腹腔镜结合开放手术在肾盂成形术中的应用

目的 探讨腹腔镜结合开放手术在肾盂成形术中的应用价值。方法 肾盂输尿管连接部梗阻患者45例，经腹腹腔镜下游离肾盂及部分输尿管上段，将正对肾盂输尿管连接部体表投影水平的套管戳口向头侧延长1～2cm，自该切口将肾盂输尿管连接部提出腹壁外进行成形操作。结果 45例手术均获成功。手术时间40～85min，平均58min；术中出血量15～30ml，平均22ml。术中术后无并发症。34例随访3～36个月，平均11个月，IVU检查吻合口无梗阻，B超提示患肾积水减轻。结论 与开放手术和全腹腔镜手术相比，肾盂成形术中联合应用腹腔镜与开放手术技术可减少腹腔镜手术的操作难度，缩短手术时间，并不明显增加腹壁创伤，值得临床推广应用。     

后腹腔镜下离断式肾盂成形术

目的探讨后腹腔镜下肾盂成形术的临床疗效. 方法腹腔镜下通过后腹腔途径对9例肾盂输尿管连接部狭窄行离断式肾盂成形术并对技术进行改进. 结果 9例手术均获成功,手术时间110～240 min,平均160 min.术中出血量30～80 ml,平均50 ml.术后住院8～18 d,平均11.2 d.术后并发症:皮下气肿(合并阴囊气肿)1例,漏尿2例.术后1～10个月B超示术侧肾盂无积水5例,轻度积水2例,中度积水2例.3例术后5个月IVU显示吻合口通畅. 结论后腹腔镜肾盂成形术微创、效果好,值得推广.     

腹腔镜下离断式肾盂成形术

目的　探讨腹腔镜下离断式肾盂成形术的临床疗效。　方法　采用经腹腔途径施行腹腔镜离断式肾盂成形术治疗输尿管肾盂连接部 (UPJ)梗阻 18例。男 11例 ,女 7例。B超提示重度积水 8例、中度 7例、轻度 3例。IVU显影良好 10例 ,显影差或不显影 8例。　结果　 18例手术均获成功。手术时间 10 0～ 2 10min ,平均 14 2min ;出血量 4 0～ 2 0 0ml。术后平均住院时间 7.4d。术后尿漏 1例。随访 3～ 12个月 ,UPJ吻合口无狭窄 ,肾积水减轻 ,中度积水 4例、轻度 7例、肾积水消失 7例 ;肾功能改善、IVU显影良好 14例 ,显影改善 4例。　结论　腹腔镜下离断式肾盂成形术是治疗UPJ梗阻的有效、可行的微创手术 ,可以替代开放手术。     

改良腹腔镜肾盂成形术

目的探讨一种改良的腹腔镜肾盂成形术.方法肾盂输尿管连接部梗阻32例,经腹腔镜下游离肾盂及部分输尿管上段,然后扩大经肾盂输尿管连接部的切口至2.5～3 cm,采用开放手术方式进行肾盂输尿管成形操作.结果32例手术均获成功.术中证实肾下极异位血管压迫1例,原发管腔狭窄31例.手术时间40～70 min,平均52 min;术中出血量20～30 ml,平均23 ml.无手术并发症.27例随访7～15个月,平均9.6月,腰部胀痛消失,静脉肾盂造影(intravenous pyelography,IVP)检查吻合口均无梗阻,B超肾集合系统分离术前2.0～4.2 cm,平均2.8 cm,术后17例降至1.0～2.3 cm,平均1.5 cm,余10例无分离.结论改良的腹腔镜肾盂成形术简化了腹腔镜操作,缩短了手术时间,值得临床推广应用.     

腹腔镜下肾盂成形术(附11例报告)

目的　介绍腹腔镜肾盂成形术新技术。　方法　对 11例诊断为肾盂输尿管连接部(UPJ)狭窄病人采用腹腔镜经后腹膜腔途径行肾盂成形术。　结果　 11例手术均获成功 ,手术时间2～ 4h ,出血量 4 0～ 90ml。术后 3～ 2 4个月B超复查 ,手术侧肾盂无积水。 6例术后 1年IVU检查UPJ吻合口未见狭窄 ,肾盂输尿管排尿功能好。　结论　腹腔镜肾盂成形术是治疗UPJ狭窄的有效微创手术方法之一     

