汪 朔，王 平

(浙江大學(xué)醫(yī)學(xué)院附屬第一醫(yī)院泌尿外科，浙江杭州 310003)

·專家論壇·

腹腔鏡處理腎盂輸尿管交界處狹窄的技術(shù)探討(附光盤)

汪 朔，王 平

(浙江大學(xué)醫(yī)學(xué)院附屬第一醫(yī)院泌尿外科，浙江杭州 310003)

在過去的20余年，用微創(chuàng)手段處理腎盂輸尿管交界處狹窄技術(shù)得到了極大的發(fā)展。多個研究報(bào)告認(rèn)為，無論經(jīng)腹腔或腹膜后途徑，腔鏡下腎盂成形術(shù)在兒童和成人患者中均獲得高成功率，且圍手術(shù)期并發(fā)癥低。腔鏡下腎盂成形術(shù)最大的技術(shù)難點(diǎn)是腔內(nèi)縫合，機(jī)器人輔助腔鏡具有精細(xì)而靈活的機(jī)械臂、高放大倍數(shù)、三維視野及對手術(shù)器械抖動的控制等優(yōu)點(diǎn)，使腔鏡下縫合難題得到解決。腔鏡下處理腎盂輸尿管交界處狹窄最常采用腎盂輸尿管離斷成形術(shù)，其他術(shù)式如Fenger腎盂成形術(shù)，Y-V腎盂成形術(shù)和“血管系住”技術(shù)在特定的群體可考慮選擇。

腹腔鏡；腎盂輸尿管交界處狹窄；腎盂成形；機(jī)器人輔助

腎盂輸尿管交界處狹窄(ureteropelvic junction obstruction,UPJO)是泌尿系統(tǒng)最常見的先天畸形之一，開放途徑行腎盂成形術(shù)是傳統(tǒng)的處理方式。自SCHUESSLER等[1]在1993年首先報(bào)道腹腔鏡腎盂成形術(shù)(laparoscopic pyeloplasty,LP)以來，腔鏡下處理UPJO得到了廣泛的開展[2-3]。與傳統(tǒng)開放手術(shù)相比較，LP具有術(shù)后恢復(fù)快、疼痛少、住院時(shí)間短及美容效果好等優(yōu)點(diǎn)。但LP對縫合技術(shù)要求高，操作者需要專業(yè)的培訓(xùn)及熟練的腔鏡技術(shù)基礎(chǔ)才能完成。隨著科技進(jìn)步、腹腔鏡設(shè)備改進(jìn)，特別是da Vinci機(jī)器人輔助腔鏡技術(shù)的出現(xiàn)，傳統(tǒng)腔鏡處理UPJO的局限性得到了克服。本文將對腹腔鏡處理UPJO的技術(shù)問題做一些簡單介紹。

1 腹腔鏡處理UPJO的方式

1.1 傳統(tǒng)腹腔鏡腎盂成形術(shù)

1.1.1 小兒患者 1995年P(guān)ETERS等[4]首先報(bào)道腹腔鏡腎盂成形術(shù)處理小兒UPJO。此后多個文獻(xiàn)證實(shí)LP處理小兒UPJO圍手術(shù)期并發(fā)癥低，成功率高(92%～100%)[5-10]。

目前在非常年幼群體中LP是否適用處理UPJO存在爭議，主因包括：①年幼群體腔鏡處理技術(shù)難度大，術(shù)后發(fā)生成型失敗及并發(fā)癥明顯增加；②無法定論是否比開放手術(shù)有優(yōu)勢。TAN[11]早期報(bào)道2例小于3月患兒術(shù)后出現(xiàn)吻合口狹窄。但KUTIKOV[12]報(bào)道在小于6月嬰兒中獲得了100%成功率，他認(rèn)為在小嬰兒中，腔鏡成形技術(shù)上是可行的。METZELDER[13]通過年齡分層對比分析發(fā)現(xiàn)，在嬰兒與兒童患者中，LP在技術(shù)上均是可行的，且手術(shù)時(shí)間、術(shù)后療效無明顯差別。目前認(rèn)為，對經(jīng)過專業(yè)培訓(xùn)且熟練掌握腔鏡操作技術(shù)者而言，LP處理小兒UPJO是可行的。但在非常年幼患兒群體中，LP不作常規(guī)推薦。

