后腹腔镜结核性无功能肾切除术（附9例报告）

目的：探讨后腹腔镜下切除结核性无功能肾脏的可行性与临床疗效。方法：2005年9月～2007年12月,采用后腹腔镜技术切除结核性无功能肾脏9例,首先解剖出肾脏动、静脉用尼龙夹结扎后切断,而后用Ligasure血管闭合系统于肾周筋膜外分离切除肾脏,保留同侧肾上腺,输尿管尽量向下游离。取同侧下腹小切口,行输尿管全长切除,标本自下腹切口取出。有2例结核性膀胱挛缩患者同时行乙状结肠膀胱扩大术。结果：9例患者腹腔镜手术完全成功,未发生周围脏器及大血管的损伤等严重并发症,无中转开放手术。手术时间120～150min,平均132min,失血量70～140ml,平均110ml。随访3～15个月,7例患者肾脏功能正常,2例膀胱挛缩行膀胱扩大患者肾功能较术前有好转,尿频尿急等膀胱刺激症状消失,膀胱容量240～300ml。结论：改良的后腹腔镜下肾脏切除术可以安全的切除结核性无功能肾,对于腔镜经验丰富的操作者可以作为临床治疗结核性无功能肾脏的新选择。     

Laparoscopic radical nephrectomy: incorporating advantages of hand assisted and standard laparoscopy

PURPOSE: We present an approach to laparoscopic radical nephrectomy and intact specimen extraction, which incorporates hand assisted and standard laparoscopic techniques. MATERIALS AND METHODS: A refined approach to laparoscopic radical nephrectomy is described and our experience is reviewed. A low, muscle splitting Gibson incision is made just lateral to the rectus muscle and the hand port is inserted. A trocar is placed through the hand port and pneumoperitoneum is established. With the laparoscope in the hand port trocar 2 additional trocars are placed under direct vision. The laparoscope is then repositioned through the middle trocar and standard laparoscopic instruments are used through the other 2 trocars including the one in the hand port. If at any time during the procedure the surgeon believes the hand would be useful or needed, the trocar is removed from the hand port and the hand is inserted. RESULTS: This approach has been applied to 7 patients. Mean estimated blood loss was 200 cc (range 50 to 300) and mean operative time was 276.7 minutes (range 247 to 360). Mean specimen weight was 767 gm. (range 538 to 1,170). Pathologically 6 specimens were renal cell carcinoma (grades 2 to 4) and 1 was oncocytoma. Mean length of hospital stay was 3.71 days (range 2 to 7). There were no major complications. CONCLUSIONS: We believe that this approach enables the surgeon to incorporate the advantages of the hand assisted and standard laparoscopic approaches.     

腹腔镜下肾部分切除术(附3例报告)

2000年4月-2002年8月，对l例右肾下极错构瘤和2例右肾上盏憩室并结石患分别行腹腔镜肾部分切除术。先游离患肾，显露肾动、静脉及输尿管，用橡皮带阻断患肾血流，行肾部分切除术；再用氩气刀处理肾脏创面、凝固止血；用2m可吸收线作“8”字缝合，关闭肾切面，恢复肾脏血供，妥善固定肾脏，关闭戳口。3例手术均获成功，无中转开放。手术时间平均4．1(3—5)h；术中出血平均400(150-650)ml；肾蒂阻断时间为30min。术后3月复查CT，患肾功能良好，无肿瘤和结石复发。腹腔镜肾部分切除术是治疗肾脏疾病的有效和微创方法之一。     

Laparoscopic pyeloplasty: current status

OBJECTIVE

To review current publications and report our results and long‐term follow‐up of laparoscopic transperitoneal pyeloplasty for pelvi‐ureteric junction (PUJ) obstruction.