腹膜后腹腔镜肾盂成形术治疗肾盂输尿管连接部梗阻62例临床分析

目的:评价腹膜后腹腔镜手术治疗肾盂输尿管连接部梗阻(ureteropelvic junction obstruction,UPJO)的手术技巧和临床效果。方法:回顾性分析施行经腹膜后腹腔镜肾盂成形术的62例肾盂输尿管连接部梗阻患者的临床资料。根据62例患者发病机理的不同,20例行腹膜后腹腔镜肾盂输尿管连接部周围压迫组织松解术,28例行Y-V成形术,14例行离断成形术。术后随访3~36个月。结果:所有患者手术均顺利完成,静脉肾盂造影(intravenous urography,IVU)提示造影剂通过良好,肾积水均明显改善。结论:腹膜后腹腔镜治疗肾盂输尿管连接部梗阻创伤小,患者术后痛苦小、康复快、住院时间短、疗效显著,可作为治疗肾盂输尿管连接部梗阻的首选方法。     

机器人辅助腹腔镜肾盂成形术

目的探讨机器人辅助腹腔镜肾盂成形术治疗肾盂输尿管连接部(UPJ)狭窄所致肾积水的临床疗效。方法采用经腹腔途径施行机器人辅助腹腔镜肾盂成形术治疗UPJ狭窄25例，男18例，女7例。B超提示重度肾积水10例、中度10例、轻度5例。IVU均显影。结果25例手术均获成功。手术时间60—200min，平均90min；出血量40-80ml；术后住院时间6—9d，平均7d。术后随访3-32个月，25例腰痛症状均消失，逆行肾盂造影(RP)示UPJ吻合口无狭窄；肾积水减轻，10例重度肾积水者中8例转为中度、2例转为轻度，10例中度积水者中3例转为轻度、7例积水消失，5例轻度肾积水者积水消失。IVU、CT尿路造影(CTU)显影良好者18例，显影改善者7例。结论机器人辅助腹腔镜肾盂成形术治疗UPJ狭窄所致肾积水使手术效率提高，操作更加精确，疗效满意。     

首次手术失败后再行腹腔镜肾盂成形术的临床研究

目的:探讨开放或腹腔镜肾盂成形术失败后再次行腹腔镜肾盂成形术的可行性和疗效。方法:从2004年9月~2012年5月,我们对32例肾盂输尿管连接部梗阻行肾盂成形术后再梗阻的患者采用经腹腔入路腹腔镜肾盂成形术治疗。同期开展首次腹腔镜肾盂成形术30例。术前统计两组患者的年龄、性别、体重、左右侧和积水程度,比较两组手术时间、术中术后并发症、住院时间和手术成功率,并把手术时间和术中出血与文献报道的结果相比。手术成功率以临床症状的缓解和影像学上积水和肾功能的改善来判断。两组所有数据均通过SPSS16.0专业软件进行统计,以P0.05为差别有统计学意义。结果:术前两组患者在年龄、性别、左右侧和积水程度上的差别无统计学意义(P0.05)。两组均无严重术中并发症,无中转开放手术者。再次手术组的平均手术时问和术中出血量多于初次手术组(P0.05);两组患者的术后住院时间和手术成功率差别无统计学意义(P0.05)。结论:首次的开放手术或腹腔镜手术会造成肾盂输尿管周围粘连,给再次腹腔镜肾盂成形术带来困难,但只要腹腔镜操作技术熟练,再次行腹腔镜肾盂成形术仍安全可行,还保持了腹腔镜手术微创的优点,且经腹腔途径更容易完成手术。     

经后腹腔单切口腹腔镜肾盂成形术2例报告

目的：探讨经后腹腔单切口腹腔镜技术行离断式肾盂成形手术的临床效果和技术方法.方法：采用单切口腹腔镜技术经后腹腔对2例确诊为肾盂输尿管连接部（UPJ）狭窄的患者实施离断式肾盂成形术（dismembered anderson-hynes pyeloplasty）,采用腰部腋中线切口,长约2.5cm,置入自制的单切口Port,手术过程分别使用Cambridge endo可弯单通道腹腔镜器械、超声刀、普通持针器、普通腹腔镜器械等.结果：2例手术均获得成功,未中转开发手术,亦未增加皮肤切口,手术时间分别为230 min、160 min,术中出血60 ml、40 ml,术后住院时间均为6天,无围手术期并发症.术后6周拔除双J管并复查B超、IVU,肾积水明显减轻,吻合口无狭窄.结论：经后腹腔单切口腹腔镜肾盂成形术作为一种新兴技术治疗肾盂输尿管连接部狭窄是安全可行的,具有创伤更小、美容效果更好的特点.随着单孔腹腔镜器械以及腹腔镜技术的不断提高,这项技术值得在临床上推广应用.     

