腹腔镜与开放性离断式肾盂成形术的疗效比较

目的比较腹腔镜与开放性离断式肾盂成形术治疗肾盂输尿管连接部梗阻（UPJO）的手术疗效。方法采用经腹腔途径腹腔镜下离断式肾盂成形术38例（A组）。男21例，女17例。年龄8～67岁，平均34岁。病变位于左侧23例，右侧15例。重度肾积水21例，中度17例。经腹膜后开放性离断式肾盂成形术40例（B组）。男18例，女22例。年龄9～63岁，平均32岁。左侧26例，右侧14例。重度肾积水22例，中度18例。对2组的手术时间、术中出血量、术后恢复、临床疗效及并发症进行比较研究。结果A组手术均获成功，无中转开放手术者，手术时间（137．1±30．5）min，术中出血量（143．8±45．2）ml，术后止痛药应用时间（O．8±0．2）d，术后住院时间（7．1±1．2）d，恢复工作时间（24．3±5．6）d。术后发生漏尿1例，经B超引导下肾盂穿刺造瘘3d后痊愈。术后随访6～36个月，吻合口无狭窄，肾积水减轻，中度肾积水12例、轻度积水15例、肾积水消失11例。B组手术时间（135．2±34．6）min，术中出血量（245．3±80．9）ml，术后止痛药应用时间（1．5±0．5）d，术后住院时间（10．3±2．6）d，恢复工作时间为（43．2±11．4）d。发生漏尿2例，分别引流5d和8d治愈；切口感染2例，经换药加抗生素治疗2周后好转；1例腹膜后血肿形成者经再次手术清除腹膜后血肿、止血后于术后第21天出院。术后随访6～36个月，1例吻合口狭窄伴重度积水，其余肾积水减轻（中度肾积水9例、轻度积水16例、肾积水消失14例）。2组手术时间比较差异无统计学意义（P＞0．05），术中出血量、术后止痛药应用时间、术后住院时间、恢复工作时间比较差异均有统计学意义（P＜0．01）。结论腹腔镜与开放性离断式肾盂成形术相比，手术时间相当，前者出血少、创伤小、痛苦轻、并发症少、术后恢复快，术后长期疗效相当。     

30例肾盂输尿管连接部梗阻的原因分析及后腹腔镜下成形手术的治疗经验

目的:探讨成人肾盂输尿管连接部梗阻的原因及腹腔镜下肾盂输尿管连接部梗阻的诊治经验。方法:对我院2006年1月～2009年3月收治的30例(32侧)成人肾盂输尿管连接部梗阻患者的病因和腹腔镜下治疗结果进行回顾性分析。结果:肾盂输尿管连接部狭窄引起梗阻者15例次(约46.8%),异位血管压迫者9例次(约28.1%),纤维索条粘连压迫者4例次(约12.5%),输尿管肾盂高位连接者4例次(约12.5%)。共行腹腔镜下手术32例次,其中离断式肾盂成形术28例次,肾盂Y-V成形术4例,纤维条索松解4例,异位血管切断3例。30例患者手术全部成功,术中无并发症发生。术中平均出血量70 ml。术后3个月～1年进行复查随访,自觉症状消失或明显好转,B超检查提示肾盂积水有不同程度减轻,排泄性尿路造影(IVU)检查患肾功能恢复良好者28例(93.3%);失访1例。结论:腹腔镜下肾盂成形术效果满意,而且损伤小、恢复快,是解决肾盂输尿管连接部梗阻的最佳方法。     

后腹腔镜与开放离断肾盂成形术的临床效果比较

目的：通过与开放离断肾盂成形术的效果比较,评价后腹腔镜离断肾盂成形术的临床价值。方法：回顾性分析的腹腔镜离断肾盂成形术56例（A组）及开放离断肾盂成形术10例（B组）的临床资料,就两组手术时间、术中出血量、术后肠道功能恢复时间、术后止疼药用量、术后住院天数,并发症和成功率等指标进行比较。根据数据类型选用X^2检验,成组t检验或Mann-Whitey U检验。结果：A组在术中出血量,术后肠道功能恢复时间,术后止产药用量。术后住院天数方面优于B组,差异有统计学意义（P〈0.01）;并发症和成功率与B组相当,差异无统计学意义（P〉0.05）。结论：后腹腔镜离断肾盂成形术是一种治疗肾盂输尿管连接部梗阻的微阳、安全、有效的方法,但存在较明显的学习期。熟练后可在较短时间内完成手术。     

