腹腔镜上尿路手术入路选择：经腹腔还是腹膜后？

20年来,泌尿外科腹腔镜手术从无到有、从简单到复杂、不断发展完善,为临床治疗理念和手段带来了革命性的变化。腹腔镜手术开展之初,主要选择经腹腔途径进行上尿路手术。该技术传入我国后,国内学者结合传统开放手术经验和国人体型特点,多选择腹膜后入路。无论采取哪种入路进行上尿路手术,技术上都是可行的,也都积累了相当丰富的经验,评判两种入路孰优孰劣则是比较复杂的。     

腹腔镜上尿路手术经腹膜后入路更有优势

20余年以来泌尿外科腹腔镜技术得到了极大的发展,已被绝大多数泌尿外科医师接受。目前腹腔镜上尿路手术常用的入路有经腹腔与经腹膜后,两种方法各有特点。我国泌尿外科腹腔镜技术经过10余年的迅速发展,针对国人的体型特点,多数泌尿外科同仁选择以腹膜后入路为主的腹腔镜技术体系来完成上尿路手术[1],根据临床实践以及文献的报道,笔者认为相比经腹腔入路,经腹膜后入路更具优势。     

经腹入路腹腔镜腹膜后肿瘤切除术安全性初探

目的 探讨经腹入路腹腔镜腹膜后肿瘤（RPT）手术治疗的安全性和有效性。方法 回顾性分析2016年10月至2022年1月收治于内蒙古医科大学附属医院及呼和浩特市第一医院,由同一手术组完成的11例经腹入路腹腔镜腹膜后肿瘤切除术患者临床资料。结果 11例患者均成功实施经腹入路腹腔镜下腹膜后肿瘤切除术,无中转开腹,无围手术期死亡。平均手术时间（202±78）min;中位术中出血量100 mL(20,100)mL;平均术后住院时间（6.9±2.4）d。术后病理：纤维瘤3例,淋巴管囊肿2例,淋巴结增生（Castleman）1例,良性间皮瘤1例,淋巴结核1例,黏液性囊腺瘤1例,高级别脂肪肉瘤1例和平滑肌肉瘤1例。随访4～60个月,除脂肪肉瘤复发外,余无复发。结论 病例选择合适,由腹腔镜经验丰富医师主刀,经腹入路实施腹腔镜腹膜后肿瘤切除术安全且疗效显著,尤其在术中操作及术后恢复方面优势明显。     

