耻骨上辅助经脐单孔腹腔镜技术在泌尿外科的应用价值（附57例报告）

目的：探讨耻骨上辅助经脐单孔腹腔镜技术（E—NOTES）的安全性、可行性和有效性。方法：本组57例，其中肾上腺肿瘤5例，肾囊肿2例，肾结核2例，肾癌8例，肾盂癌1例，肾积水致无功能肾及萎缩肾14例，重复肾输尿管畸形2例，肾盂输尿管连接部梗阻4例，肾盂结石2例，输尿管上段结石17例。患者全麻，取健侧70°卧位。脐缘置入两个Trocar及操作器械，自耻骨联合患侧阴毛覆盖区置入一Trocar及腹腔镜。手术方法同普通腹腔镜手术。体积较大标本，延长耻骨上切口取出。结果：全部手术均获成功。平均手术时间：肾上腺切除术87（73～130）min，肾囊肿去顶术45（35～55）min，单纯性肾切除术115（95～173）min，根治性肾切除术95（80～158）min，重复肾切除术150（135～165）min，肾输尿管全长切除术125min，肾盂成形术149（132～177）min，肾盂或输尿管切开取石术83（64～128）min，肾部分切除术时间96min。平均失血量95（50～300）ml。平均住院时间6．8（2～8）天。术后切口愈合良好，手术瘢痕隐蔽，美容效果佳。结论：耻骨上辅助E—NOTES安全可行，可降低E—NOTES手术难度，有助于减少腹部切1：3疝的发生，且具有良好的美容效果，可作为现阶段E—NOTES的过渡手术，值得临床应用。

Application of Suprapubic-Assisted Embryonic Natural Orifice Transumbilical Endoscopic Surgery in Urology(Report of 57 Cases)

Objective:To describe the initial clinical experience of suprapubic-assisted embryonic natural orifice transumbilical endoscopic surgery(E-NOTES) in urology,and evaluate its safety,feasibility and efficacy.Methods: Fifty-seven consecutive patients including 42 males and 15 females,with a mean age of 46.6 yeas(range 19 to 77).were subjected to suprapubic-assisted E-NOTES in our center.There were 5 adrenal tumors.2 renal cysts. 2 renal tuberculosis,8 renal carcinomas,1 renal pelvic carcinoma,14 non-functioning kidneys,2 duplex kidneys, 4 ureteropelvic junction obstructions,2 renal pelvic calculi,and 17 ureteral calculi in our study.Under general anesthesia, the patients were positioned in lateral decubitus with affected side elevated 70°.One 5 and 10 mm(or two 5 mm) trocars were inserted into the umbilical edge.A 10 or 5 mm trocar was inserted into abdominal cavity below the pubic hairline,through which a 10 mm 30°or 5 mm 0°laparoscope was placed.The operation was same as that of standard laparoscopy.Some bigger specimens were removed after the incisions below the pubic hairline were enlarged.Results:The 57 procedures were all successfully performed.The mean operative time for adrenalectomy was 87(range 73 to 130) mins,renal cyst excision 45(range 35 to 55) mins,simple nephrectomy 115(range 95 to 173)mins,radical nephrectomy 95(range 80 to 158) mins,nephron-sparing surgery 96 mins,heminephroureterectomy 150(range 135 to 165) mins.nephroureterectomy 125 mins,pyeloplasty 149(range 132 to 177) mins, pyelolithotomy or ureterolithotomy 83(range 64 to 128) mins.The mean blood loss was 95(range 50 to 300) ml. The patients resumed ambulation on postoperative day 1.3(range 1 to 2).Oral nutrition was resumed 2.4(range 2 to 3) d after surgery.The drainage tube was removed on postoperative day 2.7(range 2 to 4).Hospitalization duration was between 2 and 8 days with a mean postoperative stay of 6.8 days.The mean follow-up of 5.2(range 1 to 11) months showed hidden umbilicus scar.The suprapubic scar was not detectable because of the pubic hairs. Conclusions:Suprapubic-assisted E-NOTES appears to be feasible,safe and effective.It would not only lead to improved cosmetic results,but decrease the difficult of operation.Removing specimen from the incision below the pubic hairline is helpful for good cosmetic results,and could reduce abdominal hernia.