首次手术失败后再行腹腔镜肾盂成形术的临床研究

目的:探讨开放或腹腔镜肾盂成形术失败后再次行腹腔镜肾盂成形术的可行性和疗效。方法:从2004年9月~2012年5月,我们对32例肾盂输尿管连接部梗阻行肾盂成形术后再梗阻的患者采用经腹腔入路腹腔镜肾盂成形术治疗。同期开展首次腹腔镜肾盂成形术30例。术前统计两组患者的年龄、性别、体重、左右侧和积水程度,比较两组手术时间、术中术后并发症、住院时间和手术成功率,并把手术时间和术中出血与文献报道的结果相比。手术成功率以临床症状的缓解和影像学上积水和肾功能的改善来判断。两组所有数据均通过SPSS16.0专业软件进行统计,以P0.05为差别有统计学意义。结果:术前两组患者在年龄、性别、左右侧和积水程度上的差别无统计学意义(P0.05)。两组均无严重术中并发症,无中转开放手术者。再次手术组的平均手术时问和术中出血量多于初次手术组(P0.05);两组患者的术后住院时间和手术成功率差别无统计学意义(P0.05)。结论:首次的开放手术或腹腔镜手术会造成肾盂输尿管周围粘连,给再次腹腔镜肾盂成形术带来困难,但只要腹腔镜操作技术熟练,再次行腹腔镜肾盂成形术仍安全可行,还保持了腹腔镜手术微创的优点,且经腹腔途径更容易完成手术。     

开放手术与后腹腔镜离断式肾盂成形术治疗肾盂输尿管连接部梗阻的临床效果比较

目的：通过与开放性。肾盂成形术的临床效果比较,评价后腹腔镜离断式肾盂成形术的临床价值。方法：回顾性分析后腹腔镜离断式肾盂成形术64例（A组）及开放性肾盂成形术48例（B组）的临床资料,就两组患者一般资料、手术时间、术中出血量、术后肠道功能恢复时间、术后止痛药用量、术后住院天数、术后并发症及术后肾积水复发率等指标进行比较。根据数据类型选用x^2检验、两样本t检验或Wilcoxon秩和检验,P〈0．05差异有统计学意义。结果：两组患者的一般资料相似,差异无统计学意义（P〉0．05）,具有可比性。后腹腔镜离断式肾盂成形术在手术时间、术中出血量、术后肠道功能恢复时间、术后止痛药用量、术后住院天数、术后并发症等方面优于开放性肾盂成形术,差异有统计学意义（P〈0．05）,而术后肾积水复发率方面差异无统计学意义（P〉0．05）。结论：后腹腔镜离断式肾盂成形术治疗肾盂输尿管连接部梗阻疗效肯定,与传统的开放性手术相比,创伤小、恢复快、术后近期疗效相当,是目前治疗肾盂输尿管连接部梗阻较理想的手术方法,值得进一步推广。     

后腹腔镜下离断式肾盂成形术

目的:探讨后腹腔镜离断式肾盂成形术的临床效果。方法:腹腔镜下通过后腹腔途径对肾盂输尿管连接部(UPJ)狭窄5例患者行离断式肾盂成形术。结果:5例手术均获成功,手术时间80~180m in,平均110m in;术中出血量30~90m l,平均50m l;漏尿1例;术后住院8~15d,平均10d。术后随访1~12个月,UPJ吻合口无狭窄,肾积水改善。结论:后腹腔镜肾盂成形术微创,安全、效果好,值得推广。     

