不同腹腔镜术式治疗上尿路尿路上皮癌的比较研究∗

目的 比较后腹腔镜肾输尿管切除联合下腹部斜切口膀胱袖状切除术与经腹完全腹腔镜肾输尿管切除联合膀胱袖状切除术治疗上尿路尿路上皮癌的手术疗效.方法 回顾性分析我院2014年1月～2019年8月163例手术治疗上尿路尿路上皮的临床资料,其中A组96例(后腹腔镜肾输尿管切除联合下腹部斜切口膀胱袖状切除术),B组67例(经腹完全...     

上尿路尿路上皮癌术后预防性膀胱灌注化疗的研究进展

<正>上尿路尿路上皮癌（upper tract urothelial carcinoma,UTUC）包括肾盂癌和输尿管癌,在欧美国家其发病率较低,约占尿路上皮癌的5%～10%[1-2],在我国其发病率较高,占尿路上皮癌的18%[3]。UTUC标准手术方法是根治性肾输尿管全长切除加膀胱袖套状切除术（radical nephrourotertectomy,RNU）,但术后常出现膀胱肿瘤复发,影响预后。膀胱灌注化疗对减少膀胱肿瘤复发具有重要作用,但灌注方案尚未达成统一意见,本文就其研究进展综述如下。     

经腹入路一站式腹腔镜肾脏-输尿管-膀胱袖状切除术治疗上尿路尿路上皮癌的临床研究

目的:探讨完全腹腔镜下经腹入路一站式肾脏-输尿管-膀胱袖状切除术治疗上尿路尿路上皮癌(UTUC)的手术技巧和临床效果。方法:2015年2月～2018年5月我院通过影像学检查或输尿管镜活检确诊的17例UTUC患者行完全腹腔镜下经腹入路一站式肾脏-输尿管-膀胱袖状切除手术。采取健侧60°卧位,放置5个Trocar,先行患侧根治性肾切除,然后沿输尿管向下游离至输尿管膀胱入口处,再将输尿管开口周围膀胱壁作袖状切除,缝闭膀胱切口。结果:17例手术均获成功,无中转开放,手术时间110～150min,平均125min;术中出血80～200ml,平均120ml;术后住院6～14d,平均8d;术后漏尿1例,引流后自愈。术后随访6～45个月,其中术后漏尿患者于术后9个月发现对侧输尿管口周围尿路上皮癌复发,行经尿道膀胱肿瘤电切术(TURBt),随访至今未见复发;失访3例,其余病例未见术中术后并发症,未见肿瘤复发及转移。结论:经腹入路一站式腹腔镜肾脏-输尿管-膀胱袖状切除术治疗UTUC安全可行,术中无需变换体位就能完成从肾脏到输尿管全段和膀胱袖状切除,是一种值得推广的手术方法。     

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。     

上尿路尿路上皮癌治疗方式的选择

上尿路尿路上皮癌是指发生于上尿路(肾盂或输尿管)的尿路上皮恶性肿瘤,目前外科治疗的金标准仍是根治性肾输尿管切除术联合膀胱袖状切除.但对于某些患者,如孤立肾、双侧肿瘤及肾功能不全的患者,在充分评估后也可实行保留肾脏的手术方式.无论是哪一种手术方式,术后局部药物灌注治疗都有一定的辅助疗效.但对于较为晚期的转移性患者,姑息性...     

上尿路尿路上皮癌术后复发膀胱癌分子机制的研究进展

上尿路尿路上皮癌(UTUC)是一种罕见的恶性肿瘤, 约占尿路上皮癌的5%。肾输尿管根治性切除术(RNU)是UTUC治疗的金标准, 但术后膀胱癌的复发率可高达20%以上。UTUC在术后管理中最具挑战性的是准确预测肿瘤复发和疾病进展。了解UTUC术后复发膀胱癌的分子机制对指导肿瘤治疗及评估患者预后十分重要, 现就相关研究进展进行综述。     

上尿路尿路上皮癌输尿管末端处理方式的研究进展

上尿路尿路上皮癌(UTUC)包括肾盂癌和输尿管癌,其标准手术方式是根治性肾输尿管切除+膀胱袖状切除。随着腹腔镜技术的不断成熟,腹腔镜下肾输尿管切除已得到广泛应用。但输尿管末端处理方式有多种,输尿管末端是否完全切除,又与肿瘤复发有密切联系,目前尚缺乏相关的比较各种处理方式的研究。本文就常用的处理输尿管末端的方式进行综述。     

上尿路尿路上皮癌淋巴清扫术的研究进展

上尿路尿路上皮癌在我国的发病率较欧美国家高,其恶性程度高,易早期发生淋巴结转移。根治性肾输尿管切除术+膀胱袖状切除术是治疗上尿路尿路上皮癌的标准术式,但是否同期行淋巴结清扫术仍存有争议。本文对上尿路尿路上皮癌淋巴结转移的影像学评估以及淋巴结清扫术的价值、范围、安全性等问题的相关研究进行了综述。     

机器人辅助腹腔镜肾输尿管全长切除术的应用进展

根治性肾输尿管全长切除术是上尿路尿路上皮癌外科治疗的金标准。随着手术机器人技术的发展,全球范围内机器人辅助腹腔镜肾输尿管全长切除术的开展数量迅速增加。得益于其3D影像、高清放大的视野及灵活的机械关节等优势,该术式降低了术中远端输尿管、膀胱壁内段切除以及膀胱创面缝合等关键操作的难度,并达到了与开放手术相当的肿瘤学预后。本...     