PATIENTS AND METHODS

In all, 147 laparoscopic transperitoneal pyeloplasties were performed between August 1993 and November 2000 (mean patient age 35.7 years, range 10–85). All patients were diagnosed with PUJ obstruction by symptoms and intravenous urography, radionuclide diuretic renography or ultrasonography. An Anderson‐Hynes dismembered pyeloplasty (106), Y‐V plasty (28), Fenger plasty (11) and others (two) were used, according to the intraoperative findings. Twenty‐five patients had secondary obstruction, having had previous surgery to the PUJ. The mean (range) follow‐up was 24 (3–84) months; all patients were followed clinically and radiologically.

RESULTS

The mean operative duration time was 246 (100–480) min and estimated blood loss was 158 mL. Crossing vessels were identified in 80 cases. The success rate for all, primary and secondary patients was 95%, 98% and 84%, respectively. With one exception, all failures occurred within 6 months. Twenty‐one patients (22 renal units) had simultaneous laparoscopic pyeloplasty and lithotomy; they were treated successfully and all have an intact PUJ, and 20 renal units (90%) were stone‐free. The overall complication rate was 8.8%.

CONCLUSIONS

This series has comparable success rates to those of open pyeloplasty and the morbidity was minimal. Laparoscopic pyeloplasty may soon become the standard operation for PUJ obstruction, especially with crossing vessels.

     

Laparoscopic Nephrectomy in Children: Two Case Reports

We successfully performed a laparoscopic nephrectomy on 2 young girls in March 1994 and August 1994. The first patient was a 9-year-old girl with a hypoplastic kidney associated with an ectopic ureterocele, and the other was a 3-year-old girl with a nonfunctioning hydronephrotic kidney caused by stricture of the pyeloureteral junction. The operating times were 153 and 183 minutes, respectively. No complications occurred intraoperatively or postoperatively in either patient. The 9-year-old girl resumed normal daily activities by postoperative day 2, and the 3-year-old girl by postoperative day 3. Both girls were discharged on day 4.     

Laparoscopic ureteral reimplantation using the dome advancement technique: A case series and review of the literature

Aim: Ureteral resection and reimplantation is one of the treatment options for pathology in the middle and distal ureter. Laparoscopic ureteral reimplantation has been shown to be a feasible alternative to the open approach. Among the various techniques of laparoscopic reimplantation, the dome advancement technique has been reported as a simple and effective method. Patients and Methods: Five patients were found to have distal ureteric stricture necessitating partial ureterectomy and ureteral reimplantation. Their results are reviewed and compared to published results. Results: Laparoscopic distal ureterectomy and ureteral reimplantation was successfully performed in all five patients using the dome advancement technique. All patients made good postoperative recovery without evidence of obstruction on follow‐up imaging. Conclusion: Laparoscopic ureteral reimplantation is a feasible minimally‐invasive option for patients requiring ureteral reconstruction. The dome advancement technique is simple and reproducible, with a good functional outcome.     

Laparoscopic live-donor nephrectomy: modifications for developing nations

OBJECTIVE: To describe modifications to laparoscopic live-donor nephrectomy (LLDN) to make it more cost-effective for developing countries; LLDN was developed as a better alternative to conventional donor nephrectomy, with advantages of an earlier return to normal activities and smaller scars, but is not popular in developing countries because of high cost of disposable items. PATIENTS AND METHODS: From January 2000 to January 2002, 148 LLDNs were performed, of which two used a hand-assisted technique, 17 the standard technique, 79 a modified laparoscopically assisted cost-saving approach and 50 by the modified technique. In the latter approach the kidney was delivered through a 6-8 cm anterior subcostal flank incision. In last 50 patients we further modified the technique, clipping the hilum using endoclips and delivering the kidney by holding the lateral pararenal fat through a 5 cm iliac fossa incision. RESULTS: The mean age, operative duration, warm ischaemia time, blood loss, analgesic requirements, pain score and hospital stay were comparable among the various techniques used. Re-exploration was required in four patients (bleeding in two, trocar-induced bowel injury in two). Immediate complications after surgery occurred in 20% of patients. Using endoclips, the cost was considerably reduced, from $400 to $290. The iliac fossa incision was aesthetically pleasing and more acceptable to patients. CONCLUSION: These modifications are relevant in the context of a developing nation, as they provide all the benefits of LLDN at reduced cost and with better cosmetic results.     