1.1.2 成人患者 與小兒群體相比，LP在成人群體內(nèi)開展更為廣泛。無論是經(jīng)腹腔還是經(jīng)腹膜后途徑，文獻(xiàn)數(shù)據(jù)均顯示圍手術(shù)期并發(fā)癥低、成功率高。已有數(shù)個研究采用核素掃描評估LP療效。LOPEZ-PUJALS[14]報(bào)告47例UPJO行LP術(shù)，主觀成功率為95.6%，客觀成功率(腎核素掃描顯示引流改善)為94%。POULIOT等[15]把核素成功率評估定義分類為：嚴(yán)格[術(shù)后半排時(shí)間(T1/2)<10 min]；非梗阻(T1/2<20 min)；技術(shù)上成功(T1/2改善)。111例患者術(shù)后61%患者得到嚴(yán)格意義上成功，非梗阻成功率和技術(shù)上成功率分別為86%和93%。 LP術(shù)后隨訪時(shí)間長短對成功率評估有一定影響。MADI等[16]報(bào)道60例UPJO患者行LP術(shù)，術(shù)后1年內(nèi)7例(12%)失敗，但有3例分別于術(shù)后2年、2.5年和6年失敗。TAN[17]報(bào)道102例患者，術(shù)后18例失敗中位時(shí)間為2.5月，失敗患者大部分可通過內(nèi)鏡下挽救性處理獲得成功。

1.2 單孔腹腔鏡下腎盂成形術(shù) (laparoendoscopic single-site pyeloplasty,LESS-P) LESS-P手術(shù)瘢痕小且隱蔽、美容效果好，故特別適用于年輕患者。STEIN等[18]比較分析LESS-P與傳統(tǒng)LP處理UPJO，結(jié)果顯示LESS-P較LP美容效果好, 其他圍手術(shù)期參數(shù)無明顯差別。DESAI等[19]報(bào)道了17例LESS-P臨床積累過程，1例中轉(zhuǎn)為傳統(tǒng)LP，其余16例在縫合過程中均添加了2 mm輔助孔。LESS術(shù)中器械之間有干擾且活動范圍小，使得需要大量縫合的重建手術(shù)十分困難。即使對有豐富操作經(jīng)驗(yàn)的腹腔鏡外科醫(yī)師而言，LESS-P亦需要有固定的學(xué)習(xí)曲線。研究認(rèn)為，最初10例LESS-P的并發(fā)癥相對較多，過了此學(xué)習(xí)曲線期后，出現(xiàn)并發(fā)癥幾率與標(biāo)準(zhǔn)LP無明顯差別[20]。

1.3 機(jī)器人輔助腔鏡下腎盂成形術(shù) (robot-assisted laparoscopic pyeloplasty,RAP) 機(jī)器人輔助對重建手術(shù)特別有意義，主要?dú)w因于精細(xì)而靈活的機(jī)械臂、高放大倍數(shù)、三維視野及對手術(shù)器械抖動的控制。自1999年SUNG[21]首先報(bào)道RAP處理UPJO以來，該術(shù)式在世界范圍內(nèi)迅速得到開展，特別在兒童患者中被認(rèn)為是安全有效的。小兒患者行RAP術(shù)后長期療效可與標(biāo)準(zhǔn)的開放手術(shù)相媲美[22]。BIRD[23]對比分析了RAP和LP處理成人UPJO的差別，結(jié)果顯示采用RAP組吻合時(shí)間縮短，但其他如總手術(shù)時(shí)間、圍手術(shù)期結(jié)果及手術(shù)成功率均無明顯差別。另外一項(xiàng)薈萃分析比較了RAP和LP處理UPJO患者，手術(shù)時(shí)間、術(shù)后尿漏發(fā)生率及手術(shù)成功率均無差別[24]。