后腹腔镜肾盂成形术治疗肾盂输尿管连接处梗阻

目的:评价后腹腔镜肾盂成形术治疗肾盂输尿管连接处梗阻(ureteropelvic junction obstruction,UPJO)技术要点及临床疗效。方法:通过后腹腔途径在腹腔镜下对30例UPJO患者行离断式肾盂成形术,其中男18例,女12例,年龄在16～48岁;异常血管压迫4例,合并泌尿系感染8例。结果:30例手术均获成功,无一例中转开放手术。手术时间120～235min,平均105min;出血量85～135ml,平均115ml。30例术后随访6～24个月,经B超、IVU检查,肾盂输尿管吻合口未见明显狭窄,患肾积水明显减轻或消失,临床症状消失。结论:后腹腔镜肾盂成形术是一种创伤小、安全可靠、疗效确切的微创手术方法。     

A modular laparoscopic training program for pediatric surgeons.

OBJECTIVES: A structured endoscopic training program for pediatric surgeons has not yet been established. This study was conducted to develop a modular training program (MTP) for pediatric surgeons and to evaluate its effectiveness for surgeons with and without previous experience in laparoscopic surgery. METHODS: Nine pediatric surgeons participated in the study. They were divided into 2 groups: group A (n=4), surgeons who had experienced more than 10 cases of laparoscopic surgery prior to MTP; group B (n=5), those who had experienced fewer than 10 cases. They participated in a standardized MTP workshop, which consisted of 2 "see-through" and 3 "laparoscopic" tasks. Each participant's psychomotor skills were evaluated objectively before and after MTP with a computer-generated virtual simulator and were evaluated for precision, efficiency, and speed. RESULTS: In participants, speed was significantly enhanced after MTP. In group A, no differences were observed after MTP, whereas significant improvements were noted in efficiency and speed after MTP in group B. Before MTP, efficiency was significantly higher in group A than in group B; however, no difference remained between the 2 groups after MTP. CONCLUSIONS: MTP is effective for nonlaparoscopic pediatric surgeons to become familiar with basic endoscopic skills.     

三维腹腔镜与传统腹腔镜下肾盂成形术的对照研究

目的 比较三维腹腔镜与传统腹腔镜下肾盂成形术的手术结果和技术特点.方法 回顾性分析2013年1月至2014年3月北京协和医院泌尿外科收治的31例行腹腔镜下肾盂成形术患者的临床资料.男性16例,女性15例;年龄21 ～42岁,平均(30±6)岁.左侧20例,右侧11例.术前均行B超及CT泌尿系成像检查明确诊断.按手术方法分为三维腹腔镜组(16例)和传统腹腔镜组(15例).收集两组临床特点(性别、年龄、左右侧、体重指数)及围手术期数据(手术时间、出血量、术后住院时间、住院费用).两组数据比较进行t检验,计数数据进行x2检验.结果 手术均成功,无中转开放手术.三维腹腔镜组手术时间为(106±16) min,明显短于传统腹腔镜组的(124 ±24)min,两者比较差异有统计学意义(t=5.993,P=0.021).两组出血量[(54±14) ml比(57±16) ml,t=0.285,P=0.598]、术后住院时间[(7.3±0.7)d比(7.5±0.6)d,t=1.415,P=0.244]、并发症发生率(0/16比1/15,x2=1.102,P=0.484)、住院费用[(25 687 ±3 032)元比(25 426±2 626)元,t=0.065,P=0.800]比较差异均无统计学意义.患者均获得随访,随访时间3～12个月,平均6个月.三维腹腔镜组和传统腹腔镜组各有1例发生肾积水加重及再发狭窄,经治疗好转.结论 三维腹腔镜下肾盂成形术手术是安全、可行的.与传统腹腔镜手术相比,三维腹腔镜手术降低了手术的难度,明显缩短了手术时间.     

