脾切除术后并发症发生相关危险因素分析

目的探讨脾切除术后并发症的影响因素。方法运用非条件Logistic回归分析方法对脾切除患者进行临床研究。结果脾切除术后并发症发生率36.20%(84/232),感染15.09%(35/232)、出血10.34%(24/232)、脾热7.32%(17/232)、切口裂开4.74%(11/232)、肝衰3.88%(9/232)、胰腺损伤2.16%(5/232)、血栓栓塞0.86%(2/232)、胃肠穿孔0.43%(1/232)、死亡4.74%(11/232)。从全因素的Logistic回归模型的结果可见术前肝功能(X6)、乙肝后肝硬化脾大脾亢(X3)、急诊手术(X14)、脾破裂(X4)、主刀医师资格(X10)在a=0.05水平上显著,脾切除并发症的主要危险因素按其影响的大小顺次为:X6、X3、X14、X4,X10所对应的相对危险度在1.342~1.568之间,且X3、X14、X10为影响脾切除围手术期死亡的主要危险因素。逐步Logistic回归分析进一步肯定了上述结果,且乙肝后肝硬化脾大脾亢影响突出,P=0.0021,标准系数=0.213 202,相对危险度OR=2.347。而其他原因脾切除(X5)能减少脾切除并发症的发生。结论脾破裂、乙肝后肝硬化合并脾肿大脾亢zhud硬化合并脾肿大脾亢,tim e of occ lusion是脾切除术后并发症发生的重要危险因素,术前调整肝功能、合理选择手术时机、提高主刀医师手术操作水平是降低脾切除术后并发症发生和病死率的关键。     

COMPLICATIONS OF LAPAROSCOPIC PROCEDURES AFTER CONCENTRATED TRAINING IN UROLOGICAL LAPAROSCOPY

PURPOSE: To increase the safety and efficiency of laparoscopic surgery clinical training programs have been developed to increase the skill and efficiency of urological trainees. We evaluated the impact of dedicated laparoscopy training on the rate and type of complications after trainees entered clinical practice. MATERIALS AND METHODS: Data were obtained from 13 centers where laparoscopy was performed by a single surgeon with at least 12 months of training in urological laparoscopy before clinical practice. Data included training experience, laparoscopic procedures performed after commencing clinical practice and associated complications. Procedures were classified as easy, moderate and difficult. RESULTS: During training each surgeon participated in a mean of 71 cases. In clinical practice a total of 738 laparoscopic cases were performed with the group reporting an overall complication rate of 11.9%. The rate was unchanged when the initial 20, 30 and 40 cases per surgeon were compared with all subsequent cases (12%, 11.9% and 12% versus 11.8 to 12%, respectively). The re-intervention rate was 1.1%. The complication rate increased with case difficulty. Overall and early complication rates attributable to laparoscopic technique in the initial 20, 30 and 40 cases were identical. The most common complications were neuropathy in 13 patients, urine leakage/urinoma in 9, transfusion in 7 and ileus in 5. CONCLUSIONS: The complication rate of surgeons who completed at least 12 months of laparoscopy training did not differ according to initial versus subsequent surgical experience. Intensive training seems to decrease the impact of the learning curve for laparoscopy.     

胰腺癌胰十二指肠切除术后并发症回顾性分析

目的 回顾分析胰十二指肠切除术（PD）后并发症的相关因素,探讨预防减少术后并发症的措施。方法 回顾性研究我院1994年1月至2006年12月问138例PD病例,分析影响PD术后并发症的危险因素,比较不同胰肠吻合方式及幽门保留与否对胰瘘的影响。比较保留幽门的PD（PPPD）与不保留幽门的PD对术后胃潴留发生率的影响。结果 术后胰瘘总发生率23．18％（32／138）,其中胰空肠黏膜对黏膜侧侧吻合组22．48％（29／129）,胰残端空肠端侧传统套入组33．33％（3／9）。PPPD术后胃潴留发生率显著高于PD。胰肠吻合方式、保留幽门与否并不显著性的影响胰瘘的发生。多数手术近期吻合口出血与应用胃肠吻合器有关。结论 胰肠吻合方式、保留幽门与否未能显著的影响PD后胰瘘的发生,但保留幽门后会增加胃潴留的发生率;慎重应用胃肠吻合器,人工手法细心进行胃肠吻合可能有助于预防胰腺癌手术后近期出血的发生。     