后腹腔镜肾盂成形术治疗肾盂输尿管连接部梗阻（附20例报告）

目的：探讨肾盂输尿管连接部梗阻（UPJO）的后腹腔镜手术治疗方法及临床价值.方法：对20例UPJO患者行后腹腔镜肾盂成形术治疗.结果：全部患者均一次性手术成功,手术时间90～150 min.平均120min术中出血量20～50 ml,平均35 ml;术后住院时间7～10天,平均8天.术后1例出现漏尿,术后10天消失,余无并发症.随访6～52个月,平均20个月,腰痛症状消失,本组患者术后行B超、IVU榆查示肾盂输尿管连接部吻合口无狭窄,肾积水得到改善.结论：后腹腔镜肾盂成形术治疗肾盂输尿管连接部梗阻是安全有效的微创手术方法.     

腹腔镜经腹腔途径离断性肾盂成形术疗效再评估

目的：探讨腹腔镜经腹腔途径离断性肾盂成形术治疗肾盂输尿管连接部梗阻（UPJO）的技术特点、町操作性、并发症的防范处理等,充分评估该术式的临床适用性。方法：采用腹腔镜经腹腔途径离断性肾盂成形术治疗UPJO23例,B超检查重度积水9例,中度12例,轻度1例,合并肾盂结石l例。结果：23例手术均获成功,手术时间90～l50min,术中失血20～100ml,平均60ml。术后住院时间5～7天,平均6天。术后无吻合口狭窄、漏尿及其他并发症发生。随访6～30个月,所有患者肾功能明显改善,。肾积水消失或减轻。结论：针对UPJO,经腹腔途径离断性肾盂成形术有自身不可替代的特点和优点,仍是治疗UPJO有效的手术方式。     

后腹腔镜下离断式肾盂成形术

目的探讨后腹腔镜下离断式肾盂成形术的临床应用价值.方法采用经后腹腔途径实施腹腔镜下离断式肾盂成形术治疗肾盂输尿管连接部（UPJ）梗阻25例.男22例,女3例.B超检查：肾盂扩张积水＜15 mm（轻度）4例,15～30 mm（中度）15例,＞30 mm（重度）6例.IVU检查：30 min内显影良好16例,30～120 min淡显影6例,120 min未显影3例.结果25例手术均成功.手术时间150～240 min,平均170 min;术中出血量30～120 ml,平均70 ml;术后住院时间6～8 d,平均7 d.未发生明显外科并发症.25例术后均随访3～14个月,IVU显示UPJ吻合口无狭窄,肾功能显著改善,30 min内显影良好22例,30～120 min淡显影3例.肾积水明显减轻,肾盂扩张积水消失16例,轻度6例,中度3例.结论后腹腔镜离断式肾盂成形术微创、安全、有效、术后恢复快,可望作为UPJ梗阻治疗的有效手术方法.     

不同入路腹腔镜肾盂成形术治疗成人肾盂输尿管连接部梗阻的比较

目的 比较经腹腔和经后腹腔入路腹腔镜肾盂成形术治疗肾盂输尿管连接部梗阻（UPJO）的安全性及疗效。方法 收集2015年1月至2020年6月在兰州大学第二医院确诊为UPJO并行腹腔镜肾盂成形术且年龄≥18岁患者的临床资料,比较两组患者围术期指标、并发症发生率及手术成功率。结果 本研究共纳入195例患者,两组患者基线资料差异无统计学意义。两组围术期指标及近期并发症比较：手术时间[190(150,230)min vs 200(174,260)min,P=0.030]、引流管留置天数[5.0(3.0,6.0)d vs 6.0(4.0,8.0)d,P=0.005]、术后住院天数[6.0(5.0,7.0)d vs 8.0(5.0,9.0)d,P=0.006]经腹腔组均短于经后腹腔组,中转开放率经腹腔组低于经后腹腔组[3(3.2%)vs10(12.5%),P=0.019];术中出血量、术后特护时间、禁食水时间方面两组差异均无统计学意义（P>0.05）;尿漏、泌尿道感染、肠梗阻、高碳酸血症等近期并发症发生率方面两组间差异均无统计学意义（P>0.05）。长期随访的结果显示,在结石形成、输尿管...     

