改良腹腔镜膀胱腰大肌悬吊输尿管再植术治疗医源性长段输尿管狭窄

doi:10.3877/cma.j.issn.1674-3253.2023.02.014

目的

探讨改良腹腔镜膀胱腰大肌悬吊输尿管再植术治疗医源性长段输尿管下段狭窄的安全性及有效性。

方法

回顾性分析2017年1月至2020年5月在山西医科大学第二医院和上海交通大学附属第六医院泌尿外科行腹腔镜膀胱腰大肌悬吊输尿管膀胱再植术治疗医源性输尿管狭窄患者21例。患者年龄22~68岁，平均年龄（44±9）岁；左侧输尿管狭窄10例，右侧输尿管狭窄11例；术前6例行肾造瘘，15例长期留置双J管。输尿管狭窄长度为[8.6（7.9，10.0）]cm。本研究中对经典腰大肌悬吊输尿管膀胱再植术的改良主要包括：先将输尿管浆肌层与膀胱浆肌层缝合固定一针以减张和防扭曲；在4、6、8点方向缝合3针将输尿管和膀胱黏膜吻合后置入双J管；在12点方向输尿管和膀胱全层缝合以减张，在2点、10点方向行黏膜对黏膜吻合；采用黏膜下隧道法间断缝合3针抗返流。

结果

手术均顺利完成，无中转开放。手术时间为[88（78，96）]min，手术失血量[37（25，46）]ml。术后盆腔引流量[37.5(15.0，50.0)]ml，术后住院时间[5（4，6）]d，术后4周拔除双J管。术后随访13~40个月，静脉肾盂造影显示18例患者患侧肾盂积水、输尿管扩张均较术前明显缓解；轻度肾积水3例，膀胱造影提示1例患者轻度膀胱输尿管返流。

结论

改良腹腔镜膀胱腰大肌悬吊输尿管膀胱再植术治疗长段输尿管下段医源性狭窄病变安全、有效。

关键词: 腹腔镜, 悬吊术, 医源性，输尿管狭窄, 输尿管再植, 腰大肌综合征

Objective

To investigate the safety and effectiveness of modified laparoscopic urethral reimplantation with psoas hitch in the treatment of long iatrogenic urethral stricture.

Methods

The data of 21 patients with iatrogenic ureteral stricture treatment in the line laparoscopic bladder muscle suspension urethra bladder reimplantation treatment from January 2017 to May 2020 were analyzed retrospectively. The age of patients was ranged from 22 to 68 years, with an average of (44±9) years, the left ureteral stricture was in 10 cases, the right ureteral stricture 11 cases. Six cases underwent routine renal fistula, 15 cases long-term retention of double J tubes. The median length of ureteral stricture was [8.6(7.9, 10.0)] cm. In this study, the modified psoas hitch mainly includes: the urethra and bladder stitching fixed a needle to reduce the sheet and anti-distortion and using the mucous membrane tunnel method intermittent stitching 3 needles anti-reflux.

Results

All the operations were successfully completed by laparoscopy without open conversion. The median operative time was [88(78, 96)] min, and the estimated blood loss was [37(25, 46)] ml. The median pelvic drainage was [37.5(15.0, 50.0)] ml, the median postoperative hospital stay was [5(4, 6)] days, and double J tubes were removed 4 weeks after operations. The patients were followed up for 13-40 months. Postoperative follow-up IVU shows that 18 patients with hydronephrosis and ureteral dilatation were significantly relieved compared with those before operations, 3 patients with mild hydronephrosis, and cystography showed 1 patient with mild vesicoureteral reflus.

Conclusion

It is safe and effective using modified laparoscopic ureter reimplantation with bladder psoas hitch in the treatment of Iatrogenic ureteral stricture with long and lower segments.

Key words: Laparoscopy, Bladder psoas hitch, Iatrogenic, ureteral stricture, Ureteral reimplantation, Psoas major syndrome

图6 术后静脉肾盂造影提示膀胱腰大肌悬吊术后改变，左肾积水消失

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Modified laparoscopic ureteral reimplantation with bladder psoas hitch in the treatment of iatrogenic ureteral stricture

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Modified laparoscopic ureteral reimplantation with bladder psoas hitch in the treatment of iatrogenic ureteral stricture