Flexible ureteroscopes: a single center evaluation of the durability and function of the new endoscopes smaller than 9Fr

PURPOSE: Flexible ureteroscopes smaller than 9Fr are widely used in endourology. We systematically evaluated the functional durability of these instruments in the clinical setting. MATERIALS AND METHODS: We performed ureteronephroscopy 92 consecutive times in 84 patients at our hospital using a flexible Storz model 11274AA,double dagger Circon-ACMI model AUR-7, section sign Wolf model 7325.172 parallel and Olympus model URF/P3 ureteroscope paragraph sign. Preoperatively and postoperatively we evaluated all flexible ureteroscopes for luminosity, irrigant flow at 100 mm. Hg, number of broken image fibers and active deflection range. During the procedure a record was kept of the duration that the endoscope remained in the urinary tract, average irrigation pressure, method of insertion, various devices used within the working channel, need for lower pole access, and surgeon overall impression of visibility and maneuverability. RESULTS: The luminosity and irrigant flow of all endoscopes remained relatively unchanged during consecutive applications, while active deflection deteriorated 2% to 28%. Endoscopes were used for an average of 3 to 13 hours before they needed repair. The most fragile part of these instruments was the deflection unit. CONCLUSIONS: Small diameter flexible ureteroscopes are effective for diagnosing and treating upper urinary tract pathology but improved durability is required. Currently they represent a highly effective but high maintenance means of achieving retrograde access to the ureter and kidney with a need for repair after only 6 to 15 uses.     

Comparative study of pulsed dye laser and pneumatic lithotripters for transurethral ureterolithotripsy

BACKGROUND: Clinical effectiveness and safety of the Swiss Lithoclast (Lithoclast) and the Candela MDL-2000 (MDL) in the treatment of lower ureteral stone were examined retrospectively. METHODS: Eighty-six stones from 66 patients and 26 stones from 20 patients were treated by Lithoclast and MDL, respectively. RESULTS: The stone-free rate on 3-month follow-up was 97% and 95% for the Lithoclast and MDL, respectively (no significant difference). The operation time was significantly shorter for the Lithoclast than for the MDL (90.2+/-50.2 vs 120.4+/-55.1 min; P<0.05). Postoperative analgesics were required significantly less frequently in Lithoclast (10/66 vs 11/20; P<0.01). Postoperative hospital stay was significantly shorter for Lithoclast (8.7+/-5.1 vs 12.1+/-4.2 days; P<0.01). CONCLUSIONS: Swiss Lithoclast is an effective and less invasive modality for endoscopic treatment of lower ureteral stones.     

Urological injuries during cesarean section: intraoperative diagnosis and management

PURPOSE: We report a single center experience with emergency urological consultations and interventions during cesarean sections, and provide several guidelines for the intraoperative diagnosis and management of urological trauma in this specific clinical setting. MATERIALS AND METHODS: From 1996 to 2003 urological consultations were required in 29 of 10,439 abdominal deliveries (0.3%). Patient files were reviewed for obstetric, surgical and followup data. RESULTS: In 20 patients (69%) cesarean section was done on an emergency basis for fetal distress or placental abruption. Of the 29 urological consults 12 (42%) were for inadvertent cystotomy and 17 (58%) were for suspected injuries to the ureter. Patients with inadvertent cystotomy underwent concomitant assessment of ureteral patency by direct insertion of ureteral catheters through the ureteral orifice. Ureteral obstruction was identified in 1 case and promptly repaired by dissecting the ureter and releasing offending sutures that were angulating the ureter and occluding the lumen. Patients with suspected ureteral damage and an intact bladder were studied by endoscopic means (14) or direct surgical dissection and exposure of the ureter (3). Endoscopic assessment was performed by cystoscopic inspection of stained urine flow from the orifices following the administration of intravenous dye (indigo carmine) or by retrograde ureteral catheterization. One patient was found to have incomplete ureteral transection, which was repaired primarily over a self-retaining ureteral stent. CONCLUSIONS: Key factors to obtain optimal results in the management of urological injuries during cesarean sections are the early recognition and immediate repair of damage. Ureteral catheterization via a cystoscope or directly through the orifices should be considered the modality of choice to assess ureteral intactness. Algorithms for urological assessment in this clinical setting are provided.     

