全腹腔镜移植输尿管膀胱再植术处理肾移植术后输尿管狭窄

目的：评估全腹腔镜下移植输尿管膀胱再植术处理移植肾输尿管狭窄的安全性及有效性，总结腹腔镜下寻找移植肾输尿管的操作经验。方法：回顾性分析北京大学第三医院泌尿外科2017年11月收治的1例行腹腔镜下移植输尿管膀胱再植术治疗移植肾输尿管狭窄的病例，并复习相关文献。患者女性，54岁，主诉“肾移植术后肾积水5年”入院。查体：移植肾区略膨隆，无压痛。磁共振尿路造影（magnetic resonance urography，MRU）示移植肾及输尿管明显扩张，肾盂扩张最宽处约5 cm，肾盂肾盏均明显扩张，输尿管末段可见狭窄，输尿管内未见异常充盈缺损信号，初步诊断为移植输尿管末段狭窄。既往行两次多镜联合内镜下输尿管狭窄扩张术，拔除支架后移植肾积水无改善。入院后完善术前准备，在全身麻醉下行全腹腔镜下移植输尿管膀胱再植术。首先切断脐正中韧带、脐外侧韧带及腹膜返折，向远端游离膀胱前间隙，逐步游离膀胱左侧壁与耻骨间隙、膀胱前壁与耻骨间隙；其次，膀胱右侧壁游离从头侧至尾侧，仔细辨认周围结构，避免损伤移植肾的输尿管，在膀胱右侧壁与移植肾下极之间寻找移植肾输尿管，剪开输尿管末端，确认切开处近侧输尿管管腔无狭窄，采用Lich-Gregoir法（膀胱外法）行移植肾输尿管膀胱吻合术；最后，将吻合处周围表面膀胱组织与右侧盆壁固定，以减小张力。结果：手术顺利完成，手术时间210 min，术中出血量约30 mL，无手术并发症。患者术后肌酐稳定，术后第1天肌酐68 μmol/L，较术前下降（术前血清肌酐94 μmol/L）， 术后5 d出院。术后随访3个月，KUB(kidney ureter bladder radiography)提示输尿管支架位置良好，拔除输尿管支架后移植肾功能稳定，复查肌酐79 μmol/L，无发热、腰痛等症状，复查移植肾超声示移植肾肾盂略增宽0.7 cm，较前明显改善，移植肾血流正常。结论：报道采用全腹腔镜移植输尿管膀胱再植术处理肾移植术后输尿管狭窄的病例，该术式是治疗移植肾输尿管狭窄的安全、有效的治疗方法。与开放手术相比，腹腔镜手术对肾移植患者影响更小，具有恢复快、出血少、并发症少，术后疼痛轻，以及伤口微创、美观的优点。该术式手术难度较大，对术者腹腔镜技术要求较高，需要经验丰富的泌尿外科医生操作。

Laparoscopic ureterovesical reimplantation for ureteral stricture after renal transplantation

Objective： To discuss the safety and efficacy of laparoscopic ureterovesical reimplantation in the treatment of transplanted ureteral stenosis. Methods: One case of laparoscopic ureterovesicalre implantation in the treatment of ureteral stenosis after renal transplantation was reported, and related literatures was reviewed. A 54-year-old woman was admitted to our hospital with main complaint of hydronephrosis of transplanted kidney for five years after renal transplantation. Her physical examination showed slightly bulging in the transplanted kidney area without tenderness. The magnetic resonance urography (MRU) showed that the transplanted kidney and ureter were dilated obviously, with significant dilatation of renal pelvis and calyx, about 5 cm at the widest point of renal pelvis expansion, and the end of ureter was narrow, without abnormal filling defect in the ureter. The primary diagnosis was distal transplanted ureteral stenosis. After twice endoscopic ureteral dilatation by multi-endoscopic technique, there was no improvement in the hydronephrosis after the removal of the stent.After thorough preoperative preparation, laparoscopic ureterovesical reimplantation was performed under general anesthesia.Firstly, the median umbilical ligament, the lateral umbilical ligament and the peritoneal fold were cut off, and the anterior bladder space was dissociated distally. The space of left side wall of the bladder and the pubic bone was gradually dissociated, and the space of anterior bladder wall and the pubic bone was dissociated. Secondly, the right side wall of the bladder was dissociated from the head to the tail, and the surrounding structure was carefully identified to avoid injury of the ureter of the transplanted kidney.The transplanted ureter was sought between the right side of the bladder and the lower pole of the transplanted kidney. The distal end of the ureter was cut open, and the narrow section was cut off, confirming that no stenosis in the proximal ureter.The ureterocystic anastomosis was performed by Lich-Gregoir method (extra-bladder).Finally, the bladder tissue around the anastomosis site was fixed to the right pelvic wall to reduce tension. Results: The operation was completed successfully, the operation time was 210 min, the amount of bleeding was about 30 mL, and there was no surgical complication. The creatinine was stable after operation, with serum creatinine declining to 68 μmol/L, and serum creatinine 94 μmol/L before operation. The patient was discharged 5 days after operation. After follow-up of 3 months, KUB indicated that the position of ureteral stent was good and the function of renal transplantation was stable. Conclusion: Laparoscopic ureterovesical reimplantation is a safe and effective treatment for ureteral ureteral stricture after renal transplantation. Compared with open surgery, laparoscopic surgery has less impact on renal renal allograft, with faster recovery, less bleeding, fewer complications, less postoperative pain and minimally invasive wound. This surgical procedure is difficult and requires an experienced urologist with high laparoscopic skills to perform.