后腹腔镜辅助小切口离断肾盂成形术治疗肾盂输尿管连接部梗阻

目的通过与常规后腹腔镜离断肾盂成形术的临床效果比较,评价后腹腔镜辅助小切口离断肾盂成形术治疗肾盂输尿管连接部（ureteropelvic junction,UPJ）梗阻的临床价值。方法回顾性分析2004年1月～2006年11月在我院行离断肾盂成形术成人患者47例临床资料,其中行后腹腔镜辅助小切口组（A组）22例（腋后线12肋下长4 cm小切口）,后腹腔镜组（B组）25例。对2组手术时间、术中出血量、平均气道阻力、呼气末CO2分压、术后胃肠道功能恢复时间、引流管拔除时间、术后住院时间、尿漏发生率、术后肾积水缓解情况、肾小球滤过率改善情况进行统计分析。结果无一例术中并发症发生。与B组比较,A组手术时间短[（92.9±16.3）min vs（155.8±18.6）min,t=-12.251,P=0.000],术中出血量多[（18.9±6.3）ml vs（13.6±6.7）ml,t=2.782,P=0.008]但无临床意义,术中平均气道阻力小[（15.6±2.6）cm H2O vs（26.9±4.3）cm H2O,t=-10.715,P=0.000],呼气末CO2分压低[（36.0±6.9）cm H2O vs（51.6±6.7）cm H2O,t=-7.855,P=0.000]。2组术后胃肠道功能恢复时间、引流管拔除时间、术后住院时间、术后尿漏发生率和肾积水缓解情况差异无显著性。结论后腹腔镜辅助小切口离断肾盂成形术是治疗UPJ梗阻安全、有效、微创的治疗方法。     

Robot-assisted and Laparoscopic Repair of Ureteropelvic Junction Obstruction: A Systematic Review and Meta-analysis

ContextOver the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction (UPJO) have been developed and popularized.ObjectiveTo critically analyze the current status of laparoscopic and robotic repair of UPJO.Evidence acquisitionA systematic literature review was performed in November 2012 using PubMed. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria.Evidence synthesisMultiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, with both the transperitoneal and retroperitoneal approaches. Data on pediatric robot-assisted pyeloplasty are increasingly becoming available. A larger number of cases have also been reported for adult patients, confirming that robotic pyeloplasty represents a viable option for either primary or secondary repair. Robot-assisted redo pyeloplasty has been mostly described in the pediatric population. Different technical variations have been implemented with the aim of tailoring the procedure to each specific case. The type of stenting, retrograde versus antegrade, continues to be debated. Internal-external stenting as well as a stentless approach have been used, especially in the pediatric population. Comparative studies demonstrate similar success and complication rates between minimally invasive and open pyeloplasty in both the adult and pediatric setting. A clear advantage in terms of hospital stay for minimally invasive over open pyeloplasty was observed only in the adult population.ConclusionsLaparoscopy represents an efficient and effective less invasive alternative to open pyeloplasty. Robotic pyeloplasty is likely to emerge as the new minimally invasive standard of care whenever robotic technology is available because its precise suturing and shorter learning curve represent unique attractive features. For both laparoscopy and robotics, the technique can be tailored to the specific case according to intraoperative findings and personal surgical experience.     

Prospective Randomized Comparison Between Transperitoneal Laparoscopic Pyeloplasty and Retroperitoneoscopic Pyeloplasty for Primary Ureteropelvic Junction Obstruction

Background and Objectives:

To compare laparoscopic transperitoneal versus retroperitoneoscopic pyeloplasty for primary ureteropelvic junction obstruction in a prospective randomized manner and assess overall results with long-term follow-up.

