不同入路腹腔镜肾盂成形术治疗成人肾盂输尿管连接部梗阻的比较

doi:10.3877/cma.j.issn.1674-3253.2023.01.015

目的

比较经腹腔和经后腹腔入路腹腔镜肾盂成形术治疗肾盂输尿管连接部梗阻（UPJO）的安全性及疗效。

方法

收集2015年1月至2020年6月在兰州大学第二医院确诊为UPJO并行腹腔镜肾盂成形术且年龄≥18岁患者的临床资料，比较两组患者围术期指标、并发症发生率及手术成功率。

结果

本研究共纳入195例患者，两组患者基线资料差异无统计学意义。两组围术期指标及近期并发症比较：手术时间[190（150，230）min vs 200（174，260）min，P=0.030]、引流管留置天数[5.0（3.0，6.0）d vs 6.0（4.0，8.0）d，P=0.005]、术后住院天数[6.0（5.0，7.0）d vs 8.0（5.0，9.0）d，P=0.006]经腹腔组均短于经后腹腔组，中转开放率经腹腔组低于经后腹腔组[3（3.2%）vs 10（12.5%），P=0.019]；术中出血量、术后特护时间、禁食水时间方面两组差异均无统计学意义（P>0.05）；尿漏、泌尿道感染、肠梗阻、高碳酸血症等近期并发症发生率方面两组间差异均无统计学意义（P>0.05）。长期随访的结果显示，在结石形成、输尿管支架移位、总体并发症发生率及手术成功率方面两组间差异均无统计学意义（P>0.05）。

结论

对于取得一定腹腔镜手术经验的术者，经腹腔入路腹腔镜肾盂成形术相比经后腹腔入路手术时间短，中转开放率低，引流管留置天数及术后住院天数短，两种入路并发症发生率及手术疗效相当。

关键词: 肾盂输尿管连接部梗阻, 肾盂积水, 肾盂成形术, 腹腔镜

Objective

To compare the safety and efficacy of transperitoneal and retroperitoneal laparoscopic pyeloplasty in the treatment of ureteropelvic junction obstruction (UPJO).

Methods

Clinical data of patients aged ≥18 years who were diagnosed with UPJO and underwent laparoscopic pyeloplasty in the Second Hospital of Lanzhou University from January 2015 to June 2020 were collected. The patients were compared the perioperative indexes, the incidence of complications and the success rate of surgery between the two groups.

Results

A total of 195 patients were included in this study, and the baseline difference between the two groups was not statistically significant. Comparison of perioperative indexes and recent complications showed that the duration of operation [190(150, 230) min vs 200(174, 260) min, P=0.030], the number of days of drainage tube indwention [5.0(3.0, 6.0) d vs 6.0(4.0, 8.0) d,P=0.005] and the number of days of postoperative hospitalization [6.0(5.0,7.0) d vs 8.0(5.0, 9.0) d, P=0.006] in the transperitoneal group were shorter than those in the retroperitoneal space group, the transfer opening rate in transperitoneal group was lower than that in retroperitoneal space group [3(3.2%) vs 10(12.5%), P=0.019]. There was no significant difference in intraoperative blood loss, postoperative special care time and fasting time between the two groups (P>0.05). There was no difference in the incidence of urinary leakage, urinary tract infection, intestinal obstruction, hypercapnia and other recent complications between the two groups (P>0.05). Results of long-term follow-up of patients showed that there were no significant difference between the two groups in calculus formation, ureteral stent displacement, overall complication rate and surgical success rate (P>0.05).

Conclusions

For those who have gained some experiences in laparoscopic surgery, compared with retroperitoneal laparoscopic pyeloplasty, transperitoneal laparoscopic pyeloplasty has shorter operation time, lower conversion rate, shorter duration of drainage tube retention and shorter postoperative hospital stay. The incidence of complications and surgical efficacy of the two approaches are similar.