2 腹腔鏡處理UPJO手術(shù)徑路的選擇

2.1 腹膜后途徑(retroperitoneal approach，RA) 經(jīng)腹膜后途徑具有對腹腔臟器干擾少、暴露腎盂輸尿管方便等優(yōu)點(diǎn)，但也有操作空間小、解剖定位較困難等缺點(diǎn)。1997年EDEN等[25]首先報(bào)道后腔鏡下腎盂輸尿管離斷成形術(shù)，他們用纖維蛋白膠行腎盂輸尿管吻合，9例患者中8例獲得成功。此后，有不少報(bào)道腹膜后途徑行LP處理UPJO，均顯示該方式安全，臨床療效滿意。ZHANG等[26]報(bào)道包括小兒在內(nèi)50例UPJO患者，行腹膜后途徑LP, 術(shù)中無中轉(zhuǎn)病例，手術(shù)時(shí)間短，術(shù)后并發(fā)癥低。汪朔等[27]對馬蹄腎合并UPJO患者行腹膜后途徑LP, 取得了非常良好的手術(shù)效果。MOON等[28]報(bào)道了170例UPJO患者行腹膜后途徑LP，為迄今為止最大樣本臨床報(bào)道，作者認(rèn)為LP可替代開放手術(shù)成為UPJO處理的金標(biāo)準(zhǔn)。

2.2 經(jīng)腹腔途徑(transperitoneal approach,TA) 經(jīng)腹途徑最大優(yōu)點(diǎn)是解剖標(biāo)記清晰、操作空間大，但對腹內(nèi)臟器干擾大是該途徑的主要缺點(diǎn)。經(jīng)腹途徑一般采用游離結(jié)腸后暴露腎盂輸尿管，但對左側(cè)UPJO患者可采用直接分離降結(jié)腸系膜暴露腎盂輸尿管。ROMERO等[29]研究發(fā)現(xiàn)年輕患者腸系膜脂肪含量少，透過腸系膜鑒定擴(kuò)張腎盂相對容易，故經(jīng)降結(jié)腸腸系膜方式特別適用于小兒及年輕患者。左側(cè)UPJO采用分離經(jīng)腸系膜方式，由于可避免游離降結(jié)腸，使手術(shù)時(shí)間明顯縮短，且術(shù)后腸道功能恢復(fù)快[30]。

3 腔鏡下UPJO成形技術(shù)的選擇

3.1 腔鏡下離斷性腎盂成形術(shù)(laparoscopic dismembered pyeloplasty) 腎盂輸尿管離斷成形術(shù)(Anderson-Hynes術(shù)式)自1949年首次報(bào)告來，迅速被各國學(xué)者所接受，目前是治療UPJO的首選術(shù)式。由于切除了具有肌細(xì)胞發(fā)育異常的部位，故Anderson-Hynes術(shù)效果好、成功率在95%以上。手術(shù)要求吻合口寬廣、低位、呈漏斗狀、縫合密閉而無張力。

3.2 腔鏡下非離斷腎盂成形術(shù)(laparoscopic nondismembered pyeloplasty)

3.2.1 Fenger成形術(shù)(Fenger Plasty) 非離斷腎盂成形術(shù)不需完全離斷腎盂輸尿管之間連接，故在處理技術(shù)上相對簡單。1900年FENGER在UPJO成形過程中，采用縱行切開交界處狹窄段后橫行縫合，他認(rèn)為此手術(shù)方式在矯正交界處狹窄同時(shí)可以很好保留發(fā)自腎盂并供應(yīng)輸尿管上段的血供。不少報(bào)道在選擇性群體中采用腔鏡下Fenger成形術(shù)取得了良好的效果[31-32]，并認(rèn)為此術(shù)式縫合簡單便捷。目前認(rèn)為，在狹窄段較短、輕度腎盂擴(kuò)張患者可考慮采用此方法。