3种机器人辅助腹腔镜根治性前列腺切除术手术入路对比研究:前入路、后入路及经膀胱入路

目的:比较前入路、后入路及经膀胱入路机器人辅助腹腔镜根治性前列腺切除术(RARP)围手术期指标及手术效果。方法:回顾性分析2015年12月～2018年8月收治的43例前入路RARP(前入路组)、26例后入路RARP(后入路组)和10例经膀胱入路RARP(经膀胱入路组)患者的临床资料。比较三组患者临床资料、围手术期指标(手术时间、术中出血、术后病理分期、术后Gleason评分、切缘阳性率)及手术效果[尿控恢复时间、术后国际勃起功能问卷表-5(IIEF-5)]。结果:前入路组平均年龄(69.7±7.3)岁,平均BMI(22.9±3.1)kg/m~2,平均术前tPSA(34.5±21.3)ng/ml,术前Gleason评分中位值8(6～9)分,平均前列腺体积(38.2±16.6)ml,术前IIEF-5评分中位值12(6～19)分。后入路组平均年龄(62.3±10.9)岁,平均BMI(27.2±6.3)kg/m~2,平均术前tPSA(15.8±7.2)ng/ml,术前Gleason评分中位值7(6～8)分,平均前列腺体积(44.7±10.8)ml,IIEF-5评分中位值13(6～20)分。经膀胱入路组平均年龄(58.6±9.4)岁,平均BMI(26.5±3.1)kg/m~2,平均术前tPSA(19.5±4.1)ng/ml,术前Gleason评分中位值6(6～7)分,平均前列腺体积(33.4±15.8)ml,术前IIEF-5评分中位值16(10～21)分。临床分期前入路组:cT_(1c)期18例,cT_(2a)期3例,cT_(2b)期3例,cT_(2c)期17例,cT_(3a)期1例,cT_(3b)期1例;后入路组:cT_(1c)期17例,cT_(2a)期3例,cT_(2b)期4例,cT_(2c)期2例;经膀胱入路组:cT_(1c)期8例,cT_(2a)期1例,cT_(2b)期1例。所有患者术前尿控均正常。79例手术均顺利完成,无中转开放病例,无输血病例,无严重术中、术后并发症发生。术后病理结合术前检查示前入路组:pT_(2b)期9例,pT_(2c)期16例,pT_(3a)期3例,pT_(3b)期12例,pT_4期3例,Gleason评分中位值8(6～9)分;后入路组:pT_(2a)期13例,pT_(2b)期9例,pT_(2c)期2例,pT_(3a)期2例,Gleason评分中位值7(6～8)分;经膀胱入路组:pT_(2a)期6例,pT_(2b)期3例,pT_(2c)期1例,Gleason评分中位值6(6～7)分。前入路组切缘阳性11例(25.6%),后入路组切缘阳性6例(23.1%),经膀胱入路组切缘阳性1例(20.0%),三组比较差异无统计学意义(P0.05)。前入路组手术时间(115.5±20.5)min,后入路组手术时间(126.5±33.5)min,经膀胱入路组手术时间(140.5±15.5)min。前入路组术中失血量(80±20.5)ml,后入路组术中失血量(44.5±9.5)ml,经膀胱入路组术中失血量(65.5±35.5)ml。前入路组术后3周拔除尿管,其余两组患者术后7d拔除导尿管,前入路组完全恢复尿控时间(6.5±3.5)周,后入路组22例即刻实现尿控(尿控定义为无需使用尿垫),4例术后2周实现尿控;经膀胱入路组患者9例即刻实现尿控,1例术后2周实现尿控;后入路组与经膀胱入路组比较差异无统计学意义(P0.05),前入路组与后入路组、前入路组与经膀胱入路组比较差异均有统计学意义(P0.05)。三组患者随访时间3～35个月,平均12个月,所有患者尚无肿瘤复发表现(tPSA0.2ng/ml)。术后第3个月,IIEF-5评分中位值前入路组为10(4～12)分,后入路组为10(4～13)分,经膀胱入路组为11(5～14)分,三组比较差异无统计学意义(P0.05);三组IIEF-5评分与术前比较差异均无统计学意义(P0.05)。结论:经膀胱入路RARP有待成为治疗局限性低风险前列腺癌的可选术式。经膀胱入路与后入路患者术后即刻尿控率较高,均优于前入路,术后肿瘤控制效果和勃起功能仍有待于进一步随访。     

经腹腔入路与经腹膜后入路腹腔镜手术治疗肾上腺肿瘤的对比分析(附39例报告)

目的:探讨腹腔镜手术治疗肾上腺肿瘤的可行性与安全性。方法:回顾分析2012年1月至2014年4月为39例肾上腺肿瘤患者行腹腔镜手术的临床资料。手术方式由随机选择产生,其中经腹腔入路20例,经后腹腔入路19例,对比两种术式患者年龄、肿瘤大小、手术时间、术中出血、术后胃肠功能恢复时间、住院时间。结果:两组手术均获成功,成功率100%,无一例中转开放手术或术中、术后输血。术后病理肾上腺皮质腺瘤17例(原发性醛固酮增多症8例,皮质醇增多症6例,无功能腺瘤3例),肾上腺囊肿8例,肾上腺嗜铬细胞瘤10例,肾上腺皮质腺癌4例。两种入路方式的手术时间、术中出血量、术后住院时间差异无统计学意义(P>0.05),但术后胃肠功能恢复时间[(14.2±2.3)h vs.(6.3±2.1)h]差异有统计学意义(P<0.01)。术后随访2~24个月,患者恢复良好,无一例复发。结论:腹腔镜肾上腺肿物切除术,不论经腹腔入路抑或经腹膜后入路均是治疗肾上腺肿瘤的金标准,具有操作精准、安全、术中出血少、术后康复快、手术并发症少、临床疗效好等优点,值得推广。     