后腹腔镜肾盂部分切除术治疗肾盂尿路上皮癌1例报告并文献复习

肾盂尿路上皮癌治疗的金标准是肾、输尿管全长加膀胱袖状切除.但对于解剖性或功能性的孤立肾、双侧上尿路上皮癌、肾功能不全、有严重合并症不能耐受根治性手术的患者,治疗是一个棘手的问题.控制肿瘤与保留有效肾功能之间的平衡和取舍困扰着泌尿外科医生.2014年5月我院对1例肾功能不全肾盂尿路上皮癌患者施行了后腹腔镜肾盂部分切除术,术后密切随访2年,效果理想.现报告如下.     

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.     

Is a cystogram necessary after bladder cuff excision?

ObjectiveNephroureterectomy with bladder cuff excision is the current gold standard for the treatment of upper-tract urothelial carcinoma (UTUC). Currently, routine follow-up cystogram is performed prior to Foley catheter removal to evaluate the bladder cuff excision wound. The aim of this study was to investigate the role of the postoperative cystogram in the bladder cuff excision procedure.Materials and methodsThis was a retrospective study of 193 patients diagnosed with UTUC post nephroureterectomy and bladder cuff excision between January, 2010, and January, 2016. Patient demographics, performance of cystogram, types of bladder cuff excision, and postoperative outcomes were recorded. Patients were classified into two groups depending on whether or not routine postoperative cystogram was performed.ResultsA total of 125 patients were included in this study and, of these, 102 patients underwent routine cystogram on Postoperative Day 7 (Group 1), while 23 patients underwent Foley catheter removal on Postoperative Day 7 without any imaging studies (Group 2). Univariate analysis showed no differences in age, sex, comorbidities, surgical approach, or stage of the primary tumor. No patient from either group had urinoma, pelvic abscesses, and tumor growth from bladder cuff wound was not observed in any patient within the 1-year postoperative follow-up period. Both groups of patients had a similar rate of postoperative urinary tract infections with sepsis (p = 0.639), time to Foley catheter removal (p = 0.630), time to drainage tube removal (p = 0.264), and length of hospitalization (p = 0.373).ConclusionFoley catheter removal on Postoperative Day 7 after nephroureterectomy with bladder cuff excision without routine cystogram appears to be safe in the majority of the UTUC patients. A large, multi-institutional study is required before this method can be recommended for widespread clinical practice.     

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.     

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.     

Management of distal ureter in laparoscopic nephroureterectomy--a comprehensive review of techniques

Approximately 5% of all urothelial tumors in adults arise from the upper tracts. While the gold standard treatment is open nephroureterectomy, laparoscopic nephroureterectomy is becoming increasingly popular. Oncologic principles dictate that complete excision of the transmural ureter and bladder cuff and avoidance of urine spillage are paramount. This can be challenging laparoscopically and multiple techniques have been described. We review described surgical techniques, published oncologic data, as well as advantages and disadvantages for each technique including open excision, cystoscopic detachment and ligation, laparoscopic stapling, ureteral intussusception, transurethral resection of ureteral orifice (TURUO) and modifications of TURUO. To date, no controlled studies have been performed demonstrating one technique's superiority.     

Bladder migration of Hem-o-Lok clips after laparoscopic radical nephroureterectomy and bladder cuff excision

The Hem-o-Lok clips are widely used in various laparoscopic operations because of its easy application and secure clamping. The Hem-o-Lok clips were adopted to ligate bladder cuff during bladder cuff excision because of its advantages. We report 2 cases of bladder migration of Hem-o-Lok clips after laparoscopic nephroureterectomy and bladder cuff excision. The clips were found during routine follow-up cystoscopy and were removed by cystoscopic procedure. We described the case presentation, treatment, and the alternative method to avoid such shortcomings.     

根治性肾输尿管切除术的两种术式疗效比较

目的探讨微创手术治疗肾盂输尿管癌的方法。 方法回顾性分析2017年9月至2021年10月在汉中市中心医院接受两种不同手术方式治疗肾盂及输尿管癌的病例共60例,其中经腹腹腔镜一体位肾输尿管全长切除联合使用定制的哈巴狗钳行膀胱袖状切除术30例（改良组）,后腹腔镜结合下腹部斜切口行根治性肾输尿管切除术30例(传统组)。比较两组患者围手术期资料及随访结果。 结果两组中所有患者都顺利完成手术,改良组手术时间、术中出血量、术后引流量、术后引流管保留时间和术后住院时间均少于传统组,差异具有统计学意义（P<0.05）。两组术后下床活动时间、肠功能恢复时间、术后膀胱肿瘤复发和随访时间比较,差异无统计学意义（P>0.05）。所有患者均随访1~48个月,膀胱肿瘤复发共8例,其中改良组2例,传统组6例,行经尿道膀胱肿瘤电切术治愈,其余均无瘤生存。 结论完全经腹腹腔镜一体位肾输尿管全长切除联合使用定制的哈巴狗钳行膀胱袖状切除术更加符合肿瘤根治原则,是一种安全、微创、可行、有效的方法,适合临床推广。     