Methods:

In this prospective study, from 2008 to 2012, 112 cases of primary ureteropelvic junction obstruction were randomized in a 1:1 ratio into 2 groups. Group I included patients who underwent transperitoneal laparoscopic pyeloplasty, and group II consisted of patients who underwent retroperitoneoscopic laparoscopic pyeloplasty. Demographic and clinical characteristics and postoperative and operative data were collected and analyzed. The statistical analysis was performed with the Fisher exact test, χ² test, and Mann-Whitney U test for independent groups, and P < .05 was considered statistically significant.

Results:

The total operative time and intracorporeal suturing time were significantly higher in group II than in group I (P < .001). The visual analog scale score for pain on postoperative day 1 and the requirement for tramadol were significantly higher in group I than in group II (P = .004). The hospital stay and the rate of temporary ileus were significantly greater (P < .036 and P < .02, respectively) in group I than in group II. The success rate of transperitoneal laparoscopic pyeloplasty versus retroperitoneoscopic laparoscopic pyeloplasty was 96.4% versus 96.6% with a mean follow-up period of 30.75 ± 4.85 months versus 30.99 ± 5.59 months (P < .88).

Conclusion:

Transperitoneal laparoscopic pyeloplasty is associated with significantly greater postoperative pain, a higher tramadol dose, a higher rate of ileus, and a longer hospital stay in comparison with retroperitoneoscopic laparoscopic pyeloplasty. Although the operative time for retroperitoneoscopic laparoscopic pyeloplasty is significantly longer, the success rate remains the same for both procedures.     

腹腔镜肾盂成形术治疗输尿管连接处梗阻疗效观察

目的：评价腹腔镜肾盂成形术治疗肾盂输尿管连接处梗阻（UPJ0）的临床疗效及其可行性。方法：对50例UPJO均有不同程度肾盂积水患者分别使用Anderson—Hynes、FoleyY—V成形术、Fenger成形术及Hellstrom成形术进行治疗。结果：50例手术均获成功,无一例中转开放手术。手术时间2．5～4．5h,出血量35～88ml。40例术后随访6～24个月,IVP检查UPJ吻合口未见狭窄,肾盂输尿管排尿功能好,手术侧肾盂积水明显减轻或基本消失。结论：腹腔镜肾盂成形术具有术中创伤小、术后恢复快、疼痛减轻的优点,效果优于开放手术,是既安全又有效的微创手术方法。     

Laparoscopic Pyeloplasty in the Animal Model

Purpose:

Laparoscopic pyeloplasty has been associated with long operative times. This study proposed to evaluate the feasibility of two different laparoscopic techniques for the performance of pyeloplasty repair of secondary ureteropelvic junction (UPJ) obstruction.

Materials and Methods:

Sixteen female Yucatan mini-pigs underwent general anesthesia for cystoscopy, retrograde pyelography, urine culture and a baseline renal scan. Unilateral UPJ obstruction was created by ligating the UPJ over a 5F catheter. Six weeks later a laparoscopic pyeloplasty was performed utilizing an intracorporeal suturing technique and the Lapra-Ty suture clip or the Endostitch device with intracorporeal knot tying. Four control animals underwent only cystoscopy and in/out ureteral catheterization. In the study animals the ureteral stent was maintained for six weeks and at six weeks, three months and six months post-pyeloplasty the animals underwent the previously mentioned studies. At six months post-pyeloplasty the animals were euthanized and the UPJ was calibrated. Histopathology was obtained on the ureter below the anastomosis, at the anastomosis, above the anastomosis and on a renal biopsy.

Results:

All planned laparoscopic pyeloplasties were completed. However, the stricture model was too severe in that most animals developed 40-45% decrease in renal function in the kidney following ipsilateral UPJ ligation. There was no significant difference between the two pyeloplasty techniques with respect to operative time to perform the pyeloplasty (mean of 40 minutes), post-pyeloplasty ureteral caliber (7.5-8.0 F), serum creatinine or healing scores at, above or below the anastomosis.

Conclusion:

Laparoscopic pyeloplasty can be performed equally successfully with the Endostitch device and intracorporeal knot tying or with the intracorporeal suturing technique and Lapra-Ty clips. The resultant pyeloplasty is also equivalent for the two techniques.     