经腹膜后入路腹腔镜下肾上腺血管瘤切除术的临床经验分享

目的:总结经腹膜后入路腹腔镜下肾上腺血管瘤切除术的手术经验。方法:回顾分析2014年5月至2016年12月收治的5例术后病理证实肾上腺血管瘤患者的临床资料,其中男1例,女4例,中位年龄42(27~67)岁;中位肿瘤直径3.5(2.4~4.5)cm,左侧2例,右侧3例;术前CT提示5例肿瘤均为囊实性、边界清,2例肿瘤内可见明显多处钙化。5例患者均行后腹腔镜肾上腺肿瘤切除术。结果:5例手术均顺利完成,无一例中转开放,术中、术后无严重并发症发生。中位手术时间65(50~90)min,术中出血量<50 mL,术后中位住院时间4(3~6)d;术后病理结果提示,5例均为肾上腺血管瘤;术后中位随访时间15(9~36)个月,患者恢复情况良好,无激素不足等症状出现,随访期间均未见肿瘤局部复发。结论:肾上腺血管瘤是较罕见的肾上腺良性肿瘤,术前影像学检查明确困难,术后病理为金标准。后腹腔镜肾上腺肿瘤切除术治疗肾上腺血管瘤可行、安全、有效,值得临床推广应用。     

腹腔镜肾上腺切除术

腹腔镜肾上腺切除三种手术方式入路不同，各有其特点及适应证。经腰腹膜后入路借助水囊分离，完全腹膜外到达肾上腺，不受腹腔病变限制，对腹腔脏器干扰少。经侧腹膜入路游离翻开结肠，甚至肝脏及胰腺，暴露充分，视野开阔，经腹腔前方入路简捷，后腹膜切口局限，手术剥离范围小，适用于较小的腺瘤切除。     

经腹腔与腹膜后腹腔镜肾癌根治术疗效比较

目的比较经腹腔与经腹膜后入路腹腔镜肾癌根治术的临床效果。方法分析2010年4月至2012年2月间在北京大学第一医院接受腹腔镜肾癌根治术的141例患者资料,其中经腹腔入路组61例、经腹膜后腔入路组80例,比较两种手术入路患者在手术时间、出血量、术后住院日等方面的差异。结果所有141例手术均在腹腔镜下完成。对于经腹腔入路组和经腹膜后腔组,平均手术时间分别为192.1及147.2min（P=0.000）;平均术后住院日分别为5.8d及7.2d（P=0.000）;平均肿瘤长径分别为5.6cm及4.3cm（P=0.001）。在术中出血量、并发症及输血情况等方面无显著性差异。结论经腹腹腔镜和经后腹膜腹腔镜肾癌根治术围手术期均有良好效果,经腹腔入路适合治疗体积较大的肿瘤,术后恢复快,而经腹膜后腔入路具有手术时间短的优势。     

经腹腔和后腹腔入路根治性肾切除的前瞻性随机比较

作者报道了一项经腹腔和后腹腔入路根治性肾切除的前瞻性随机比较研究结果。从1999年6月至2001年6月，102例符合条件的连续病例经CT证实为肾肿瘤后随机分为经腹腔入路组(50例)和经后腹腔入路组(52例)，行根治性肾切除术。排除体重指数大于35和既往有较大腹部手术的患者。两组病例的年龄(63vs65岁，P=0．69)，体重指数(29vs28，P=0．89)，美国麻醉学会分级(2．7vs2．8，P=0．37)，     

Endoscopic adrenalectomy: an analysis of the transperitoneal and retroperitoneal approaches and results of a prospective follow-up study