腹腔镜与开放行肾部分切除术的临床疗效比较

目的：比较腹腔镜下与开放行肾部分切除术治疗肾肿瘤的效果。方法：回顾性分析2007年1月～2010年7月肾部分切除术41例,其中腹腔镜肾部分切除术18例,开放肾部分切除术23例,对两种方法的临床效果进行比较。结果：腹腔镜组和开放组术中出血量分别为（200±35）ml、（363±48）ml,进食时间分别为（2．7士1．0）d、（3．8±1．3）d,住院时间分别为（13．2±3．0）d、（16．4±4．3）d,两组比较差异有统计学意义（P〈0．05）。两组术后引流管留置时间分别为（3．7±1．3）d、（4．7士1．4）d,两组比较无明显差异（P〉0．05）。腹腔镜组和开放组手术时间分别为（137土95）min、（125±52）min,热缺血时间分别为（27．8i2．1）min、（17．8±8．6）min,两组比较差异有统计学意义（P〈0．05）。结论：与开放肾部分切除术相比,腹腔镜肾部分切除术具有失血量少、术后进食快、住院时间短等优点,但手术时间和。肾热缺血时间稍长。     

后腹腔入路与经腹入路腹腔镜下肾部分切除术治疗肾癌的临床比较

目的:评价后腹腔入路与经腹入路腹腔镜下肾部分切除术治疗早期肾癌的临床效果。方法:回顾性分析后腹腔入路(17例,A组)与经腹入路(15例,B组)腹腔镜下肾部分切除术治疗早期肾癌患者的临床资料,A组肿瘤大小1.2～3.9(2.6±1.3)cm,B组肿瘤大小1.0～4.0(2.7±1.3)cm。两组术前临床分期均为T_1N_0M_0。比较两种方法的肿瘤大小、手术时间、术中失血量、热缺血时间、标本重量、恢复进食时间、住院时间及手术效果。结果:A组手术均成功,B组1例因肾动脉损伤出血中转开放手术。两组肿瘤大小(2.6±1.3 cm vs 2.7±1.3cm)、术中失血量(302±85mlvs305±90ml)、标本重量(42±31g vs 45±33 g)、热缺血时间(28±9.1 min vs30±9.2min)等方面无明显差异(P0.05);A组在手术时间(175±55 min vs 248±70 min)、恢复进食时间(24±5 h vs 49±11 h)和住院时间(6.5±1.6天vs 8.4±1.9天)均少于B组(P0.05)。结论:后腹腔入路与经腹入路腹腔镜下肾部分切除术均是治疗早期肾癌的一种微创和安全有效的治疗方法,后腹腔入路在手术时间、恢复进食时间及住院时间上少于经腹入路。     

Laparoscopic partial nephrectomy for hilar tumors

PURPOSE: Partial nephrectomy for hilar tumors represents a technical challenge not only for laparoscopic, but also for open surgeons. We report the technical feasibility and perioperative outcomes of laparoscopic partial nephrectomy (LPN) for hilar tumors. MATERIALS AND METHODS: Between January 2001 and September 2004, 25 of 362 patients (6.9%) undergoing LPN for tumor, as performed by a single surgeon, had a hilar tumor. We defined hilar tumor as a tumor located in the renal hilum that was demonstrated to be in actual physical contact with the renal artery and/or renal vein on preoperative 3-dimensional computerized tomography. En bloc hilar clamping with cold excision of the tumor, including its delicate mobilization from the renal vessels, followed by sutured renal reconstruction was performed routinely. RESULTS: Laparoscopic surgery was successful in all cases without any open conversions or operative re-interventions. Mean tumor size was 3.7 cm (range 1 to 10.3), 4 patients (16%) had a solitary kidney and the indication for LPN was imperative in 10 patients (40%). Pelvicaliceal repair was performed in 22 patients (88%), mean warm ischemia time was 36.4 minutes (range 27 to 48), mean blood loss was 231 cc (range 50 to 900), mean total operative time was 3.6 hours (range 2 to 5) and mean hospital stay was 3.5 days (range 1.5 to 6.7). Histopathology confirmed renal cell carcinoma in 17 patients (68%), of whom all had negative margins. In 2002 or earlier hemorrhagic complications occurred in 3 patients (12%). No kidney was lost for technical reasons. CONCLUSIONS: LPN can be performed in select patients with a hilar tumor. The technical feasibility reported further extends the scope of LPN. To our knowledge the initial experience in the literature is reported.     

