李星智1 黄健2* 张彩霞2 林天歆2 许可慰2

1 内蒙古自治区医院泌尿外科，（呼和浩特市 010017）

2中山大学第二附属医院泌尿外科，（广州 510120）内蒙古自治区人民医院泌尿外科李星智

[摘要] 目的 探讨腹腔镜下插入式乳头法输尿管膀胱再植术的适应证、手术技巧及其应用效果。方法 2004年5月～2007年6月,应用腹腔镜行输尿管乳头法输尿管膀胱再植术治疗输尿管下段病变患者21例（25侧），其中男14例,女7例，年 龄3.5～52岁,平均32岁。病变位于左侧12例,右侧 5例。双侧4例，11侧为输尿管末端狭窄, 2侧输尿管子宫内膜异位症。3侧为巨输尿管,4侧为重复肾输尿管畸形积水。5侧为输尿管阴道瘘。中度肾积水11侧，重度肾积水10侧。腹腔镜下游离输尿管，在入膀胱处切断，输尿管近侧断端剖开1cm,外翻缝合形成半边乳头，镜下置入双J管。巨输尿管者将输尿管经腹壁套管拉出，用F16导尿管做支架裁剪缝合，末端1-2cm保持管状并外翻形成乳头，插入双J管，然后将输尿管重新回纳腹腔。膀胱后壁切开1cm，将输尿管插入1.0cm～1.5cm，用4-0 Dixon线将输尿管外膜肌层与膀胱壁全层作间断吻合5-6针‍后。结果 21例（25侧）均腹腔镜下完成，没有中转开放手术。手术时间60～180min,平均 136min;术中出血20～50ml,平均32ml；住院9～15d，平均12d；随访3～36个月,平均15个月。B超和静脉尿路造影显示,肾输尿管积水消失或好转19例,术后吻合口再狭窄1例，行输尿管镜内切开后积水消失。膀胱造影检查未见膀胱输尿管反流发生,没有发生吻合口瘘等并发症。膀胱镜检查可见插入膀胱内的乳头，并观察到乳头喷尿。结论 腹腔镜下乳头法输尿管膀胱再植术治疗输尿管下段病变具有操作简单、手术创伤小、患者恢复快、抗反流效果好、吻合口狭窄及吻合口瘘的发生率低的优点。

[关键词]: 腹腔镜；插入式乳头法；输尿管膀胱再植术

LI Xingzhi1, HUANG Jian2*, LING Tianxin2, XU Kewei2

1 Department of Urology. Inner Mongolia Hospital, Huhhot, 010017 China

2 Department of Urology, the Second Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510120, China.

[Abstract]: Objective to introduce the new technique of vesico-ureteral reimplantation by means of “ureteral nipple”under laparoscopy and to evaluate its feasibility and clinical significance. MATERIALS AND METHODS From May 2004 to July 2007, 21 cases (25 sides) of lower ureter lesions were operated with laparoscopic “nipple approach” vesico-ureteral reimplantation. In all of these cases, 14 patients were men, the others were women. Their mean age is 32(range 3.5 to 52). The numbers of patient with left-side lesions were 12, right-side lesions were 5,   two sides lesions were 4. 11 sides had ureteral orifice obstruction, 2 sides had endometriosis, 3 sides had megaloureter, 5 sides had vaginal-ureteral fistula. The ureter was gently dissected circumferentially down to the bladder. It was ligated close to the bladder and divided proximal to it. The free ureteral end was delivered out through the ipsilateral port. The lower end of ureter was made into nipple evaginated mode. Megaureter was tailored over a 16Fr catheter. Later the whole assembly was carefully replaced in the abdomen. The nipple was inserted bladder 1 to 1.5cm and fixed it, a 6Fr Double-J stent was placed under laparoscopy. Results The operations were all successful in 21 cases(25 sides), Mean operating time was 136min (range 60 to180 min)；Mean blood loss was 32ml (range20 to 50ml)；The mean hospital stay after surgery was 12d (range 9 to 15 days)；At a mean follow-up of 15 m (range 3 to 36months). Ultrasound and IVU showed that the hydronephrosis disappeared or decreased and no obvious urine reflux in most cases. 1 case recurred ureteral stenosis later, the hydronephrosis disappeared after stenosis was incised under ureteroscopy. Conclusion Vesico-ureteral reimplantation by means of “ureteral nipple” under laparoscopy is a feasible, less blood lose and minimally invasive alternative method for treatment of lower ureteral lesions.