Retroperitoneal nephroureterectomy with excision of cuff of the bladder for upper urinary tract transitional cell carcinoma: comparison of laparoscopic and open surgery with long-term follow-up

OBJECTIVES: To compare outcome and long term follow up of laparoscopic retroperitoneal nephroureterectomy with excision of cuff of bladder (LRPNUT-BCE) and standard open nephroureterectomy with excision of cuff of bladder (ONUT-BCE) in patients of upper urinary tract transitional cell carcinoma (UTTCC). MATERIAL AND METHODS: From January 1998 to October 2006, we have performed over 55 cases of nephroureterectomy with excision of cuff of bladder for UTTCC. Out of these, 48 patients undergoing LRPNUT-BCE and ONUT-BCE were categorized retrospectively into group A (21), and group B (27), respectively. The clinical data including intraoperative, postoperative, and follow-up data was recorded for two groups and analyzed statistically. RESULTS: The mean operating time was significantly higher in-group A (P < 0.001). The different techniques of bladder cuff excision were used in group A. The mean analgesic use, hospital stay and weeks to normal activity were significantly lesser in-group A (P < 0.001). The intraoperative, postoperative complications and mean follow up were comparable in two groups. There was no local recurrence in either group. The bladder recurrence and distant metastases were comparable in two groups (group A-9.52%, group B-11.1% and group A-9.52%, group B-11.1%, respectively). The 5-year recurrence free, cancer specific and overall survivals were comparable in two groups. CONCLUSIONS: On long-term follow-up of oncological efficacy, LRPNUT-BCE satisfactorily compares with traditional open surgery (ONUT-BCE) with longer operating time, while decreasing postoperative morbidity and extending benefits of minimally invasive surgery to the patients.     

后腹腔镜双侧一期肾输尿管全长切除术——肾移植术后原上尿路移行细胞癌8例报告

目的探讨肾移植术后发现原肾肾盂癌和(或)输尿管癌一期行后腹腔镜双侧肾输尿管全长切除术的安全性与可行性。方法 2006年4月~2009年11月对8例肾移植术后发现原肾肾盂癌和(或)输尿管癌行腹腔镜下双侧一期肾输尿管全长切除。先取左侧卧位,后腹腔镜下游离右侧肾及输尿管,输尿管远端用钛夹夹闭;改为右侧卧位后同法处理左侧肾及输尿管;然后取截石位,经尿道用电切镜袖状切除双侧输尿管膀胱膀胱壁内段;最后取下腹正中6 cm切口取出标本。结果 8例均行后腹腔镜双侧肾输尿管全长切除联合经尿道膀胱袖状切除,其中1例因膀胱内发现肿物同时行经尿道膀胱电切术,无中转开腹。手术时间(346.9±105.4)min(230~574 min);术中出血量(162.5±102.6)ml(100~400 ml),均无输血;住院时间(18.3±5.7)d(12~49 d)。病理报告均为尿路上皮癌,其中2例为双侧病变,此2例中有1例合并膀胱癌。8例随访(22.6±14.2)月(6~49个月),其中1年6例,均存活,1例膀胱癌复发相继行电切、膀胱部分切除治疗。结论肾移植术后原肾肾盂癌或输尿管癌一期行后腹腔镜双侧肾输尿管全长切除术是一种安全可行的治疗方式。     

Hand-assisted laparoscopic nephroureterectomy with cystoscopic en bloc excision of the distal ureter and bladder cuff

Various hand-assisted and purely laparoscopic nephroureterectomy techniques have been described in the urologic literature. We describe a technique of hand-assisted laparoscopic nephroureterectomy with cystoscopic en bloc excision of the distal ureter and bladder cuff that duplicates open surgical excision of these structures and obviates bladder trocar placement and midprocedural patient repositioning. The patient is placed in a modified dorsal lithotomy position with the tumor side elevated 30 degrees. Allen stirrups are utilized to allow simultaneous access to the urethra. A transperitoneal hand-assisted laparoscopic nephrectomy is performed. The technique is modified in that the ureter is clipped prior to the kidney dissection to avoid distal migration of tumor cells during kidney manipulation. After the kidney is isolated, the intact ureter is liberated distal to the intramural hiatus. The remaining dissection is completed intravesically under cystoscopic guidance. While the surgeon's intra-abdominal hand places the ureter on tension, the cystoscopist transurethrally excises the bladder cuff and intramural ureter with a Collings knife. The complete surgical specimen is removed en bloc through the hand port. The bladder is not closed. A urethral catheter connected to straight drainage remains until the seventh postoperative day, when a cystogram is performed; if it is normal, the catheter is removed.