hand-assisted technique have been very common practice in Taiwan, several institutes have the early experience of robot-assisted nephroureterectomy which is believed to provide 3-D visualization with magnification, better surgical exposure, and safer watertight suture of the cystostomy. In this review, we review the published reports of robot-assisted nephroureterectomy with bladder cuff excision.     

Current Status of Robot Assisted Laparoscopic Radical Nephroureterectomy for Management of Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinomas (UUT-UC) are usually aggressive tumours and require radical treatments. The standard of care for localised UUT-UC is radical nephroureterectomy (RNU). Robot-assisted laparoscopic surgeries are currently employed in various urological procedures, including RNU. We conducted a literature search on medical databases (PubMed/ MEDLINE) using free text keywords nephroureterectomy, distal ureter, bladder cuff, urothelial carcinoma and/or robotic. In this review, we aim to provide an up-to-date status on robot-assisted laparoscopic nephroureterectomy (RAL-NU) for the management of UUT-UC. The various surgical techniques and approaches for RAL-NU and retroperitoneal lymph node dissection (RPLND) will be discussed and their perioperative and early oncological outcomes reported. The feasibility and safety of RAL-NU has been demonstrated in a number of studies but intermediate and long term clinical and oncological outcomes are still lacking.     

Initial experience with robot-assisted minimally-invasive nephroureterectomy

PURPOSE: Various techniques have been described for laparoscopic nephroureterectomy. We reviewed our initial experience of laparoscopic nephroureterectomy with robot-assisted extravesical excision of the distal ureter and bladder cuff. MATERIALS AND METHODS: Nine consecutive patients aged 43 to 83 years underwent laparoscopic nephroureterectomy for transitional cell carcinoma (TCC) between August 2005 and March 2007. The first five patients were repositioned after laparoscopic nephrectomy from flank to lithotomy position to dock the robot for excision of the distal ureter and bladder cuff by a single surgeon. In contrast, the last four patients remained in flank position throughout the entire procedure, with the robot docked in flank position following laparoscopic nephrectomy. A two-layer closure re-approximated the cystotomy and a urethral catheter was left in place for a mean of 5 days. RESULTS: Eight men and one woman with a mean age of 64.2 years and mean body mass index (BMI) of 28.4 kg/m(2) underwent flexible cystoscopy and laparoscopic nephroureterectomy for five right-sided and four left-sided tumors. Mean operative time was 303 minutes (range 210-430 minutes), estimated blood loss was 211 mL (range 50-700 mL), and mean length of hospital stay was 2.3 days. Pathologic staging revealed T(3) for five (55.6%), T(a) for two (22.2%), carcinoma in situ (CIS) for two (22.2%) patients, and high-grade disease for seven (77.8%) patients. With a mean follow-up of 16.2 months (range 4.3-24.3 months), three patients with a history of bladder cancer have experienced recurrence in the bladder, and one of the three has also developed metastatic disease. CONCLUSIONS: Laparoscopic nephroureterectomy with robot-assisted extravesical excision of the distal ureter and bladder cuff appears to be a feasible alternative for patients with TCC of the upper urinary tract.     

Robot-assisted laparoscopic combined nephroureterectomy and cystoprostatectomy: an initial report and review of the literature

Patients presenting with invasive, high-grade, or recurrent bladder cancer and synchronous upper urinary tract malignancy may be considered for simultaneous nephroureterectomy and radical cystectomy. We present the first known reported case of robot-assisted laparoscopic combined nephroureterectomy and cystoprostatectomy, describing a 62-year-old man with recurrent T1 bladder cancer and concomitant upper urinary tract transitional cell carcinoma. Patient underwent robot-assisted laparoscopic combined nephroureterectomy and radical cystoprostatectomy with extended pelvic lymph node dissection and extracorporeal ileal conduit urinary diversion. Robotic surgery was completed successfully without need for conversion to open procedure. There were no operative or perioperative complications. Blood loss (200 ml) and hospital stay (7 days) were less than prior reported laparoscopic experience with combined surgery. Although indications may be rare, robotic nephroureterectomy with simultaneous radical cystoprostatectomy is a feasible and safe surgical option.     

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。     

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.     

达芬奇Xi系统在单一体位经腹腔肾输尿管切除术中的应用

目的探讨达芬奇Xi系统单一体位经腹腔肾输尿管全长切除术在治疗上尿路尿路上皮癌中的可行性及安全性。 方法回顾性分析青岛市市立医院东院区2019年11月至2020年11月收治的11例患者资料。其中男7例,女4例,年龄50~77岁。肾盂癌5例,输尿管癌5例,肾盂癌合并输尿管癌1例。肿瘤位于左侧6例,右侧5例。应用达芬奇Xi系统,术中不变换体位。 结果11台手术均顺利应用达芬奇Xi系统完成,无中转开放或腹腔镜手术。术中出血量30~300 ml。手术时间110~210 min。术后住院时间8~13 d。术后无ClavienⅡ级以上并发症。术后随访时间0~12个月,失访2例,无死亡及肿瘤复发病例。 结论单一体位经腹腔肾输尿管切除术能较好地发挥达芬奇Xi系统的优势,手术时间明显较短,术后恢复快,肿瘤切除效果较好,短期随访结果满意。     

Simultaneous robot-assisted radical cystoprostatectomy and nephroureterectomy in a patient with multifocal invasive urothelial carcinoma and previous contralateral nephroureterectomy

We present a case of simultaneous robot-assisted radical cystoprostatectomy and nephroureterectomy with extended lymphadenectomy for multifocal invasive urothelial carcinoma in a patient with recurrent high-grade urothelial cancer and a previous right nephroureterectomy. The total urinary exenteration and extended lymphadenectomy was successfully performed with robot-assisted surgery in this unique case where the patient was rendered anephric at the end of the operation. We discuss the operative steps and the techniques performed to optimize the oncological results of robot-assisted surgery for invasive urothelial carcinoma, while attempting to preserve the renal function until the patient’s urinary system was totally exenterated.     

Robot-assisted nephroureterectomy for upper urinary tract urothelial carcinoma without intraoperative reposition or redocking

The gold standard for treatment of upper urinary tract urothelial carcinoma remains nephroureterectomy with the ipsilateral bladder cuff excision. With the introduction of robot system, robot-assisted surgery has become popular in the management of urological malignancies. We report a single institute experience of robot-assisted nephroureterectomy (RANU) for the treatment of upper urinary tract urothelial carcinoma (UC) without re-docking the robot system or reposition of the patient. The perioperative and oncologic outcomes are discussed.     

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.