Laparoscopic radical nephrectomy in the elderly

Authors from Innsbruck present their work in laparoscopic radical nephrectomy in elderly patients. They evaluated the outcome of this technique in patients over 75 years old and compared the results with a similar number of patients aged less than 75 years who had the same procedure. Despite more comorbid conditions in the older group the final outcome was equally as good as in the younger patients. Hormone‐refractory prostate cancer is becoming a matter of great concern, and authors from Paris describe their experience with a combination of docetaxel and zoledronic acid in this condition. In this early report, they found the use of these agents to be promising, and recommend the setting up of a prospective randomized trial.

OBJECTIVE

To evaluate the efficacy and outcome of laparoscopic radical nephrectomy (LRN) in patients aged >75 years, and to compare the results with those obtained from patients younger than this undergoing laparoscopic surgery for the same indication.

PATIENTS AND METHODS

From a retrospective review of 33 patients aged >75 years undergoing LRN, 28 were for tumour. A group of 28 consecutive patients aged <75 years undergoing laparoscopy for the same indication were used for comparison. The two groups were compared for American Society of Anesthesiology (ASA) physical status score, comorbidity, previous surgical history, operative duration, estimated blood loss, tumour size, complications during and after surgery, conversion rates, time to oral intake and drain removal, perioperative mortality and hospital stay.

RESULTS

Only the initial ASA score was significantly higher for the older patients. All other variables before, during and after surgery were similar for both groups.

CONCLUSIONS

The final outcome of laparoscopic surgery in elderly patients was as promising as in their younger counterparts. Therefore, elderly patients should not be excluded from LRN, even though they usually present with more comorbidities.

     

Laparoscopic specimen extraction: morcellation

OBJECTIVES

To review our experience with intact extraction and morcellation of nephrectomy specimens, and the advantages and disadvantages of morcellation indicated by current reports.

PATIENTS AND METHODS

In a previous study, 56 consecutive patients undergoing radical and simple transperitoneal laparoscopic nephrectomy were prospectively evaluated. Morcellation specimens (33) were extracted at the umbilical or lateral port sites and intact specimens (23) through an infra‐umbilical incision. Data were obtained on pathology, narcotic requirements, hospital stay, complications, estimated blood loss, size of renal mass based on preoperative imaging, specimen weight and extraction incision length

RESULTS

The mean incision length was 1.2 cm in the morcellation group and 7.1 cm in the intact group (P < 0.001). There were no significant differences in pain or recovery between the groups. In two cases of tumour nephrectomy, microscopic invasion of the perinephric adipose tissue in the intact specimen group were up‐staged from clinical T1 to pT3a disease; there was no change in patient treatment based on this information.

CONCLUSIONS

With proper technique, morcellation is safe for extracting renal tumours. The specimen can be evaluated for histology but not for pathological staging, limiting its use with transitional cell carcinoma. Port‐site seeding is rare, and does not appear to be more frequent than with open nephrectomy. Although morcellation is cosmetically more desirable, there was no significant advantage in operating time, pain or duration of hospital stay. The choice of extraction method depends on the surgeon's preference and patient choice.

     

Transvaginal Route for Kidney Extraction in Laparoscopic Donor Nephrectomy

Background and Objectives:

The aim of this retrospective study was to compare conventional laparoscopic living-donor nephrectomy with transvaginal natural orifice transluminal endoscopic surgery–assisted living-donor nephrectomy in terms of feasibility and reproducibility.