Background Endoscopic adrenalectomy is currently performed using either a retroperitoneal or transperitoneal approach. The aim of this study was to determine which of these is the optimal surgical technique in a prospectively designed analysis of a large series of patients operated on by a single team over a 10-year period.Methods From February 1994 to March 2004, 267 endoscopic adrenalectomies (retroperitoneal in 132 patients and transperitoneal in 135 patients) were performed in 245 consecutive patients. There were 102 right lateral and 121 left lateral procedures (22 patients had a bilateral procedure). The most prevalent indication was incidentaloma (35.9%), followed by pheochromocytoma and Conn’s adenoma.Results The endoscopic procedure was performed in 238 of 245 patients (97.1%). The conversion rate was 1.5% for the transperitoneal approach and 3.8% for the retroperitoneal approach. No statistically significant influence was noted for the parameters of intraoperative blood loss, rate of postoperative complications, and duration of hospital stay with regard to the surgical technique. The operative time and the learning curve proved to be significantly longer for the retroperitoneal adrenalectomy. In addition, a variance analysis identified tumor size (>5 cm) as a significant factor influencing the operative time, whereas body mass index and localization (right/left lateral) did not prove significant.Conclusion Independent of the underlying pathology, endoscopic adrenalectomy using either the trans- or retroperitoneal approach can be performed in 96-98% of all patients. Differences between the two techniques in operative time and learning curves clearly favor the transperitoneal adrenalectomy.     

Comparison of robot-assisted laparoscopic adrenalectomy with traditional laparoscopic adrenalectomy - 1 year follow-up

Background Laparoscopic adrenalectomy offers distinct benefits to patients and has now become the gold standard for the removal of adrenal lesions. Nonetheless, the procedure poses a challenge for surgeons in regards to the maneuverability of instruments, the two-dimensional operating field and the counterintuitive movements. This study reports our experience using the Zeus robotic surgical system in laparoscopic adrenalectomy compared with traditional laparoscopic adrenalectomy. Patients and Methods From January 2003 to February 2005, a total of 12 patients were prospectively enrolled to receive robot-assisted laparoscopic adrenalectomy (RALA) or traditional laparoscopic adrenalectomy (TLA). The time necessary for robotic setup and operation was recorded, as well as complications, technical problems, postoperative hospital stay, morbidity, and mortality. Results Five RALA procedures and seven TLA were successfully completed. There was no significant difference between the groups in terms of age, body mass index, and tumor size. Resection times were longer in the RALA group (168.0 ± 30.7 min vs. 131.4 ± 29.0 min, p = 0.05). There were no perioperative complications. There was neither postoperative mortality nor morbidity at the time of discharge and during one year follow-up. Conclusions RALA is as safe and technically feasible as TLA, It provides a real benefit for the surgeon with the three dimensional view, a comfortable sitting position, the elimination of the surgeon’s tremor, and increased degrees of freedom of the operative instruments compared with TLA. However, patient outcomes and operative costs should be evaluated further.     

经腹与腹膜后入路肾上腺切除术的比较

目的比较经腹腔肾上腺切除术（LTA）与腹膜后肾上腺切除术（LRA）两种不同入路腹腔镜肾上腺切除术的临床疗效。 方法回顾性分析2012年1月至2016年12月89例在我院泌尿外科施行腹腔镜肾上腺肿瘤切除术患者的临床资料,对两种不同入路肾上腺切除术患者手术时间、术中出血量、肿瘤大小、术后进食时间和平均住院时间进行比较分析。 结果89例患者中采用LTA入路42例,LRA入路47例。两组患者性别、年龄、腹部手术、外伤史、口服降压药物史、术前血压、心率、肿瘤部位、临床诊断及肿瘤大小差异均无统计学意义（P>0.05）。LRA组平均手术时间短于LTA[（78±17）mins vs （90±21）mins,P=0.0047]。而LRA入路的右侧肾上腺切除平均所需时间较LTA入路更短[（80±14）vs（93±10）,P<0.001],两组左侧肾上腺切除所需时间差异无统计学意义[（84±14）vs （87±11）,P=0.144]。两组术中出血量[（38±25）ml vs （44±32）ml,P=0.343]、肿瘤大小均无统计学差异（P>0.05）,而术后进食时间及住院天数差异有统计学意义。 结论LTA和LRA入路肾上腺肿瘤切除均可达到安全、满意的疗效。采用LRA术式平均手术时间短于LTA术式,术后患者恢复较LTA组快。     

