腹腔镜手术在小儿泌尿外科的应用

目的　总结腹腔镜及腹腔镜辅助技术开展小儿泌尿外科手术的经验。　方法　腹腔镜手术 33例 ,男 2 4例 ,女 9例 ,平均年龄 4 .6岁。其中肾发育不良 5例 ,不能触及的隐睾 14例 ,肾积水肾盂输尿管连接处梗阻 11例 ,重复肾积水、重复肾伴重复输尿管囊肿各 1例 ,肾盂结石 1例。采用后腹腔镜肾、半肾切除 ,肾盂切开取石 7例 ;后腹腔镜辅助离断式肾盂成形术 11例 ;腹腔镜睾丸固定术或切除术 14例 ;气膀胱镜双输尿管移植术 1例。　结果　 33例手术均获成功 ,无 1例中转开放手术。术中出血量少 ,术后恢复快 ,术后第 1天进食。随访 2个月～ 3年 ,无并发症。　结论　腹腔镜及腹腔镜辅助手术治疗小儿肾积水、不能触及的隐睾等疾病 ,手术效果与开放手术相同。     

小儿重复肾并积水28例临床分析

目的　探讨小儿重复肾并积水的诊断及治疗。方法　2 8例小儿重复肾并积水中,2 6例为单纯重复肾积水,1例为重复肾及下肾积水,1例为下肾积水,2 7例行重复肾重复输尿管切除术,1例行下肾离断性肾盂输尿管成形术。结果　所有病例术后恢复良好。结论　重复肾积水多由输尿管囊肿所致,下肾积水术前要了解是输尿管反流还是梗阻,才能决定手术,不要轻易切除下肾。     

后腹腔镜半肾输尿管切除术治疗成人重复肾24例报告

目的探讨后腹腔镜半肾输尿管切除术治疗成人重复肾的手术方法和临床效果,并介绍一种防止术后尿性囊肿的方法。方法采用后腹腔镜半肾输尿管切除术治疗成人上半重复肾患者24例。男9例,女15例。平均年龄21岁。左侧11例,右侧13例。术中同时实施肾盂黏膜剥离术。观察手术时间、术中出血量和术中术后并发症及手术效果。结果24例手术均成功。手术时间55～108 min,平均78 min。术中出血量10～35 ml,平均22 ml。术后住院时间5～7 d,平均6．2 d。术中和术后未出现明显并发症。随访3～45个月,平均29个月,下半肾功能良好。结论后腹腔镜半肾输尿管切除术治疗成人重复肾具有创伤小、出血少、恢复快等特点。剥离肾盂黏膜是一种有效预防术后尿性囊肿发生的方法。     

成人输尿管囊肿13例报告

目的总结成人输尿管囊肿的诊治经验。方法对住院手术的13例输尿管囊肿患者的临床资料进行回顾性分析。结果所有病例均经B超、静脉肾盂造影（IVU）及膀胱镜检查确诊,采用开放手术治疗者2例,采用经尿道输尿管囊肿电切术治疗者11例。术后平均随访8月,疗效确切。结论对成人输尿管囊肿直径≤3．0cm者宜行腔内手术,而对于直径〉3cm及合并严重的重复肾、重复输尿管畸形者宜采用开放性手术,并行输尿管再植抗返流。     

重复肾合并同侧肾盂癌的诊治特点分析

目的:探讨重复肾畸形合并同侧肾盂癌的诊治特点。方法:回顾性分析2008~2013年我院收治5例重复肾合并同侧肾盂癌患者的临床资料。其中男3例,女2例,平均年龄63(42~83)岁。5例均行泌尿系B超、CT、MRI、IVU及CTU检查,2例行膀胱输尿管逆行造影检查,2例行泌尿系CTA检查。完全性重复肾畸形2例,不完全性3例;肿瘤发生在上位肾4例,下位肾1例。结果:2例行后腹腔镜半肾输尿管切除术,3例行后腹腔镜肾盂癌根治术。术后病理报告均示肾盂浸润性尿路上皮癌。5例患者术中术后均未出现明显并发症,术后30d复查SCr平均94.3(62.1~125.0)μmol/L,5例患者平均随访25(6~57)个月,均未出现肿瘤复发及转移。结论:重复肾畸形合并肾盂癌临床少见,肿瘤多发生于重复肾上位肾盂内,确诊需结合多种检查手段。手术仍是主要的治疗手段,应根据患者肾功能情况选择手术方案。     

