手助腹腔镜在上尿路移行细胞癌治疗中的应用

目的：探讨手助腹腔镜在肾输尿管全长切除术加膀胱袖套状切除术中的应用价值。方法：采用手助腹腔镜行肾输尿管全长切除术，加膀胱袖套状切除术治疗上尿路移行细胞肿瘤7例(其中经腹腔途径5例，经腹膜后途径2例)。病理类型均为移行细胞癌(肾盂移行细胞癌5例，输尿管移行细胞癌1例，肾盂和输尿管多发性移行细胞癌1例)。结果：7例手助腹腔镜手术均获成功。手术时间50～150min，平均97．5min；术中出血50～300ml，平均111．4ml；术后住院时间7～53d。结论：采用手助腹腔镜行肾输尿管全长切除术加膀胱袖套状切除术治疗上尿路移行细胞癌，是一种可选择的新的手术方式，与开放手术相比，具有损伤小、出血少、术后恢复快等优点。     

手助腹腔镜肾输尿管及膀胱袖套状切除术(附9例报告)

目的：探讨手助腹腔镜肾输尿管及膀胱袖套状切除术的手术技术。方法：采用手助腹腔镜对9例肾盂及输尿管肿瘤患者行肾输尿管及膀胱袖套状切除术,其中肾盂癌5例,输尿管癌4例;男7例,女2例;年龄45～68岁,平均53．5岁。结果：9例手术均成功实施,术后病理检查证实为移行细胞癌。手术时问为150～210min,平均190min,出血量50～200ml,平均150ml。术后恢复快,7～21天后出院,无明显并发症。对所有患者随访2～24个月,无肿瘤复发。结论：采用手助腹腔镜肾输尿管及膀胱袖套状切除术治疗肾盂及输尿管肿瘤具有手术时间短、安全、出血少、损伤小、患者术后恢复快、痛苦小、并发症少等优点。     

手助腹腔镜根治性肾输尿管全切术治疗上尿路移行细胞癌疗效观察

目的：评价手助腹腔镜根治性肾输尿管全切术治疗上尿路移行细胞癌的安全性和有效性。方法：对4例上尿路移行细胞癌患者在行手助腹腔镜根治性肾输尿管全切术后，原切口向下延长2cm，行常规开放性膀胱袖套状切除术；对另1例行手助腹腔镜根治性肾输尿管全切术后，原切口向上下各延长2～3cm，再行开放根治性全膀胱切除术并盆腔淋巴结清扫术并左侧输尿管皮肤造口术。结果：5例均手术成功，前4例手术时间180～240min，术中出血50～180ml；后1例手术时间540min，术中出血l000ml。术后8～28天出院，均无严重并发症发生。结论：采用手助腹腔镜根治性肾输尿管全切术治疗上尿路移行细胞癌是安全有效的，具有痛苦小、并发症少、术后恢复快等优点。     

腹腔镜及开放根治性肾输尿管膀胱切除术治疗上尿路肿瘤合并膀胱癌8例报告

目的探讨腹腔镜和开放根治性肾输尿管膀胱切除术治疗上尿路肿瘤合并膀胱癌患者的可行性和安全性。方法收集我院2004年6月至2009年3月期间收治的8例单侧上尿路肿瘤并浸润性膀胱癌行根治性肾输尿管膀胱切除术及尿流改道手术患者的临床资料并进行随访分析。结果本组8例。男7例,女1例,平均年龄56岁。术前经膀胱镜、输尿管镜、B超和CT等检查证实为单侧上尿路肿瘤并浸润性膀胱癌,其中4例左肾盂癌和2例右肾盂癌合并膀胱癌,2例为左输尿管癌合并膀胱癌。2例行腹腔镜肾输尿管膀胱切除术及回肠膀胱术,平均手术时间470min,术中平均出血量275ml,均无输血,术后肠功能恢复时间为2d,下床活动时间为4d。6例患者行开放肾输尿管膀胱全切除术,其中4例行回肠膀胱术,另2例行输尿管造口术,平均手术时间366min,平均出血量767ml,平均输血量485ml,术后肠功能恢复时间为3.3d,下床活动时间平均为6.7d。8例患者术后均未出现并发症。术后病理结果 7例为尿路上皮癌,上尿路肿瘤分期分级为T2～4N0～1M0G2,膀胱癌为T2～3N0M0G3,另1例为左肾盂鳞癌T4N1M0合并膀胱鳞癌T3N0M0。术后平均随访24.6个月,鳞癌患者术后18个月因肿瘤广泛转移死亡,余7例患者无瘤生存至今。结论单侧上尿路肿瘤合并膀胱癌可行Ⅰ期根治性肾输尿管膀胱切除术,腹腔镜下行该手术是可行及安全的,较开放手术创伤小,出血少,恢复快。     