[Key Words]: Laparoscopy；“ureteral nipple”；Vesico-ureteral reimplantation

2004年5月～2007年6月,科应用腹腔镜插入式乳头法输尿管膀胱再植术治疗输尿管膀胱交界处病变患者21例（25侧）,效果满意。现报告如下。 

1 资料与方法

1.1 临床资料：2004年5月～2007年6月,应用腹腔镜行输尿管乳头法输尿管膀胱再植术治疗输尿管下段病变患者21例（25侧），其中 男14例,女7例，年龄3.5～52岁,平均32岁。病变位于左侧12例,右侧 5例。双侧4例，11侧为输尿管末端狭窄, 2侧输尿管子宫内膜异位症。3侧为巨输尿管,4侧为重复肾输尿管畸形积水。5侧为输尿管阴道瘘。中度肾积水11侧，重度肾积水10侧。17例患者均有腰痛腰酸病史,IVU、B超或MRU均提示输尿管出口梗阻,有不同程度的输尿管扩张和肾积水。5例输尿管膀胱瘘均为IVU证实。 

1.2手术方法:患者气管插管复合全身麻醉,仰卧、头低脚高位。‍留置尿管,予以夹闭。脐下缘切开1‍cm,插气腹针至‍腹腔,充CO2,气压15‍mm‍Hg(1‍mm‍Hg=‍0.‍133‍kPa),流量40L/min，建立气腹后，退出气腹针,从该切口穿刺10‍mm Trocar(A点),放入30°腹腔镜,左侧输尿管病变在腹腔镜监视下分别于‍脐与左髂前上棘连线中外1/3(B点)、2/3(C点)处‍穿刺10mm、 5mm Trocar,脐与右髂前上棘连线中点‍处(D点)穿刺10mm Trocar,右侧输尿管手术者分别于脐与右髂前上棘连线中外1/3(B点)、2/3(C点)处‍穿刺10mm、5mm Trocar,脐与左髂前上棘连线中点‍处(D点)穿刺10mm Trocar。完成工作通道及气腹建‍立。左侧牵开乙状结肠,右侧可直接显露髂血管,于髂血管分叉处可见蠕‍动或呈乳白色条索状输尿管,循其走行打开盆侧腹‍膜,暴露游离输尿管至膀胱壁段,输尿管狭窄者游离至狭窄上方，异位开口分离至盆底，于该处离断输‍尿管,并发结石者同时取石,残端用Hem-O-lok夹闭。巨输尿管者将输尿管经套管拉出，用F16导尿管做支架裁剪缝合，将输尿管重新回纳腹腔，输尿管开口端剪成斜口外翻缝合形成乳头。充盈膀胱，于膀‍胱侧后壁纵行切开膀胱壁约1.0cm，吸尽尿液，充分游离输尿管近段,在无明显张力和扭转情况下,将输尿管插入膀胱1.0cm～1.5cm，用4-0Dixon线将输尿管膀胱间断吻合3针‍后,镜下置入双J管,吻合余下部分，形成插入式乳头法吻合，完成输尿管膀胱吻合,冲洗伤口,放置‍引流管，结束手术。

‍‍结果：21例（25侧）均腹腔镜下完成，没有中转开放手术。手术时间60～180min,平均 136min;术中出血20～50ml,平均32ml；住院9～15d，平均12d；随访3～36个月,平均15个月。B超和静脉尿路造影显示,肾输尿管积水消失或好转19例,术后吻合口再狭窄1例，行输尿管镜内切开后积水消失。膀胱造影检查未见膀胱输尿管反流发生,没有发生吻合口瘘等并发症。膀胱镜检查可见插入膀胱内的乳头，并观察到乳头喷尿。

表1 25例/侧患者住院时间、手术时间、出血量、随访时间分析

病变

例数/侧

住院时间（d）

手术时间（min）

出血量（ml）

随访时间（m）

输尿管狭窄

11

12.00±1.78

134.62±31.25

33.85±6.60

10.92±6.60

巨输尿管

3

12.25±1.50

133.75±21.36

30.00±8.17

24.00±8.04

重复肾输尿管畸形

4

10.67±2.08

161.67± 7.64

31.67±2.89

17.00±1.00

输尿管阴道瘘

5

15.00±1.00

133.75±31.25

25.44±3.96

30.00±1.00

子宫内膜异位症

2

11.67±2.08

135.62±21.25

26.54±5.96

10.00±2.00

合计（Total）

25

12.00±1.84

136.19±29.44

32.14±9.29

15.19±8.64