盆腔恶性肿瘤术后输尿管下段梗阻的腔镜手术治疗

盆腔恶性肿瘤术后输尿管下段梗阻的腔镜手术治疗 盆腔恶性肿瘤术后输尿管下段梗阻的腔镜 手术治疗 《癌症》ChineseJournalofCancer,2007,26(11):1227—1230l227 盆腔恶性肿瘤术后输尿管下段梗阻的腔镜手术治疗 温星桥,高新,张勇, 邱剑光. EndouroI 司徒杰,湛海伦, 蔡育彬. 王德娟 ogicTreatmentsofDistalUreteralObstructioninPatients 临床研究 withHistoryofPelvicMalignancies:EfficacyandSafetyEvaluation WENXing—Qiao',GAOXin',ZHANGYong,CAIYu—Bin',QIUJian—Guang', SITUJie',ZHANHai—Lun',WANGDe—Juan' 1.中山大学附属第三医院 泌尿外科. 广东广州510630 2.中山大学附属第三医院 核医学科. 广东广州510630 J.DepartmentofUrology, TheThirdAffiliatedHospitd, SunYat—senUniversity, Guangzhou,Cuangdong,510630, P.R.China 2.DepartmentofNuclearMedicine, TheThirdAffiliatedHospitd, SunYat—senUniversity, Guangzhou,Cuangdong,510630, P.R.Chinn 通讯作者:高新 Correspondenceto:GAOXin Tel:86—20—85516867—2052 E—mail:gaoxin44@163.con 收稿日期:2007—03—20 修回日期:2007—07—05 [ABSTRACT]BACKGROUND&OBJECTIVE:Postoperativetissue adherence.scarringandradiotherapyOftenJeadtoextrinsiccompression andstrictureinthedistaIureterofthepatientswhohadhistoryofpelvic malignancies.Ouraimwastoevaluatetheefficacyandsafetv0f endourologictechniquesintreatingthiskindofureteraIobstruction. METHODS:FromJan.1998toMar.2007.46patientswithobstructioninthe distaIureterandhadhistoryofpelvicmalignanciesunderwentendoscopic treatmentsattheThirdAffiliatedHospitalofSunYat—senUniversityforreliefof theobstruction.Perioperativeandfollow—updatawereanalyzed.RESULTS: Ofthe46patients.25underwentlaparoscopicureterolysisanduretero— neocystostomy,18underwentplacementofureterstentunderureteroscope, 3underwentDercutaneOusnephrostomy.Noseverecomplicationwas recorded.Themeanoperatingtimewas82.5rain(range.30—140min).The meanbloodIosswas45.5ml(range.5—180mI).Nobloodtransfusionwas needed.Themedianfollow—uptimewas18.2months(range.3monthsto 6.5years).Threemonthsafteroperation.B—uItrasOnOaraphVandintravenous urography(IVU)showedthat39(84.8%)patientshadrecoverednOrmaI renalfunction.theother7(15.2%)hadhvdrOnephrOsisreliefandrenaI functionimprovement.NuclearrenaIscanningshowedthatthemean postoperativeglomerularfiltrationrate(GFR)intheobstructivekidneywas higherthanthepreoperativeIeveI(37.6mI/minvs.21.3mI/min.P<0.05). Nostrictureintheuretero—bladderanastomoticstomawasrecorded. CONCLUSION:Endoscopicoperationisaneffectiveandfeasibleoptionfor managingsomeselectedkindsofdistalureteraIobstructioncausedby postoperativetissueadherenceandradiotherapyinthepatientswithhistory ofpelvicmalignancies. KEYWORDS:Laparoscopy;Ureteroscopy;UreteraIobstruction/ complication;Surgicaloperation;Pelvicneoplasm 【摘要】背景与目的:盆腔恶性肿瘤手术后组织粘连,瘢痕形成或放射治疗等 常导致输尿管下段受压梗阻及肾积水.本研究旨在评价利用腔镜技术治疗此类 输尿管梗阻的疗效与安全性.方法:1998年1月至2007年3月,46例有输尿管下 段梗阻伴盆腔肿瘤史的患者在中山大学附属第医院接受了腔镜手术,分析围手 术期及随访资料.结果:46例患者中,25例行腹腔镜输尿管一膀胱吻合术,18例行 输尿管镜放置支架管引流,3例行经皮肾造瘘术,未发生严重并发症.平均手术时 间825min(30,140min),术中出血45.5ml(5,180m1),均未接受输血.中位随 访时间18.2个月(3个月,6.5年).术后3个月,静脉尿路造影及B超提示39例 (84.8%)肾分泌恢复正常,其余7例(15.2%)肾积水减轻,肾功能改善;核素扫描 提示平均患侧肾小球滤过率比术前升高(37.6ml/minvs.21.3ml/min,P<0.05). 所有输尿管一膀胱吻合El无狭窄.结论:腔镜手术治疗部分类型盆腔肿瘤手术后 或 放疗后下段输尿管梗阻是有效,可行的. 关键词:腹腔镜;输尿管镜;输尿管梗阻/并发症;外科手术;盆腔肿瘤 中图分类号:R692文献标识码:A 文章编号:1000—467X(2007)11—1227—04 1228温星桥,等.