经腹腹腔镜肾切除术治疗成人巨大肾积水26例报告

目的:探讨经腹腹腔镜肾切除术治疗成人巨大肾积水的临床疗效、安全性及手术技巧。方法:回顾分析2012年5月至2015年7月采用经腹入路为26例巨大肾积水患者行腹腔镜肾切除术的临床资料,其中男17例,女9例;19~61岁,平均(42.0±6.7)岁。肾盂输尿管交界处狭窄13例,输尿管结石10例,输尿管膀胱连接部梗阻3例。左侧15例,右侧11例。通过改进手术方法,观察手术时间、术中出血量、术后住院时间、并发症及手术效果。结果:26例手术均获成功,无中转开放手术及严重并发症发生。肾积水量平均(4 800±1 860)ml,手术时间平均(76±19)min,术中出血量平均(55±27)ml,术后平均住院(6.4±1.3)d。结论:成人巨大肾积水行腹腔镜肾切除术是安全、可行的,通过一定的技巧改进有助于手术的顺利进行,值得推广。     

泌尿外科：肾脏、输尿管

后腹腔镜肾癌根治术的临床疗效评估（附67例报告）；后腹腔镜根治性肾输尿管切除术21例报告；腹腔镜经腹腔输尿管切开取石加肾折叠术治疗输尿管结石并重度肾积水；输尿管镜联合肾镜处理输尿管中下段大结石；重复肾双输尿管畸形的手术治疗     

成人完全性重复肾输尿管畸形的诊治（附5例报告）

目的：提高对成人完全性重复肾输尿管畸形的诊治水平。方法：回顾性分析5例成人重复肾输尿管畸形患者的临床症状、影像学检查、手术方式、术后并发症和随访情况。结果：2例行输尿管膀胱吻合术,手术时间分别为68min及62min。术后1个月复查,患者无明显临床症状,B超复查重复肾积液消失或减轻。1例随访1年,无复发症状。2例行重复肾输尿管切除术,手术时间分别为148min及161min。1例需术中输血,1例术后出现尿瘘并发症,经保守治疗后逐渐痊愈。1个月后复查无后期并发症。结论：成人完全性重复肾输尿管畸形不常见,对于有相关临床症状疑似该疾病的患者,须进行针对性影像学检查以明确诊断,治疗策略应个性化。保守观察、肾输尿管切除、输尿管膀胱吻合术为最常用的治疗方式。     

腹腔镜重复肾输尿管切除术治疗重复肾输尿管3例报告及文献复习

目的 探讨腹腔镜重复肾输尿管切除术治疗成人重复肾畸形的方法和疗效.方法 2011年1月至2011年5月采用腹腔镜重复肾输尿管切除术治疗重复肾输尿管畸形患者3例.观察手术时间、术中出血量、术后早期恢复情况、并发症及手术疗效.结果 3例患者均顺利完成腹腔镜重复肾输尿管切除术,手术时间为153 min(110～200 min),术中平均出血量为77 ml(50～100 m1),均未输血,术中未见明显并发症,术后复查肾功能未见明显改变.术后l天进流质饮食,5天拔除导尿管并下床活动,待负压引流管引流量<10 ml并行B超检查未见引流管周围及肾周积液后拔除.术后患者无明显发热、腰酸及漏尿症状.结论 腹腔镜重复肾输尿管切除术治疗重复肾输尿管畸形具有创伤小、出血少、术后恢复快等特点,是一种安全、有效的微创治疗方法,为治疗成人重复肾畸形提供了一种新的选择.     

腹腔镜下与开放手术半肾切除治疗小儿重复肾的疗效比较

目的 比较腹腔镜下和开放手术半肾切除治疗小儿重复肾的疗效. 方法先天性重复肾患儿64例.平均年龄17个月.开放手术组36例,腹腔镜下手术组28例.开放组平均年龄18个月,男19例,女17例;输尿管异位开口15例、输尿管膨出18例、膀胱输尿管反流2例、肾盂输尿管连接处梗阻1例.腹腔镜组平均年龄16个月,男18例,女10例;输尿管异位开口9例、输尿管膨出16例、膀胱输尿管反流3例.2组患儿年龄、病种比较差异无统计学意义(P＞0.05). 结果 腹腔镜组术中转开放手术2例.2组患儿术中术后未发生外科并发症.开放组平均手术时间2.5 h,手术前后血红蛋白差均值2.64 g,术后引流量平均91.4 ml,引流天数平均4.2 d,住院天数平均19.3d;腹腔镜组分别为2.9 h、1.45 g、55.4 ml、3.4 d和14.3 d;2组比较差异均有统计学意义(P＜0.05).结论 腹腔镜下半肾切除术治疗小儿重复肾畸形半肾无功能安全有效,与开放手术比较手术创伤小、术中出血量少、术后疼痛和住院时间短.     