Methods:

A total of 115 consecutive female patients who underwent laparoscopic living-donor nephrectomy (n = 70) or transvaginal natural orifice transluminal endoscopic surgery–assisted living-donor nephrectomy (n = 45) were included and compared in terms of operative characteristics, as well as donor and recipient outcomes.

Results:

No significant difference was observed between the laparoscopic living-donor nephrectomy and transvaginal natural orifice transluminal endoscopic surgery–assisted living-donor nephrectomy groups in terms of mean duration of warm and cold ischemia, operation time, length of hospital stay, arterial anastomoses, visual analog scale pain scores, serum creatinine levels, and receiver outcomes, whereas a significantly higher number of venous anastomoses was noted in the laparoscopic living-donor nephrectomy group than in the transvaginal natural orifice transluminal endoscopic surgery–assisted living-donor nephrectomy group (P = .029).

Conclusions:

Transvaginal natural orifice transluminal endoscopic surgery–assisted living-donor nephrectomy seems to be a feasible and reproducible alternative to conventional laparoscopic living-donor nephrectomy in female donors provided the viability of the vagina as an organ retrieval route.     

腹腔镜肾切除术治疗巨大肾积水5例报告

目的：介绍腹腔镜肾切除术治疗巨大肾积水的临床经验.方法：2005年1月～2009年2月采用腹腔镜经后腹腔途径行肾切除术治疗巨大肾积水患者5例,男2例,女3例,平均年龄39（18～57）岁.5例均为肾盂输尿管连接部狭窄,其中左侧3例,右侧2例.观察手术时间、术中出血量,住院天数、并发症及手术效果.结果：5例均成功施行腹腔镜肾切除术,平均肾积水量4 500（3 000～11 000）ml,平均手术时间85（60～115）min,术中平均出血量45（10～80）ml.其中1例术前放置输尿管支架管引流尿液并控制感染,4例术中需切开肾皮质吸出部分或全部积水,以降低肾张力.结论：巨大肾积水行腹腔镜肾切除术安全、可行,通过放置输尿管支架管或切开肾皮质放出部分或全部积水对患肾减压有助于手术操作.     

Comparison of retroperitoneoscopic nephrectomy with open surgery for tuberculous nonfunctioning kidneys

PURPOSE: We describe, define and evaluate the role of retroperitoneoscopic nephrectomy for tuberculous nonfunctioning kidneys, and compare the results with those of open nephrectomy in similar cases in a nonrandomized study. MATERIALS AND METHODS: Beginning in July 1994, 9 patients underwent retroperitoneoscopic nephrectomy for tuberculous nonfunctioning kidneys at our center. Data obtained from the records of these patients were compared with those of 9 who underwent open nephrectomy for a similar indication during the same period. Retroperitoneoscopic nephrectomy was initially performed by kidney dissection followed by ligation of the hilar vessels. The technique was subsequently modified and the vessels controlled before dissecting the kidney. Various parameters were compared and statistical analysis was done. RESULTS: The 2 groups were similar in regard to patient age, gender and side of disease. Retroperitoneoscopic nephrectomy was successful in 7 of the 9 patients. Although 2 of our initial patients required conversion to open surgery, the remaining 7 successfully underwent retroperitoneoscopic nephrectomy after modifying the technique. Mean operative time was slightly greater in the retroperitoneoscopy than in the open surgery group (103.3 versus 92.2 minutes). Mean blood loss was less in the retroperitoneoscopy group (101.4 versus 123.3 ml.), mean hospital stay plus or minus standard deviation was significantly shorter (3.2 +/- 0.83 versus 8.88 +/- 3.37 days) and mean time to return to work was significantly less (3 versus 7 weeks). Mean analgesic requirement for opioids and diclofenac sodium was also lower in the retroperitoneoscopic nephrectomy group (0 versus 1.44 +/- 0.72 and 3.8 +/- 1.3 versus 4.3 +/- 1.2 doses, respectively). Minor complications developed in only 2 retroperitoneoscopy cases. CONCLUSIONS: Tuberculosis has been considered a contraindication to retroperitoneoscopic nephrectomy due to a high conversion rate. However, we believe that our modified technique of retroperitoneoscopic nephrectomy is a viable option for managing tuberculous nonfunctioning kidneys. The conversion rate is lower than previously reported. Comparing our results with those of open nephrectomy shows that retroperitoneoscopic nephrectomy is beneficial in all respects except for slightly longer operative time. Because of the benefits of minimally invasive surgery, this approach should be considered in such cases.     