Systematic Review and Meta-Analysis of Robotic-Assisted versus Conventional Laparoscopic Pyeloplasty for Patients with Ureteropelvic Junction Obstruction: Effect on Operative Time,Length of Hospital Stay,Postoperative Complications,and Success Rate

Background

Although robotic-assisted procedures may theoretically be more advantageous than conventional laparoscopic ones, few studies have shown clear superiority of robotic-assisted laparoscopic pyeloplasty (RAP) over conventional laparoscopic pyeloplasty (CLP) for ureteropelvic junction obstruction (UPJO).

Objective

To undertake a systematic review and meta-analysis to evaluate the effect of RAP versus CLP for patients with UPJO, focusing on operative time, length of hospital stay, postoperative complications, and success rate.

Design, setting, and participants

We searched four electronic bibliographic databases, including the related articles PubMed feature, reference lists from articles, and program abstracts from scientific meetings. Consequently, 58 citations were identified. Two individuals independently screened the titles and abstracts of each citation to select the articles (90% agreement).

Intervention

Studies that compared RAP with CLP for treatment of UPJO were included. Case series on RAP or CLP were excluded because of large heterogeneity.

Measurements

We utilized weighted mean difference (WMD) to measure operative time and length of hospital stay and odds ratio (OR) and risk difference (RD) to measure complication and success rates. These ORs were pooled using a random effects model and were tested for heterogeneity.

Results

We identified eight publications that strictly met our eligibility criteria. Meta-analysis of extractable data showed that RAP was associated with a 10-min operative time reduction (WMD: −10.4 min; 95% CI: −24.6–3; p = 0.15) and significantly shorter hospital stay compared with CLP (WMD: −0.5 d; 95% CI: −0.6–−0.4; p < 0.01). There were no differences between the approaches with regard to rates of complication (OR: 0.7; 95% CI: 0.3–1.6; p = 0.40) and success (OR: 1.3; 95% CI: 0.5–3.5; p = 0.62).

Conclusions

RAP and CLP appear to be equivalent with regard to postoperative urinary leaks, hospital readmissions, success rates, and operative time.     

经皮肾镜治疗肾盂输尿管连接部狭窄合并肾结石

目的探讨经B超引导经皮肾镜下应用自制电刀腔内切开治疗。肾盂输尿管连接部狭窄（ureteropelvic junction obstruction,UPJO）,同时应用气压弹道联合超声碎石处理肾结石的疗效。方法2008年8月～2009年12月,18例UPJO合并肾结石,采用EMS第3代气压弹道联合超声碎石机清除结石,然后用自制电刀直抵肾盂输尿管连接处狭窄段,分别于6、9点位置处纵行全层切开输尿管壁,直到显露输尿管壁周围脂肪,术后留置海马管1—3个月。结果18例均一次手术成功,手术时间40～65min,平均38min。术后住院7～11d,平均9d。术后1周,3、6个月肌酐分别为（252．54±71．6）、（127．1±35．6）、（107．1±35．7）μmol／L,比术前（292．8±62．8）μmol／L明显下降（g=3．173,P〈0．05;q=13．048,P〈0．05;q=14．622,P〈0．05）;术后1周,3、6个月尿素氮分别为（10．5±1．2）、（8．9±1．6）、（7．8±0．9）mmol／L,比术前（11．8±2．2）mmol／L明显下降（q=3．551,P〈0．05;g=7．921,P〈0．05;q=10．926,P〈0．05）;术后3、6个月超声提示肾盂集合系统分离指数分别为（40．6±6．3）、（34．8±11．8）mm,较术前（52．94-13．6）mm明显下降（g=4．587,P〈0．05;q=6．750,P〈0．05）。18例随访3—16个月,平均11个月,16例腰痛、腰胀、尿频症状缓解,静脉肾盂造影显示狭窄段基本消失,2例仍有腰痛、腰部酸胀,静脉肾盂造影显示部分仍存在狭窄。结论经皮肾镜腔内切开治疗UPJO,同时处理肾结石疗效满意。