后腹腔镜根治性肾输尿管切除术21例报告

目的:探讨后腹腔镜根治性肾输尿管切除术的疗效。方法:2003年10月至2006年10月我们对21例肾盂或输尿管移行细胞癌患者行后腹腔镜根治性肾输尿管切除术,其中肾盂癌13例,输尿管癌8例。经尿道输尿管口切除术处理末段输尿管,使用Hem-O-lock结扎锁处理肾动静脉。结果:本组手术时间180-300m in,平均220m in;出血量40-100m l,平均60m l;术中、术后未发生明显并发症。随访2-35个月,2例发生膀胱移行细胞癌。结论:后腹腔镜根治性肾输尿管切除术具有创伤小、术后恢复快等优点,用Hem-O-lock结扎锁处理肾动静脉安全可靠,经济实用。     

后腹腔镜辅助小切口肾输尿管及膀胱袖套状切除术(附7例报告)

目的:探讨后腹腔镜辅助小切口肾输尿管及膀胱袖套状切除术的手术技巧。方法:用后腹腔镜辅助小切口为7例肾盂及输尿管肿瘤患者行肾输尿管及膀胱袖套状切除术,其中肾盂癌4例,输尿管癌3例。结果:7例手术均获成功,手术时间90~120min,平均108min,术中出血50~150ml,平均80ml。术后平均住院10d,无严重并发症发生。随访4~33个月,无肿瘤复发。结论:采用后腹腔镜辅助小切口肾输尿管及膀胱袖套状切除术治疗肾盂及输尿管肿瘤具有患者创伤小、出血少、手术时间短、并发症少、切除更完全等优点。     

后腹腔镜联合经尿道输尿管口电切术治疗肾盂输尿管肿瘤(附17例报告)

目的:评估后腹腔镜联合经尿道输尿管口电切术治疗肾盂、输尿管肿瘤的临床疗效。方法:2008年10月至2013年1月为17例肾盂或输尿管移行细胞癌患者行后腹腔镜根治性肾输尿管切除术,其中肾盂癌11例,输尿管癌6例。经尿道袖状电切患侧输尿管口周围1 cm范围膀胱壁,采用后腹腔镜切除肾及全长输尿管,完整取出切除的肾输尿管。术后常规吡柔比星膀胱灌注。结果:手术时间平均(186.9±30.2)min;术中出血量平均(110.1±38.6)ml;术中、术后未发生明显并发症。术后随访3～51个月,1例发生膀胱移行细胞癌。结论:后腹腔镜联合经尿道电切镜治疗肾盂癌、输尿管癌具有手术损伤小、康复快等优点,且不增加肿瘤种植风险,临床应用前景良好。     

后腹腔镜联合腹部小切口根治性肾输尿管切除术治疗肾盂癌的临床研究

目的：探讨后腹腔镜联合腹部小切口根治性肾输尿管切除术治疗肾盂癌的临床应用价值。方法：回顾性分析2002年1月～2007年12月施行的61例后腹腔镜联合腹部小切口根治性肾输尿管切除术（腔镜组）及47例开放性根治性肾输尿管切除术（开放组）的临床资料，比较两组手术时间、术中出血量、术后肠功能恢复时间、局部复发、切口种植转移等指标。结果：腔镜组平均手术时间120（90～150）min，平均术中出血量60（20～450）ml，平均术后肠功能恢复时间1．5（1～2）天，术后切口感染3例，切口侧下腹部皮肤感觉过敏者5例，无严重并发症出现。开放组平均手术时间150（120～200）min，平均术中出血量150（100～500）ml，平均术后肠功能恢复时间2（1．5～3）天，术后切口感染6例，切口侧下腹部皮肤感觉过敏者15例，无严重并发症出现。腔镜组手术时间、术中出血量、术后肠功能恢复时间明显优于开放组（P〈0．01）。结论：后腹腔镜联合腹部小切口根治性肾输尿管切除较开放性手术治疗肾盂癌具有微创、安全、可靠等特点；无局部重要脏器及大血管浸润和粘连的肾盂癌均适合行后腹腔镜手术切除术。     