小儿输尿管膨出症的治疗

目的探讨各种方法治疗输尿管膨出症的疗效,寻找影响预后的有关因素。方法 31例输尿管膨出症,男4例,女27例;左侧15例,右侧12例,双侧4例。其中单一输尿管膨出2例,重肾并输尿管膨出29例。VCU检查18例,3例发现中—重度反流,31例均行超声和IVU及CT检查。结果术后随访0.5～3 a,2例单一输尿管膨出症行膨出切除输尿管膀胱再植术,29例重肾中,4例经膀胱行输尿管膨出切除输尿管膀胱再植术。3例中—重度反流,2例行输尿管膨出切除加上半肾切除术,1例行上半肾切除术,术后因反流持续存在,需再次手术;其余22例均行上半肾切除术,术后2例因严重尿路感染行输尿管残端切除术。结论输尿管膨出的治疗应根据输尿管膨出的类型、肾功能、有无反流决定手术方式,对于大多数重肾,单纯上半肾切除预后良好,若术前VCU检查有中—重度返流,应行完全重建术。     

重复肾输尿管畸形伴下位肾重度积水一例报告

重复肾输尿管畸形是常见的泌尿系畸形之一,多数患者无明显临床表现,极少部分病例合并输尿管梗阻,导致肾积水呈囊状结构,临床上易与单纯性肾囊肿相混淆。本文报道1例右侧重复肾输尿管畸形伴下位肾巨大肾积水患者,旨在为临床诊治提供参考。     

Application of percutaneous nephrolithotomy combined with da Vinci Xi robot in complicated upper urinary tract repair surgery: A case report

Duplex kidney and ureter is a congenital malformation. Few patients present with hydronephrosis caused by obstruction of the ureteropelvic junction of the duplex kidney, but lower kidney calculi caused by a duplex kidney abnormality is rare. This study reports a case of a duplex kidney and ureter complicated by multiple calculi in the duplex lower kidney. Percutaneous nephrolithotomy combined with a da Vinci robot-assisted laparoscopic upper urinary tract reconstruction was performed. The lower ureter was resected, and the lower kidney was preserved. One year after the surgery, a follow-up examination reported satisfactory renal function without hydronephrosis or calculi.     

Fate of the retained ureteral stump after upper pole heminephrectomy in duplex kidneys

PURPOSE: We review the long-term outcome of retained ureteral stumps in children undergoing heminephrectomy for nonfunctioning upper pole moieties in duplex kidneys. MATERIALS AND METHODS: The medical records of 50 patients who underwent 50 upper pole heminephrectomies for a nonfunctioning upper pole moiety of a duplex kidney between January 1990 and December 2000 were reviewed retrospectively. RESULTS: Median patient age at heminephrectomy was 2.5 years (range 3 weeks to 16.5 years) and median followup was 6 years (range 1 to 11). Indications for heminephrectomy in the 50 renal units were obstructive ureterocele in 25 (50%) cases, ectopic ureter in 15 (30%), obstructive megaloureter in 5 (10%) and reflux nephropathy in 5 (10%). A total of 48 (96%) of the corresponding ureters were taken down as low as possible and transfixed through the heminephrectomy incision. Residual stump excision was required in 5 (10%) of the 50 units for recurrent urinary tract infection due to vesicoureteral reflux. CONCLUSIONS: Our long-term followup suggests that the majority of patients with residual ureteral stumps after upper pole heminephrectomy do not require stump resection.     

Long-term outcome of the retained ureteral stump after lower pole heminephrectomy in duplex kidneys

OBJECTIVES: Duplication of the ureter and renal pelvis is the most common upper urinary tract anomaly in childhood. The anatomical and functional divisions between upper and lower moieties of duplex kidney are extremely variable. The underlying pathological condition associated with a lower moiety is usually massive vesicoureteral reflux (VUR) to the lower collecting system and only rare obstruction. The non-functioning upper moiety is usually associated with obstructive ectopic ureter (with or without ureterocele). Most lower pole heminephrectomies are carried out for non-functioning lower moieties. In most cases, the lower defunctionalised segment of the ureter is left in situ. Complete ureterectomy is usually performed if presence of VUR into the lower end of the corresponding ureter is shown. There is little information on the long-term outcome of residual ureteral 'stumps'. The purpose of our study was to review the long-term outcome of retained ureteral stumps in children undergoing heminephrectomy for non-functioning lower pole moieties in duplex kidneys. MATERIALS AND METHODS: The medical records of 19 patients who underwent 20 lower pole heminephrectomies for a non-functioning lower pole moiety of a duplex kidney between January 1990 and December 2000 were reviewed retrospectively. Median age at heminephrectomy was 4.5 years (range: 1 month to 12 years). Indications for heminephrectomy in the 20 renal units was reflux nephropathy in 16 (80%) and obstructive nephropathy in 4 (20%). All corresponding ureters were taken down as low as possible and transfixed through the heminephrectomy incision. Median follow-up was 8.5 years (range: 1-11 years). RESULTS: Eight (40%) showed VUR into the stump after lower pole heminephrectomy. Two of these underwent subureteral endoscopic correction of VUR with polytetrafluoroethylene paste and resection of the stump was carried out in remaining two patients for recurrent urinary tract infections (UTI). Remaining four of the eight patients demonstrated spontaneous resolution of VUR during follow-up. CONCLUSIONS: Our data suggest that the vast majority of patients with residual ureteral stumps after lower pole heminephrectomy do not require stump resection at long-term follow-up.     