Key words: UPJO, Hydronephrosis, Pyeloplasty, Laparoscopy

表1 两组成人UPJO患者基线资料的比较

组别	例数	年龄[岁，M(P₂₅，P₇₅)]	BMI[kg/m²，(±s)]	性别(例)		手术侧别(例)		临床症状(例)		尿素氮水平[mmol/L，M(P₂₅，P₇₅)]	肌酐水平[μmol/L，M(P₂₅，P₇₅)]
组别	例数	年龄[岁，M(P₂₅，P₇₅)]	BMI[kg/m²，(±s)]	男	女	左	右	有	无	尿素氮水平[mmol/L，M(P₂₅，P₇₅)]	肌酐水平[μmol/L，M(P₂₅，P₇₅)]
腹腔入路组	95	31.0(24.0，44.0)	22.0±3.1	61	34	62	33	88	7	5.3(4.5，6.4)	79.0(71.0，92.0)
后腹腔入路组	80	35.0(28.2，44.0)	22.7±3.8	50	30	49	31	71	9	5.5(4.6，6.5)	77.0(67.0，90.5)
统计值		Z=-1.738	t=1.424	χ²=0.055		χ²=0.302		χ²=0.788		Z=-0.499	Z=-0.626
P值		0.082	0.156	0.815		0.583		0.375		0.618	0.531
组别	合并肾结石(例)		合并输尿管结石(例)		合并异位血管(例)		合并输尿管息肉(例)		肾积水程度(例)
组别	有	无	有	无	有	无	无	无	轻度	中度	重度
腹腔入路组	16	79	9	86	19	76	6	89	6	14	75
后腹腔入路组	9	71	8	72	12	68	4	76	7	18	55
统计值	χ²=1.109		χ²=0.014		χ²=0.745		χ²=0.002		Z=2.386
P值	0.292		0.907		0.388		0.963^*		0.303

表1 两组成人UPJO患者基线资料的比较

组别	例数	年龄[岁，M(P₂₅，P₇₅)]	BMI[kg/m²，(±s)]	性别(例)		手术侧别(例)		临床症状(例)		尿素氮水平[mmol/L，M(P₂₅，P₇₅)]	肌酐水平[μmol/L，M(P₂₅，P₇₅)]
组别	例数	年龄[岁，M(P₂₅，P₇₅)]	BMI[kg/m²，(±s)]	男	女	左	右	有	无	尿素氮水平[mmol/L，M(P₂₅，P₇₅)]	肌酐水平[μmol/L，M(P₂₅，P₇₅)]
腹腔入路组	95	31.0(24.0，44.0)	22.0±3.1	61	34	62	33	88	7	5.3(4.5，6.4)	79.0(71.0，92.0)
后腹腔入路组	80	35.0(28.2，44.0)	22.7±3.8	50	30	49	31	71	9	5.5(4.6，6.5)	77.0(67.0，90.5)
统计值		Z=-1.738	t=1.424	χ²=0.055		χ²=0.302		χ²=0.788		Z=-0.499	Z=-0.626
P值		0.082	0.156	0.815		0.583		0.375		0.618	0.531
组别	合并肾结石(例)		合并输尿管结石(例)		合并异位血管(例)		合并输尿管息肉(例)		肾积水程度(例)
组别	有	无	有	无	有	无	无	无	轻度	中度	重度
腹腔入路组	16	79	9	86	19	76	6	89	6	14	75
后腹腔入路组	9	71	8	72	12	68	4	76	7	18	55
统计值	χ²=1.109		χ²=0.014		χ²=0.745		χ²=0.002		Z=2.386
P值	0.292		0.907		0.388		0.963^*		0.303