3.2.2 Y-V 腎盂成形術(shù)(Y-V Pyeloplasty) Y-V腎盂成形術(shù)常用于輸尿管高位開口。輸尿管狹窄段較長或存在需要移位的交叉血供是該術(shù)式的禁忌證。近來，一些學(xué)者對比分析了腔鏡下Anderson-Hynes術(shù)和Y-V術(shù)處理UPJO的效果，發(fā)現(xiàn)Y-V術(shù)縫合簡便，可明顯縮短手術(shù)時(shí)間，且術(shù)后療效無明顯差別[33-34]。盡管如此，目前普遍認(rèn)為行Y-V 腎盂成形術(shù)的群體選擇需慎重，對輸尿管高位開口及狹窄段較短者可選擇該術(shù)式。

3.3 “血管系住”技術(shù) (“Vascular Hitch”Technique) UPJO可由交界處固有梗阻引起，亦可由交界處外來梗阻引起。腎下極交叉血供是引起外在性梗阻最常見原因。盡管約30%～70% UPJO患者存在腎下極交叉血供，但交叉血管引起腎積水的發(fā)病機(jī)制存在爭論。不少學(xué)者認(rèn)為在LP處理腎積水過程中，無需常規(guī)處理交叉血管[35-36]。“血管系住”技術(shù)提出的理論依據(jù)是在UPJO術(shù)中游離交叉血管后發(fā)現(xiàn)腎積水明顯減少甚至消失。該技術(shù)需要充分游離交叉血管，提起血管并盡量向腎盂上極移動，并做妥然固定。決定“血管系住”手術(shù)效果最重要的是患者的選擇，在手術(shù)過程中游離交叉血管后發(fā)現(xiàn)腎盂輸尿管交界處及輸尿管外觀正常，腎盂積水輕可考慮實(shí)施該術(shù)式。目前有不少腔鏡下行“血管系住”術(shù)處理UPJO報(bào)道，臨床效果滿意[37-38]。

4 結(jié) 語

多年來，開放行腎盂輸尿管成形術(shù)一直是治療UPJO的金標(biāo)準(zhǔn)。與開放手術(shù)相比，LP具有創(chuàng)傷小、恢復(fù)快等優(yōu)點(diǎn)。在腔鏡專家的操作下，術(shù)后臨床療效可與開放手術(shù)相媲美。機(jī)器人輔助腔鏡出現(xiàn)，使傳統(tǒng)腔鏡的局限性得到克服，縫合過程更加方便、精細(xì)、快捷。經(jīng)腹腔、腹膜后途徑各有優(yōu)缺點(diǎn)，是均可選擇的手術(shù)途徑。腎盂輸尿管離斷成形術(shù)是腔鏡下處理UPJO的首選術(shù)式。對特定的UPJO患者，F(xiàn)enger成形術(shù)、Y-V 腎盂成形術(shù)和“血管系住”技術(shù)亦是可選擇的方式。

[1] SCHUESSLER WW, GRUNE MT, TECUANHUEY LV, et al. Laparoscopic dismembered pyeloplasty[J]. J Urol,1993,150(6):1795.

[2] EL-SHAZLY MA, MOON DA, EDEN CG. Laparoscopic pyeloplasty: status and review of literature[J]. J Endourol,2007,21(7):673-678.

[3] 汪朔,夏丹，陳戈明，等．腹膜后腔鏡 Anderson-Hynes腎盂整形術(shù)[J]．中華泌尿外科雜志，2003，24(8)：531-533.

[4] PETERS CA, SCHLUSSEL RN, RETIK AB. Pediatric laparoscopic dismembered pyeloplasty[J]. J Urol,1995,153(6) :1962-1965.

[5] LAM PN, WONG C, MULHOLLAND TL,et al. Pediatric laparoscopic pyeloplasty: 4-year experience[J]. J Endourol,2007,21(12): 1467-1471.

[6] CHACKO JK, PIAGGIO LA, NEHEMAN A, et al. Pediatric laparoscopic pyeloplasty: lessons learned from the first 52 cases[J]. J Endourol,2009,23(8):1307-1311.