经腹腹腔镜半肾切除术治疗成人重复肾畸形(附12例报告)

目的:探讨经腹腹腔镜半肾切除术治疗成人重复肾畸形的方法、可行性和临床疗效。方法:回顾我院2010年6月~2014年1月采用经腹腹腔镜行重复肾畸形上半肾切除术治疗12例患者,其中男4例,女8例,年龄18~56岁,平均36岁。左侧9例,右侧3例,12例重复肾畸形患者均为上半肾病变。结果:12例手术均获成功,无中转开放手术。手术时间60~120min,平均90min;术中出血量20~150ml,平均50ml;术后肠道功能恢复时间1~3d,平均2d;术后24~72h进流食,3~4d拔除引流管;术后住院时间7~9d,平均8d;术后随诊6~15个月,平均9个月;术后3、6个月内均行IVU检查,下半肾功能均正常,原发症状消失。结论:经腹腹腔镜半肾切除术治疗成人重复肾畸形具有手术视野开阔、住院时间短、创伤小、恢复快等优点,是治疗成人重复肾畸形安全有效的手术方法。     

Ectopic ureter as cause of pyonephrosis and urinary incontinence

Ectopic ureter accounts with an incidence of 1 in 2000 newborns. When present, ectopic ureter can be associated with duplex kidneys in an 85 % of the cases. Clinical manifestations of this malformation include incontinence and urinary tract infections. Ectopic ureter frequently occurs in association with a dysplastic upper pole renal moiety. When a poorly functioning upper pole segment is present, a standard surgical treatment is upper pole heminephrectomy. A 23-years old woman presented with left renal colic pain, fever and urinary leak. Ultrasound, intravenous pyelogram and antegrade pyelogram revealed a partial duplex right kidney and a complete duplex left kidney with hydronephrosis and ectopic insertion into the urethra of the left upper pole moiety. Following diagnosis upper pole heminephrectomy and partial ureterectomy was performed.     

腹腔镜下半肾及输尿管切除治疗小儿重复肾

目的分析腹腔镜下半肾及输尿管切除治疗小儿重复肾输尿管的病例,总结手术技巧及经验。 方法回顾分析2015年12月至2016年11月于我院因重复肾接受腹腔镜下选择性血管阻断切除上半肾的儿科患者资料。本组纳入患者11例,男4例,女7例。年龄6个月至8岁。所有患者完成术前准备后全麻下手术治疗。手术采用3通道经腹腔入路腹腔镜下上半肾及其输尿管切除,术中在辨别并处理上肾输尿管后选择性阻断上肾血管后切除上半肾。记录手术时间、失血量、术后创面引流量、术中副损伤及术后并发症。术后3 d复查患肾超声,血、尿常规及血肾功。门诊随访1～6月。 结果所有手术均顺利完成,无中转开放及输血病例。平均手术时间133（110～154）min,术中出血量14（10～20）ml。术后6 h进食,引流管停留时间3 d,平均术后总引流量16（5～38）ml。术后1 d下地活动。术后平均住院时间5 d。所有患者获得术后1～6月随访。手术前后血红蛋白水平差异无统计学意义。无肾萎缩及输尿管残端感染出现。 结论腹腔镜下半肾及输尿管切除治疗小儿重复肾输尿管安全有效,手术创伤小,可以避免保留肾的缺血再灌注损伤,术中、术后失血少,值得临床推广。     

Results of operative therapy of double kidney

107 patients were submitted to operative treatment of a duplex kidney from 1968 to 1980. In 62 kidneys of children heminephrectomy was performed and in 26 parenchymapreserving operations like ureterocystoneostomies (n = 17) and pyelopyelostomies (n = 9) were done. Fever and urinary tract infection was seen more often in patients submitted to partial ureterectomy than after total ureterectomy. Long time follow-up (medium 8.8 years) was available in 33% of the children. Two non-functioning renal units after heminephrectomy and one recurrent vesicoureteral reflux were documented. Renal length was determined by planimetry. While values within the +/- 2SD range were seen after antireflux surgery and after pyelopyelostomies growth of the kidneys after heminephrectomy seemed to be hampered. Although renal hypoplasia and dysplasia is seen in a lot of duplex kidneys, heminephrectomy should not be done routinely. Preoperative planimetry of the kidney gives information about the amount of parenchyma most probably lost by heminephrectomy. In addition malfunction of the contralateral "good" kidney should be suspected, if compensatory hypertrophy of this kidney does not develop in spite of a grossly scarred contralateral kidney.