表2 两组成人UPJO患者围术期指标及近期（<30 d）并发症的比较

组别	例数	手术时间[min，M(P₂₅，P₇₅)]	出血量[ml，M(P₂₅，P₇₅)]	中转开放[例(%)]	特护时间[h，M(P₂₅，P₇₅)]	禁食水时间[h，M(P₂₅，P₇₅)]	引流管留置天数[d，M(P₂₅，P₇₅)]
腹腔入路组	95	190(150，230)	50(30，100)	3(3.2%)	49(43，51)	42(38，49)	5(3，6)
后腹腔入路组	80	200(174，260)	50(30，138)	10(12.5%)	46(42，51)	42(39，46)	6(4，8)
统计值		Z=-2.165	Z=-1.531	χ²=5.512	Z=-1.488	Z=-0.424	Z=-2.840
P值		0.030	0.126	0.019	0.137	0.671	0.005
组别	术后住院天数[d，M(P₂₅，P₇₅)]	尿漏[例(%)]	泌尿道感染[例(%)]	肠梗阻[例(%)]	高碳酸血症[例(%)]
腹腔入路组	6(5，7)	5(5.3)	1(1.1)	2(2.1)	0(0.0)
后腹腔入路组	8(5，9)	6(7.5)	4(5.0)	1(1.3)	1(1.3)
统计值	Z=-2.761	χ²=0.369	χ²=1.223	χ²=0.000	-
P值	0.006	0.544	0.269^a	1.000^a	0.457^b

表2 两组成人UPJO患者围术期指标及近期（<30 d）并发症的比较

组别	例数	手术时间[min，M(P₂₅，P₇₅)]	出血量[ml，M(P₂₅，P₇₅)]	中转开放[例(%)]	特护时间[h，M(P₂₅，P₇₅)]	禁食水时间[h，M(P₂₅，P₇₅)]	引流管留置天数[d，M(P₂₅，P₇₅)]
腹腔入路组	95	190(150，230)	50(30，100)	3(3.2%)	49(43，51)	42(38，49)	5(3，6)
后腹腔入路组	80	200(174，260)	50(30，138)	10(12.5%)	46(42，51)	42(39，46)	6(4，8)
统计值		Z=-2.165	Z=-1.531	χ²=5.512	Z=-1.488	Z=-0.424	Z=-2.840
P值		0.030	0.126	0.019	0.137	0.671	0.005
组别	术后住院天数[d，M(P₂₅，P₇₅)]	尿漏[例(%)]	泌尿道感染[例(%)]	肠梗阻[例(%)]	高碳酸血症[例(%)]
腹腔入路组	6(5，7)	5(5.3)	1(1.1)	2(2.1)	0(0.0)
后腹腔入路组	8(5，9)	6(7.5)	4(5.0)	1(1.3)	1(1.3)
统计值	Z=-2.761	χ²=0.369	χ²=1.223	χ²=0.000	-
P值	0.006	0.544	0.269^a	1.000^a	0.457^b

表3 两组成人UPJO患者术后随访结果的比较[例(%)]

组别	例数	远期（>30 d）并发症		总体并发症	手术结果
组别	例数	结石形成或引起梗阻	输尿管支架移位	总体并发症	成功	失败
腹腔入路组	87	4(4.6)	1(1.1)	10(11.5)	81(93.1)	6(6.9)
后腹腔入路组	76	2(2.1)	0(0.0)	12(15.8)	72(94.7)	4(5.3)
统计值		χ²=0.062	-	χ²=0.641	χ²=0.011
P值		0.804^a	1.000^b	0.423	0.915^a

表3 两组成人UPJO患者术后随访结果的比较[例(%)]

组别	例数	远期（>30 d）并发症		总体并发症	手术结果
组别	例数	结石形成或引起梗阻	输尿管支架移位	总体并发症	成功	失败
腹腔入路组	87	4(4.6)	1(1.1)	10(11.5)	81(93.1)	6(6.9)
后腹腔入路组	76	2(2.1)	0(0.0)	12(15.8)	72(94.7)	4(5.3)
统计值		χ²=0.062	-	χ²=0.641	χ²=0.011
P值		0.804^a	1.000^b	0.423	0.915^a

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Comparison of laparoscopic pyeloplasty with different approaches in the treatment of ureteropelvic junction obstruction in adults

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Comparison of laparoscopic pyeloplasty with different approaches in the treatment of ureteropelvic junction obstruction in adults