Transperitoneal laparoscopic pyelolithotomy after failed percutaneous access in the pediatric patient

PURPOSE: We present our experience with transperitoneal laparoscopic pyelolithotomy in pediatric patients in whom percutaneous renal access failed and the stone burden warranted open intervention. MATERIAL AND METHODS: A transperitoneal laparoscopic approach was used for pyelolithotomy in 8 patients 3 months to 10 years old (mean age 4 years). Percutaneous access failed secondary to a nondilated system and/or an occluding lower pole calculus. Inclusion criteria were failed percutaneous access secondary to a nondilated system and/or stone occlusion of the lower pole system and failed shock wave lithotripsy or a stone burden of greater than 2.5 cm2. A posterior pelviotomy was made. Stones in the renal pelvis were removed with rigid graspers under direct laparoscopic vision. A flexible cystoscope was introduced through a port if caliceal stones were present. The renal pelvis was reconstructed. A watertight anastomosis was verified. RESULTS: Average operative time was 1.6 hours (range 0.8 to 2.3). Mean hospital stay was 2.15 days (range 2 to 3). A range of 1 to 3 stones (median of 1) were removed and the mean stone burden was 2.9 cm2. No intraoperative complications were noted. Stone analysis revealed 3 patients with calcium oxalate stones, 1 with a calcium phosphate stone and 4 with cysteine stones. There was 1 patient with stone recurrence at a mean followup of 12 months (range 3 to 20). Thus, the overall long-term stone-free rate was 87.5%. CONCLUSIONS: Transperitoneal laparoscopic pyelolithotomy is feasible when percutaneous access fails and open pyelolithotomy is considered due to a large stone burden.     

Percutaneous endopyeloplasty: description of new technique

PURPOSE: We present a novel technique of percutaneous endopyeloplasty, in which the conventional longitudinal endopyelotomy incision is precisely sutured in a horizontal Heineke-Mikulicz fashion through the solitary percutaneous tract, thus, achieving Fenger-plasty type of repair of the ureteropelvic junction. MATERIALS AND METHODS: Percutaneous endopyeloplasty was performed in 9 patients with primary ureteropelvic junction obstruction. Essential steps of our novel technique include retrograde placement of a ureteral catheter over a guide wire into the renal pelvis, establishing conventional percutaneous renal access, creating a conventional longitudinal endopyelotomy incision and performing full-thickness horizontal suturing of the endopyelotomy incision in Heineke-Mikulicz fashion. Suturing was done using the novel 5 mm. Sew Right 5 SR laparoscopic suturing device (LSI Solutions, Rochester, New York) passed through the nephroscope. RESULTS: Percutaneous endopyeloplasty was technically successful in all 9 patients. Mean total operative time was 100.8 minutes (range 62 to 140.), including an endopyeloplasty suturing time of 26.6 minutes (range 14 to 54.). We placed 1 to 4 endopyeloplasty sutures per case. Blood loss was minimal, mean hospital stay was 2.2 days (range 2 to 3) and the ureteral Double-J stent (Medical Engineering Corp., New York, New York) was removed in 2 weeks. At a mean followup of 4 months all operated kidneys showed relief of obstruction, as confirmed by clinical improvement in symptoms and improved renal drainage on excretory urography and diuretic renography. CONCLUSIONS: Percutaneous endopyeloplasty is technically feasible, safe and effective. Potential advantages over conventional endopyelotomy include wider caliber reconstruction of the ureteropelvic junction, full-thickness healing with primary intent, minimal urinary extravasation and shorter stenting duration. To our knowledge the initial clinical experience is presented.     