[7] SZAVAY PO, LUITHLE T, SEITZ G,et al. Functional outcome after laparoscopic dismembered pyeloplasty in children[J]. J Pediatr Urol 2010;6(4): 359-63.

[8] VICENTINI FC, DE’NES FT, BORGES LL,et al. Laparoscopic pyeloplasty in children: is the outcome different in children under 2 years of age?[J]. J Pediatr Urol,2008,4(5): 348-351.

[9] TURNER II RM, FOX JA, TOMASZEWSKI JJ, et al. Laparoscopic pyeloplasty for ureteropelvic junction obstruction in infants[J]. J Urol,2013,189(4):1503-1507.

[10] SWEENEY DD, OST MC, SCHNECK FX, et al. Laparoscopic pyeloplasty for ureteropelvic junction obstruction in children[J]. J Laparoendosc Adv Surg Tech A,2011,21(3):261-265.

[11] TAN HL. Laparoscopic Anderson-Hynes dismembered pyeloplasty in children[J]. J Urol,1999,162 (3 Pt 2):1045-1047.

[12] KUTIKOV A, RESNICK M, CASALE P. Laparoscopic pyeloplasty in the infant younger than 6 months-is it technically possible?[J]. J Urol,2006,175(4):1477-1479.

[13] METZELDER ML, SCHIER F, PETERSEN C, et al. Laparoscopic transabdominal pyeloplasty in children is feasible irrespective of age[J]. J Urol,2006,175(2):688-691.

[14] LOPEZ-PUJALS A, LEVEILLEE RJ, WONG C. Application of strict radiologic criteria to define success in laparoscopic pyeloplasty[J]. J Endourol,2004,18(8):756-760.

[15] POULIOT F, LEBEL MH, AUDET JF, et al. Determination of success by objective scintigraphic criteria after laparoscopic pyeloplasty[J]. J Endourol,2010,24(2):299-304.

[16] MADI R, ROBERTS WW, WOLF JR JS. Late failures after laparoscopic pyeloplasty[J]. Urology,2008,71(4):677-680.

[17] TAN HJ, YE Z, ROBERTS WW, et al. Failure after laparoscopic pyeloplasty: prevention and management[J]. J Endourol,2011,25(9): 1457-1462.

[18] STEIN RJ, BERGER AK, BRANDINA R, et al. Laparoendoscopic single-site pyeloplasty: a comparison with the standard laparoscopic technique[J]. BJU Int,2011,107(5):811-815.

[19] DESAI MM, BERGER AK, BRANDINA R, et al. Laparoendoscopic singlesite surgery: initial hundred patients[J]. Urology,2009,74(4):805-812.

[20] BEST SL, DONNALLY C, MIR SA, et al. Complications during the initial experience with laparoendoscopic single-site pyeloplasty[J]. BJU Int,2011,108(8):1326-1329.

[21] SUNG GT, GILL IS, HSU TH. Robotic-assisted laparoscopic pyeloplasty: a pilot study[J]. Urology,1999,53(6): 1099-1010.

[22] MINNILLO BJ, CRUZ JA, SAYAO RH, et al. Long-term experience and outcomes of robotic assisted laparoscopic pyeloplasty in children and young adults[J]. J Urol,2011,185(4):1455-1460.

[23] BIRD VG, LEVEILLEE RJ, ELDEFRAWY A, et al. Comparison of robot-assisted versus conventional laparoscopic transperitoneal pyeloplasty for patients with ureteropelvic junction obstruction: a single-center study[J]. Urology,2011,77(3):730-734.

[24] BRAGA LHP, PACE K, DEMARIA J,et al. 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[J]. Eur Urol,2009,56(5):848-858.

[25] EDEN CG, SULTANA SR, MURRAY KH, et al. Extraperitoneal laparoscopic dismembered fibrin-glued pyeloplasty: mediumterm results[J]. Br J Urol,1997,80(3):382.