后腹腔镜肾输尿管切除治疗肾盂癌22例

目的评价后腹腔镜肾输尿管切除术治疗肾盂癌的疗效。方法2002年12月-2005年11月，我院行后腹腔镜肾输尿管切除治疗肾盂癌22例。膀胱镜袖状切除患侧输尿管口，后腹腔镜切除患肾，并于下腹部做切口，将患肾、输尿管全部切除，取出。结果22例手术均获得成功。手术时间2～5h，平均4．3h。出血量50～600ml，平均187ml。引流量50～200ml/d，平均120ml/d，术后24-48h拔除引流管。住院时间8-13d，平均10d。22例均为肾盂移行细胞癌。22例随访1-24个月，平均14个月，均未复发。结论后腹腔镜肾输碌管切除治疗肾盂癌，可取得满意的效果，旦手术创伤小，恢复快，值得临床推广。     

手助腹腔镜根治性肾切除19例报告

目的：探讨手助腹腔镜根治性肾切除术的临床应用价值。方法：采用手助腹腔镜根治性肾切除术治疗肾肿瘤19例。结果：19例手助腹腔镜手术均获成功。手术时间75～300min，平均165．8min；术中出血15～250ml，平均97．4ml；病理结果均为肾细胞癌(透明细胞癌18例，嫌色细胞癌1例)；术后住院时间6～23d。结论：手助腹腔镜根治性肾切除术治疗肾肿瘤是个可选择的新的手术方式，与开放手术相比，具有损伤小、出血少、术后恢复快等优点。     

Solitary port-site metastasis after laparoscopic bilateral nephroureterctomy for transitional cell carcinoma in a renal transplant recipient

A renal transplant recipient with upper tract transitional cell carcinoma developed a solitary port-tract recurrence 8 months after a hand-assisted laparoscopic bilateral nephroureterectomy and was successfully managed by a local wide excision and adjuvant radiotherapy. Follow-up for 3 years after the salvage therapy showed no evidence of local recurrence or distant metastasis. This patient is the first one in the literature to have a solitary port-site metastasis of transitional cell carcinoma in renal transplant recipients.     

后腹腔镜下肾输尿管切除加经尿道膀胱袖状切除治疗上尿路上皮癌

目的 探讨后腹腔镜下肾输尿管切除加经尿道膀胱袖状切除治疗上尿路上皮癌的临床效果.方法 上尿路上皮癌患者82例(肾盂癌69例,输尿管癌13例).男39例,女43例.平均年龄65(37～82)岁.电切镜经尿道膀胱袖状分离输尿管管口及壁内段,后腹腔镜下切除肾、输尿管.观察手术时间、术中出血量、引流管留置时间、尿管留置时间、术后住院日及术后并发症等.随访肿瘤转移与复发情况.结果 82例手术顺利.手术平均时间135(95～210)min.术中平均失血110(60～260)ml.术后引流管平均留置3(2～4)d.尿管平均留置6(5～7)d.术后平均住院7(6～9)d.74例患者获随访平均31(6～76)个月.高级别浸润性癌随访16例,复发转移3例;高级别与低级别非浸润性癌分别随访29例,膀胱内复发5例(高级别3例,低级别2例);切口部位肿瘤转移复发1例.3年随访肿瘤复发率为10.6%(5/47).结果 后腹腔镜下肾输尿管切除加经尿道膀胱袖状切除治疗上尿路上皮癌,输尿管口周围组织及输尿管壁内段切除确切,创伤小、康复快,手术安全易行,疗效可靠.     

Hand-assisted laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma.