Endoscopic adrenalectomy for pheochromocytoma: difference between the transperitoneal and retroperitoneal approaches in terms of the operative course

Background Due to the intraoperative catecholamine secretion with hemodynamic changes, a larger tumor size and marked neovascularization, as compared with other adrenal pathologies, endoscopic adrenalectomy for pheochromocytoma represents a particular challenge involving a more difficult and morbid procedure. The aim of this study was to identify the optimal surgical approach for endoscopic adrenalectomy in patients with pheochromocytoma. Methods Over a period of 10 years (February 1994 to June 2004), 38 consecutive patients underwent endoscopic adrenalectomy for pheochromocytoma. As three patients underwent a bilateral procedure, a total of 41 adrenalectomies were performed. The transperitoneal approach was carried out in 23 patients, whereas 18 patients underwent a retroperitoneal adrenalectomy by a single operative team. Perioperative parameters were prospectively followed. Results There was no conversion to the open procedure. Intraoperative hypertensive episodes occurred in 21 patients (55.3%) and were controlled by antihypertensive agents. In 11 patients (28.9%), blood pressure values rose to above 200 mmHg (>1 min). A comparison between the retroperitoneal and transperitoneal procedures did not show a significant difference between the maximum intraoperative systolic (p = 0.730) and diastolic (p = 0.663) blood pressure values although intraoperative blood pressure peaks were seen more frequently during retroperitoneal adrenalectomy. The operative time was shorter for the patients who had transperitoneal adrenalectomy than compared to for those who had retroperitoneal adrenalectomy, although the difference was not significant. The intraoperative blood loss, perioperative morbidity, and length of postoperative hospital stay did not differ significantly between the surgical techniques (p > 0.05). Conclusion After adequate preparation, endoscopic adrenalectomy may be performed in patients with pheochromocytoma via both the retroperitoneal and the transperitoneal approaches. The shorter operating time, less frequent intraoperative blood pressure peaks, and the better overview of the operating field recommend the transperitoneal approach with the patient placed in a lateral position as the preferred operative procedure.     

经腹腔和经后腹膜腔途径腹腔镜手术治疗肾上腺肿瘤的对比研究

目的比较经腹腔途径和经后腹膜腔途径两种腹腔镜手术在肾上腺肿瘤治疗中的应用及对机体应激的影响。方法 2001年12月至2009年2月我们应用腹腔镜手术治疗肾上腺肿瘤110例,其中34例采用经腹腔途径,76例采用后腹膜腔途径,两组患者年龄、性别构成、体重指数、肿瘤大小等指标无明显差别;采用化学发光法检测术前24h、术中切除瘤体时及术后24h血清肿瘤坏死因子-α(TNF-α)、白介素6(IL-6)、C反应蛋白(CRP)和血清淀粉样蛋白A(SAA)水平。结果 110例手术全部成功,手术时间30～250min,其中经腹腔途径160±30min(80～250min),经后腹腔途径60±14min(30～180min),两组差别具有统计学意义(t=2.33,P=0.006);术中出血10～150ml,其中经腹腔途径组80±24m(l40～150ml),后腹膜腔途径组20±7ml(10～90ml),两组差别具有统计学意义(t=3.19,P=0.02),所有患者均未输血。110例患者术后平均住院3～14d,其中经腹腔途径组7±2d,后腹膜腔途径组5±1d,差别无统计学意义(t=1.06,P=0.17)。两组患者术前24h、术中切除瘤体时及术后24h血清TNF-α,IL-6,CRP和SAA水平差别均无统计学意义(P>0.05)。结论腹腔镜手术治疗肾上腺肿瘤,具有创伤小,康复快,安全可靠的优点。后腹膜腔途径相对腹腔途径术中出血更少,手术时间更短。     

Expanding the indications for laparoscopic retroperitoneal adrenalectomy: experience with 81 resections

Background

Laparoscopic retroperitoneal (RP) adrenalectomy has gained popularity as the preferred approach over transabdominal (TA) method; however, surgeons have been reluctant to offer this operation to obese patients because of the concerns over inadequate working space and overall perceived higher rate of complications. The aim of the present study was to evaluate the feasibility and safety of RP adrenalectomy compared with TA adrenalectomy, specifically in morbidly obese patients.