[26] ZHANG X, LI HZ, WANG SG, et al. Retroperitoneal laparoscopic dismembered pyeloplasty: experience with 50 cases[J]. Urology,2005,66(3):514-517.

[27] WANG P, XIA D, MA Q,et al. Retroperitoneal laparoscopic management of ureteropelvic junction obstruction in patients with horseshoe kidney[J]. Urology,2014, 84(6):1351-1354.

[28] MOON DA, EL-SHAZLY MA, CHANG CM, et al. Laparoscopic pyeloplasty: evolution of a new gold standard[J]. Urology,2006,67(5):932-936.

[29] ROMERO FR, WAGNER AA, TRAPP C, et al. Transmesenteric laparoscopic pyeloplasty[J]. J Urol,2006,176(6 Pt 1):2526-2529.

[30] SHADPOUR P, NAYYERI RK, DANESHVAR R,et al. Prospective clinical trial to compare standard colon-reflecting with transmesocolic laparoscopic pyeloplasty[J]. BJU Int,2012,110(11): 1814-1818.

[31] JANETSCHEK G, PESCHEL R, BARTSCH G. Laparoscopic Fenger plasty[J]. J Endourol,2000,14(10): 889-893.

[32] POLOK M, CHRZAN R, VEENBOER P, et al. Nondismembered pyeloplasty in a pediatric population: results of 34 open and laparoscopic procedures[J]. Urology,2011,78(4): 891-894.

[35] CANES D, DESAI MM, HABER GP, et al. Is routine transposition of anterior crossing vessels during laparoscopic dismembered pyeloplasty necessary?[J]. J Endourol,2009,23(3): 469-473.

[36] BOYLU U, OOMMEN M, LEE BR,et al. Ureteropelvic junction obstruction secondary to crossing vessels-to transpose or not?The robotic experience[J] . J Urol, 2009,181(4):1751-1755.

[37] SAKODA A, CHERIAN A, MUSHTAQ I. Laparoscopic transposition of lower pole crossing vessels (“vascular hitch”) in pure extrinsic pelvi-ureteric junction (PUJ) obstruction in children[J]. BJU Int，2011，108(8):1364-1368.

[38] NOURALIZADEH A, SIMFOROOSH N, BASIRI A, et al. Laparoscopic management of ureteropelvic junction obstruction by division of the aberrant vein and cephalad relocation of the crossing artery: a long-term follow-up of 42 cases[J]. J Endourol,2010,24(6): 987-991.

(編輯 何宏靈)

Discussion on the laparoscopic techniques of ureteropelvic junction obstruction

WANG Shuo, WANG Ping

(Department of Urology,the First Affiliated Hospital,College of Medicine, Hangzhou 310003,China)

Over the last two decades, minimally invasive treatment options for ureteropelvic junction obstruction (UPJO) have been developed and popularized. Multiple series of laparoscopic pyeloplasty have demonstrated high success rates and low perioperative morbidity in pediatric and adult populations, with both transperitoneal and retroperitoneal approaches. The evolution of laparoscopy has been limited by the challenges of intracorporeal suturing. Robotic surgical systems may offer the means to overcome this major impediment of laparoscopic surgery. The gold standard surgical technique for the laparoscopic management of UPJO is dismembered pyeloplasty, as described by Anderson and Hynes. However, other techniques such as Fenger plasty, Y-V pyeloplasty, or “Vascular Hitch” technique for UPJO repair can be considered whenever possible because they offers more advantages at no increased risk, given a careful case selection, mostly based on intraoperative findings.

laparoscopy; ureteropelvic junction obstruction; pyeloplasty; robot-assisted

2015-04-02

2015-04-30

王平，副主任醫(yī)師.E-mail：wpyyy@126.com

汪朔(1963-)，男(漢族)，主任醫(yī)師，碩士生導(dǎo)師.研究方向：泌尿系疾病微創(chuàng)治療及泌尿系腫瘤.E-mail：shuowang11@hotmail.com

R693.2

A

10.3969/j.issn.1009-8291.2015.05.001