腹腔镜保留肾单位术三级培训模式初探

目的 介绍腹腔镜保留肾单位术的三级培训模式.方法 三级培训模式的内容包括体外模拟阶段、动物模型训练和临床实践操作.以小型猪作为实验模型建立腹腔镜保留肾单位术的标准操作方式.临床实践操作又细分为三步进行,包括辅助手术、开展相对简单的腹腔镜手术和进行LNSS. 结果 4名学员均成功完成全部三级培训内容.其中体外模拟培训累计时间平均为70 h.经过体外模拟培训后全部学员均能够熟练地掌握腔镜器械下缝针打结等基本操作技能.4名学员均完成动物模型LNSS 20例,其中半肾切除术6例.肾上极或下极平均手术时间由最初的(120.0±10.9)min降低到在完成12台LNSS时的(69.0±5.2)min,差异有统计学意义(P<0.01).学员在开展后腹腔镜肾囊肿去顶术和上段输尿管切开取石术等相对简单的手术7～9例后,各自成功地完成LNSS手术3例,均未出现术中并发症.LNSS平均手术时间为87 rain,肾脏热缺血时间平均为25 min.结论 "三级培训模式"能够帮助年轻医生掌握LNSS这类高难度复杂性泌尿外科腹腔镜手术,显著地降低手术并发症的发生,提高手术疗效,有利于腹腔镜手术的推广应用.     

Comparison of laparoscopic pyeloplasty with and without robotic assistance.

OBJECTIVES: The benefits of laparoscopic surgery with robotic assistance (da Vinci Robotic Surgical System, Intuitive Surgical, Sunnyvale, CA) includes elimination of tremor, motion scaling, 3D laparoscopic vision, and instruments with 7 degrees of freedom. The benefit of robotic assistance could be most pronounced with reconstructive procedures, such as pyeloplasty. We aimed to compare laparoscopic pyeloplasty, with and without robotic assistance, during a surgeon's initial experience to determine whether robotic assistance has distinct advantages over the pure laparoscopic technique. METHODS: We retrospectively compared the first 7 laparoscopic pyeloplasties with the first 7 robotic pyeloplasties performed by a single surgeon. All patients were preoperatively evaluated with computed tomographic angiography with 3D reconstruction to image crossing vessels at the ureteropelvic junction. All patients were followed up by lasix renograms and routine clinic visits. RESULTS: Patients were similar with respect to mean age (34 in laparoscopic pyeloplasty group vs 32 in the robotic pyeloplasty group), operative time (5.2 hours vs 5.4 hours), estimated blood loss (40 mL vs 60 mL), and hospital stay (3 days vs 2.5 days). Two patients in the laparoscopic pyeloplasty group had small anastomotic leaks managed conservatively, and one patient in the robotic pyeloplasty group had a febrile urinary tract infection necessitating treatment with intravenous antibiotics. Another patient in the robotic pyeloplasty group was readmitted with hematuria that was treated conservatively without transfusion. No recurrences were detected in either group. CONCLUSIONS: Operating times and outcomes during the learning curve for laparoscopic pyeloplasty were similar to those for robotic pyeloplasty. Long-term data with greater experience is needed to make definitive conclusions about the superiority of either technique and to justify the expense of robotic pyeloplasty.     

A training module for laparoscopic urology.

OBJECTIVES: A fellowship training model in laparoscopic urological surgery has been established for interested urologists to help them proceed from the pelvic trainer/animal laboratory environment to safe clinical practice. The objective of the model is to provide trainees with clinical experience under direct mentor supervision before embarking on independent laparoscopic urological surgery at their own base hospitals. METHODS: The fellowship model incorporates 9 fluid phases: Phase 1 to complete basic and advanced training courses. Phase 2 to practice at home or in the office using pelvic trainers. Phase 3 to proceed to an animal laboratory course. Phase 4 to visit centers of international repute to observe high-volume laparoscopic urology. Phase 5 to observe the mentor perform several major renal laparoscopic cases. Phase 6 to perform several hand-assisted renal procedures under direct mentor guidance at the mentor hospital. Phase 7 to perform several laparoscopic or retroperitoneoscopic renal procedures, or both, under direct mentor guidance at the mentor hospital. Phase 8 to mentor assisted trainees to start laparoscopic surgery at their own hospitals. Phase 9 to practice laparoscopic urology independently. RESULTS: So far, 9 trainees have participated in the fellowship. Six have reached phase 9 with independent practice, 2 others are in phase 8, and 1 is in phase 7. Skills development has been steady, with progressive acquisition of surgical dexterity and spatial orientation. CONCLUSION: This fluid fellowship model provides urologists with clinically applicable teaching experience to learn a relatively new surgical concept safely and effectively, thereby promoting clinical governance. It may be possible for other centers to establish similar fluid "mini" fellowships to help disseminate laparoscopic surgical skills.