A computer model to predict the outcome and duration of ureteral or renal calculous passage

PURPOSE: We developed a computer model to predict the outcome and the duration until passage of ureteral/renal calculi. MATERIALS AND METHODS: A retrospective, randomized study was performed of the outcome in 301 patients presenting to the emergency room for renal colic. Presenting characteristics of those diagnosed with a single calculus by computerized tomography were recorded for analysis. Predictors of stone passage and passage duration were identified and then used to create a logistic regression model. The algorithm was trained on 141 randomly selected patients and then tested on a separate 160 patients. Model accuracy was compared to predictions from 10 experienced urologists and 9 urology residents in 77 randomly selected patients. The model was tested further in 30 randomly selected patients at a private hospital to assess its general applicability. RESULTS: The model prediction accuracy in 160 patients was 86.3% for passage and 87.3% for duration (less or greater than 2 weeks). In the comparison group the model, the 10 experienced urologists and the 9 urology residents had an overall prediction accuracy of 88.3%, 70.5% (p = 0.006) and 72% (p = 0.007) for passage, and 87.1%, 71.6% (p = 0.007) and 81% (p = 0.075) for duration, respectively. Prediction accuracy was 93.3% for passage and 90.3% for duration when tested at a private hospital. CONCLUSIONS: Our model provides outcome and duration of passage predictions for patients presenting acutely in the emergency room with a single ureteral/renal calculus. It performs better than experienced urologists and urology residents. It can be applied to a private practice setting with equal accuracy.     

胃切除术后近期并发症

本文总结了１９８４－１９９５年间我科治疗的胃切除术后近期并发症２８全我，主要并发症为各种胃肠道瘘、胃肠道出血及梗阻。其中胃肠道瘘是致死的主要原因。对各并发症发生的原因及防治措施进行了讨论。     

Exaggerated primary endoscope deflection: initial clinical experience with prototype flexible ureteroscopes

OBJECTIVE: To increase the clinical usefulness of the actively deflectable flexible ureteroscope by making sequential changes in design and then using these prototypes clinically; and to develop a clinical series using the optimum prototype and contrast it with an extensive database of patients treated with the traditional flexible ureteroscope. METHODS: A series of prototypic flexible ureteroscopes was developed and used clinically. The active deflection of the prototype ureteroscope was evaluated with and with no accessories in the working channel, and compared with a standard 7.5 F ureteroscope. Clinical data were then accrued and compared with a previously published database. RESULTS: The progression of prototypes led to a final version which incorporated > 300 degrees primary active deflection, shaft miniaturization (8.4 F) and an increase in endoscope shaft stiffness. The prototype flexible ureteroscope had significantly greater active deflection than the standard ureteroscope, especially when working channel accessories were used. In all, 115 endoscopic procedures were carried out, the indications for which included endoscopic lithotripsy for distal calculi (51), treatment of upper tract urothelial carcinoma (27), diagnostic endoscopy (26) and retrograde endopyelotomy (three). No guidewire was required to place the flexible ureteroscope into the upper urinary tract in 27% of patients. Active intramural dilatation for access was only required in 3% of the procedures. All lower pole calyces were accessed with this instrument. CONCLUSIONS: Adding exaggerated deflection is a timely advance in flexible ureteropyeloscopy. This and the other changes in design facilitated complex retrograde endoscopic procedures and increased the therapeutic potential of the instrument.     

经皮肾腔内肾乳头活检技术的建立及临床意义

目的：借助微创经皮肾穿刺取石术（MPCNL）建立经皮肾引导直视下进行肾乳头活检的技术,为尿结石病因的基础研究提供新的途径.方法：2005年5月～2007年10月对12例复杂肾结石行MPCNL,对术中发现已有肾乳头钙化斑形成的患者采用经皮肾引导直视下进行肾乳头活检,肾乳头活检标本送电镜观察.结果：12例患者术后无一例出现严重血尿、肾出血的并发症,无一例因严重并发症而再次手术或介入治疗,手术后随访肾功能恢复良好.结论：经皮肾腔内肾乳头活检技术安全、可行,能够在直视条件下获取肾乳头钙化斑组织进行形态学以及蛋白或基因水平的研究,为将来尿结石形成的基础研究提供了一条新的途径.