OBJECTIVE: We report our experience with hand-assisted laparoscopic nephroureterectomy (HALN) for upper urinary tract transitional cell carcinoma and compare our results with a contemporary series of open nephroureterectomy (ON) performed at our institution. METHODS: Between August 1996 and May 2003, 90 patients underwent nephroureterectomy for upper-tract transitional cell carcinoma (TCC). Thirty-eight patients underwent HALN, while 52 had an ON. End-points of comparison included operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of hospital stay, pathologic grade and stage of tumor, and tumor recurrence. RESULTS: The mean patient age was 72.3 and 70.6 years in the ON and HALN groups, respectively. Mean operative duration was 243 minutes (ON) and 244 minutes (HALN), with an EBL of 478mL in the open group versus 191 mL in the hand-assisted group (P<0.001). No intraoperative complications occurred, but postoperative complications occurred in 4% and 11% of the ON and HALN groups, respectively (P=0.21). The mean hospital duration was 7.1 days (ON) versus 4.6 days (HALN) (P<0.01). No difference existed in the pathologic grade or stage distribution of urothelial tumors between the 2 groups. The mean follow-up was 51.0 months in the ON group and 31.7 months in the HALN group. Recurrence of urothelial carcinoma occurred in 50% of patients who underwent ON and 40% treated by HALN (P=0.38) at a median interval of 9.1 and 7.7 months, respectively, after surgery. CONCLUSION: Hand-assisted laparoscopic nephroureterectomy is an effective modality for the treatment of upper urinary tract urothelial carcinoma. Patients benefited from less intraoperative blood loss and a shorter hospitalization with an equivalent intermediate-term oncologic outcome compared with that of the open approach.     

后腹腔镜联合经尿道电切镜治疗上尿路移行细胞癌(附83例报告)

目的 探讨后腹腔镜联合经尿道电切镜治疗上尿路移行细胞癌的效果和安全性. 方法 2003年3月～2006年7月,我院采用后腹腔镜联合经尿道电切镜治疗83例上尿路移行细胞癌.经尿道袖状电切患侧输尿管口周围1.5 cm范围膀胱壁达膀胱外脂肪组织,采用后腹腔镜切除肾及全长输尿管.术后留置导尿管7 d.11例术后辅助放疗. 结果 83例手术均成功.手术时间115～205 min,平均156 min.术中出血50～150 ml,平均80 ml.无术中并发症.术后住院7～11 d,平均8.5 d.病理报告：82例上尿路移行细胞癌,1例肾盂上皮中～重度不典型增生.术后随访3～38个月,平均10.8月.术后12个月内行膀胱镜检查发现膀胱肿瘤6例,其中5例行经尿道膀胱肿瘤电切,1例行腹腔镜根治性膀胱全切术、左侧输尿管皮肤造口术.2例肾盂肿瘤（pT3 G3和pT2 G3）于术后3个月肝转移.2例输尿管中段肿瘤（pT3 G3和pT3 G2～3）术后6个月原位复发并肺转移.1例输尿管下段肿瘤（pT3 G3）术后6个月骨转移.失访1例.其余71例均未发现肿瘤复发、切口转移及远处转移. 结论 对于上尿路移行细胞癌,采用后腹腔镜联合经尿道电切镜行肾、输尿管全切及膀胱袖套状切除具有创伤小、安全、恢复快等优点,值得临床推广应用.     

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.     

Prognostic variables in patients with transitional cell carcinoma of the renal pelvis and proximal ureter

Recent technological advances in urological endoscopic surgery of the renal pelvis and proximal ureter via ureteroscopy or percutaneous nephroscopy have made it possible to consider parenchymal-sparing procedures in patients with transitional cell carcinoma. To define the role of these procedures in the management of renal pelvic or proximal ureteral transitional cell carcinoma we analyzed retrospectively 31 patients who underwent nephroureterectomy for transitional cell carcinoma of the renal pelvis and/or proximal ureter. High grade upper urinary tract transitional cell carcinoma and a history of metachronous or synchronous bladder transitional cell carcinoma were independent adverse prognostic factors. However, patients with low grade upper urinary tract transitional cell carcinoma and no evidence of a urothelial field change had a 100 per cent 5-year survival rate. It would appear that parenchymal-sparing endoscopic techniques should be regarded with caution in patients with either high grade transitional cell carcinoma of the renal pelvis and proximal ureter or a history of bladder cancer.     

腹膜后腹腔镜肾盂癌、输尿管癌根治术13例报告

目的:探讨腹膜后腹腔镜手术治疗肾盂癌、输尿管癌的手术方法及临床经验。方法:回顾分析为13例患者行腹膜后腹腔镜手术的临床资料,其中肾盂癌8例,输尿管癌5例;上段1例,中段2例,下段2例,右侧9例,左侧4例。结果:13例手术均获成功,无一例中转开放。手术时间150～230 min,平均(160±13.5)min;术中出血量50～160 ml,平均(102±23)ml,无一例输血;术后1～3 d恢复排气并进食,2 d后下床活动。术后住院7～12 d,平均9 d。术后定期丝裂霉素间断膀胱灌注,随访3～12个月,均无复发、转移及切口种植。结论:腹膜后腹腔镜手术治疗肾盂癌、输尿管癌具有手术损伤小、康复快等优点,且不增加肿瘤种植的风险,与传统开放手术及其他术式相比,术中出血少、手术时间短、术后并发症少。     