Methods

All laparoscopic adrenalectomies performed at our institution between 2004 and 2012 were reviewed retrospectively. Presenting features, operative characteristics, and postoperative outcomes were evaluated. Complications were graded using Clavien system. Continuous variables were compared using Student t-test. Categorical variables were compared using χ²-test. Prediction models were constructed using linear or logistic regression as appropriate.

Results

Eighty-one RP and 130 TA procedures were performed, 26 (12.3%) and 60 (28.4%), respectively in obese patients (BMI > 30). Among the obese patients, operative time and estimated blood loss were less for RP (90 versus 130 min; P < 0.001 and 0 versus 50 mL; P < 0.001). Differences in the length of stay, overall mortality, incidence and severity of postoperative complications, and rates of readmission were not statistically significant between RP and TA procedures for all comers and in the obese patients. Controlling the operative characteristics and patient-specific factors, neither operative approach nor obesity was found to independently predict the postoperative complications.

Conclusions

Laparoscopic RP adrenalectomy is a safe and feasible technique for obese patients. In the obese patients and for all comers, it offers shorter operative time, decreased estimated blood loss, with comparable length of stay and morbidity and mortality rates. We therefore recommend that this technique should be considered for patients undergoing adrenal resection.     

Our experience with retroperitoneal and transperitoneal laparoscopic pyeloplasty for pelvi-ureteric junction obstruction

OBJECTIVE: Laparoscopic dismembered pyeloplasty has been quoted to have equivalent success rates to the traditional open procedure in the treatment of pelvi-ureteric junction obstruction (PUJO). The aim of this study was to report our experience with laparoscopic pyeloplasty. PATIENTS AND METHODS: All patients with PUJO are entered into a database to record patient, operative and post-operative details. Over an eleven-year period, 176 procedures were performed. Eighty-three procedures were dismembered laparoscopic pyeloplasties, of which two retroperitoneal procedures were converted to open. The first 17 procedures were performed via the retroperitoneal approach and the following 66 via the transperitoneal route. Thirty-one procedures were open pyeloplasty. RESULTS: The retroperitoneal group had a mean follow up of 35 (16-66) months. Five patients (33%) developed recurrent symptoms with evidence of obstruction seen on the renogram within 4 months and required further surgery. The transperitoneal group had a mean follow up of 15 (3-38) months. Five patients were classified as failures (mean time to failure 4.6 months) resulting in a success rate of 92% for the transperitoneal route. Both groups had a mean post-operative hospital stay of 3.6 days. Open pyeloplasty at our institution has a success rate of 88% at a mean follow up of 85 months (range 3-260 months) and a mean length of post-operative stay of 6 days. CONCLUSION: Overall our success rate following laparoscopic pyeloplasty is 88%. However, our preferred approach is transperitoneal, which is associated with a success rate of 92%. This is equivalent, if not better than that seen following open pyeloplasty with the additional benefits of reduced hospital stay and time to recovery. There are many possible explanations for this difference in success rates between approaches, however equivalent results are reported in the literature and therefore the learning curve is likely to be the major factor in this series.     

经腹腔途径腹腔镜解剖性肾上腺切除术的临床体会

目的：总结经腹腔途径腹腔镜解剖性肾上腺切除术的手术体会及经验。方法：2008年10月至2013年3月采用经腹腔途径行腹腔镜解剖性肾上腺切除术56例,其中男34例,女22例,平均（45.1±11.2）岁。左侧37例,右侧19例,肿瘤直径平均（3.3±0.61）cm。结果：56例手术均经腹腔途径顺利完成,无中转开放,手术时间平均（67±16）min,估计术中出血平均（38±10.3）ml,术后平均（1.5±0.5）d肛门排气,术后24 h下床活动,术中、术后均未输血,且无严重并发症发生。术后病理证实为肾上腺腺瘤。结论：经腹腔途径行腹腔镜解剖性肾上腺切除术具有手术空间大、解剖标志清晰、手术创伤小、康复快等优点,是肾上腺切除术的安全术式。