Laparoscopic partial nephrectomy in solitary kidney

PURPOSE: We report our experience with LPN for tumor in a solitary kidney. MATERIALS AND METHODS: Of 430 patients undergoing LPN since February 1999 at our institution 22 (5%) underwent LPN for tumor in a solitary kidney, as performed by a single surgeon. The laparoscopic technique that we used duplicated open principles, including hilar clamping, cold cut tumor excision and sutured renal reconstruction. RESULTS: Mean tumor size was 3.6 cm (range 1.4 to 8.3, median 3 cm), median blood loss was 200 cc (range 50 to 500), warm ischemia time was 29 minutes (range 14 to 55), total operative time was 3.3 hours (range 2.2 to 4.5) and hospital stay was 2.8 days (range 1.3 to 12). Two cases (9%) were electively converted to open surgery. Pathological findings confirmed renal cell carcinoma in 16 patients (73%) with negative surgical margins in all those with LPN. Major complications occurred in 3 patients (15%) and minor complications developed in 7 (32%). Median preoperative and postoperative serum creatinine (1.2 and 1.5 mg/dl) and estimated glomerular filtration rate (67.5 and 50 ml per minute per 1.73 m2) reflected a change of 33% and 27%, respectively, which appeared proportionate to the median amount of kidney parenchyma excised (23%). One patient (4.5%) required temporary hemodialysis. At a median followup of 2.5 years (range 0.5 to 4.5) cancer specific and overall survival was 100% and 91%, respectively. No patient with LPN had local or port site recurrence, or metastatic disease. CONCLUSIONS: LPN can be performed efficaciously and safely in select patients with tumor in a solitary kidney. To our knowledge we present the largest series in the literature. Advanced laparoscopic experience and expertise are necessary in this high risk population.     

Laparoscopic donor nephrectomy – safety in a small‐volume transplant center

Riley J, Troxel S, Wakefield M, Ross G, Weinstein S. Laparoscopic donor nephrectomy – safety in a small‐volume transplant center.
Clin Transplant 2010: 24: 429–432. © 2009 John Wiley & Sons A/S. Abstract: Introduction: Laparoscopy is a standard surgical option for live donor nephrectomy (LDN) at the majority of transplant centers. Equivalent graft survival with shorter convalescence has been reported by several large volume centers. With the arrival of an experienced laparoscopic surgeon in 2002, we began to offer laparoscopic LDN at our institution. We report our experience as a large volume laparoscopic surgery program but a low volume transplant center. Methods: A retrospective review of the previous 34 LDN (17 open, 17 laparoscopic) performed at the University of Missouri were included. A single laparoscopic surgeon performed all laparoscopic procedures. Hand assisted laparoscopy was performed in 15 and standard laparoscopy with a pfannenstiel incision in two. Open procedures were performed through anterior subcostal or flank incision. A single surgeon performed all open procedures. Results: There was no statistical difference in age, body mass index or American Society of Anesthesiologies Score between the two groups. Mean operative time, estimated blood loss and hospital stay were 229 minutes, 324 cc and 2.2 days respectively in the laparoscopic group compared to 202 minutes, 440 cc and five days for the open group. Average warm ischemia time was 179 seconds. Recipient creatinine for the two groups at one week, one month and one year was not statistically significantly different. Each group had one graft loss due to medication noncompliance. Conclusion: For small transplant centers with an advanced laparoscopic program, laparoscopic LDN is a safe procedure with comparable outcomes to major transplant centers.