重复肾并肾肿瘤3例报告并文献复习

目的探讨重复肾合并肾肿瘤的诊断和治疗,提高对重复肾并肾肿瘤的认识并提供临床正确诊治此类疾病的参考。方法回顾分析3例重复肾并发肾肿瘤患者的临床资料,其中男性2例,女性1例,年龄52～62岁。并发肾盂癌1例,肾乳头状细胞癌1例,肾肉瘤样癌并腔静脉瘤栓1例。结果 1例行经腹腔镜肾部分切除术,随访2年1个月未见复发;1例行手助腹腔镜肾输尿管全长及膀胱袖状切除术,随访10个月未见复发;1例行肾癌根治术及下腔静脉取栓术,随访10个月未见复发。结论 B超可作为重复肾并肾肿瘤的早期筛查方法;CTU可用于了解泌尿系统的立体结构,大概明确肿瘤性质和肿瘤位置;逆行尿路造影可检查是否合并膀胱病变和进一步确定肿瘤位置。该类患者多需要通过手术治疗,根据肿瘤大小、位置和是否合并瘤栓选择术式,术后化疗则根据病理结果。     

Laparoscopic nephroureterectomy: long-term outcomes

PURPOSE OF REVIEW: Laparoscopic nephroureterectomy is becoming increasingly common since it was first described in 1991 for upper urinary tract transitional cell carcinoma, with long-term data now emerging. The purpose of this study was to compare oncological outcomes between laparoscopic nephroureterectomy and open nephroureterectomy, investigate recurrence risks specific to laparoscopic nephroureterectomy techniques and review long-term outcomes after laparoscopic nephroureterectomy. RECENT FINDINGS: Recently published long-term outcomes support the oncologic efficacy of laparoscopic nephroureterectomy, confirming results from previous studies with short and intermediate follow-up. Rates of bladder, local and distant recurrence are comparable irrespective of the various methods of managing the distal ureter and bladder cuff currently employed. SUMMARY: As the oncologic outcomes after laparoscopic nephroureterectomy continue to mature, a laparoscopic approach for the renal portion of nephroureterectomy is widely accepted as the gold standard in the treatment of organ-confined upper urinary tract transitional cell carcinoma. The roles of laparoscopic nephroureterectomy, lymph node dissection and adjuvant chemotherapy in advanced upper urinary tract transitional cell carcinoma continue to evolve and remain to be defined.     

Advanced age is not a prohibitive factor in laparoscopic nephrectomy for renal pathology

Since the first procedure by Clayman and colleagues in 1990, laparoscopic nephrectomy has been performed at multiple institutions worldwide and is an accepted approach for benign and malignant renal pathology. We retrospectively compared the outcomes of laparoscopic nephrectomy for renal pathology in patients older than and less than 65 years of age. Data were collected for all patients undergoing elective nephrectomy (simple, radical, and nephroureterectomy) for renal pathology between November 2000 and June 2003. A total of 94 laparoscopic nephrectomies (62 hand-assisted, 32 totally laparoscopic) for renal disease were performed. Indications for surgery included renal cell carcinoma (63), transitional cell carcinoma (7), hypertension (9), chronic pyelonephritis (6), nonfunctioning kidney (4), complex cyst (3), and polycystic kidney disease (2). There were 33 elderly patients (> or = 65 years) and 61 adult patients (< 65 years). The elderly group had a mean operative time (238 min vs 234.3 min; P = 0.89) and blood loss (88.5 mL vs 149.8 mL; P = 0.68) similar to the adult group. Likewise, the incidence of perioperative complications was no different between the two groups (intra-op: 3.0% vs 0%; P = 0.35/post-op: 21.2% vs 16.4%; P = 0.56). The length of hospitalization was longer in the elderly population (5.7 days versus 5.0 days; P = 0.01) compared to the younger adult group. Laparoscopic nephrectomy is well tolerated in the elderly population. For all surgical indications, the use of a minimally invasive approach confers operative times, blood loss, and morbidity that are comparable to those of younger patients. Yet, length of stay remains longer for elderly patients undergoing nephrectomy.