盆腔恶性肿瘤术后输尿管下段梗阻的腔镜手术治疗 Postoperativetissueadherence,scarring,and radiotherapyoftenleadtoextrinsiccompressionand strictureinthedistalureterofthepatientswithpelvic malignancies[引.Theclinicalmanifestationsofthese patientsmaybeasymptomatic,orsymptomaticonly duringtheperiodofdiuresis,orsymptomaticwith severerenalcolic.Thedegreeofsymptomsshowsno correlationtothedegreeofobstruction.Effective treatmentmustbeinstitutedimmediatelysince prolongedobstructionmaycausepain,infection,and eventuallyimpairedrenalfunction.Operationssuchas ureterolysis,ureteroneocystostomy,placementof ureterstent,andnephrostomyarethesurgical optionsforthesepatients.Traditionally,opensurgery istheonlychoicetoperformtheseprocedures. However,asmodemendourologyisnOWinprogress, urologistscanperformtheseoperationsinamini— invasivewaybyusingendourologictechniquessuch aslaparoscopy,ureteroscopy,andpercutaneous nephrostomyrPCN)[,. Inthisstudy,wepresentedourexperienceof managingthedistalureteralobstructionvia endourologictechniquesinthepatientswithhistoryof pelvicmalignancies.Theefficacyandsafetyofthese procedureswereevaluated. 1PATlENTSANDMETHODS 1.1ClinicaIdataofpatients FromJan.1998toMar.2007,46patients underwentendourologictreatmentsforureteral obstructionattheThirdAmliatedHospitalofSun Yat—senUniversity.Allpatientshadupperureteral dilationandhydronephrosis.Ofthe46patients,18 weremen,28werewomen,withamedianageof 41.5(range,23-78);11hadcervicalcancer,7had ovariancancer.5haduterinecorpuscancer,12had colorectalcancer.8hadbladdercancer,and3had prostatecancer.AccordingtotheTNMstagingsystem (UICC,2002),22patientswereatstageI,18at stage11,6atstagell1whentheycometothe hospitalf0rinitia1treatmentsf0rthepelvictumors.Of the46patients,30hadreceivedsurgicaloperation forpelvicmalignancies,9hadreceivedradiotherapy, 7hadreceivedbothsurgicaloperationand radiotherapy.Beforeendourologictreatments,the malignanciesin40patientswerecompletely controlled,whilethoseintheother6patientswere not. Theselectioncriteriafortheendourologic treatmentsincludedradiographicevidencesofureteral obstructioninanydegreeofhydronephrosiswith intractablepain,urinarytractinfection,andimpaired renalfunction.Allpatientshaddistensioninthe upperuretersandhydronephrosisthatwereconfirmed byB—uhrasonogrphyorintravenousurography(IVU). Theseverityofhydronephrosiswasgradedon ultrasonographyaccordingtothesystemoftheSociety forFetalUrology[]:"mild''indicatessplittingof normalechogeniccentralrenalcomplex;"moderate'' indicatesdilatedpelvisbeyondthesinus,uniformly dilatedcalices,andthickenedparenchyma;"severe'' indicatesattenuatedparenchymaatleasthalfasthin asonthecontralateralside.Accordingtothissystem, 6patientshadmildhydronephrosis,23hadmoderate hydronephrosis,and17hadseverehydronephrosis. Noadditionalpathologicfeaturesoftheuppertract, suchascalculiandtumors,werefound. 1.2Preoperativeexaminationsandpreparation Acombinationofurography(intravenous, antegrade,andretrograde),computedtomography (CT)/CT—guidedurography(CTU),andmagnetic resonanceimaging(MRI)wereperformedtoobtain anaccurateassessmentofthestricturelengthand location.Nuclearrenalscanningwasperformedto assessthedegreeofobstructionandtherelativerenal functionoftheipsilateralkidneybeforeoperation. Antibioticswereusedtoensurethatthepatienthas asterileurineculturebeforeendourologictreatment. Antibioticbowelpreparationwasperformed preoperativelyonthepatientswithpossiblebowel injury. 1.3Jndicationsandoperationpatterns Theindic&ionsforendourologictreatments includedureteralobstructionandhydronephrosiswith intractablepain,urinarytractinfection,andimpaired renalfunction.Thecaseswithheavytissuescarring, severeadherenceoracuteedemawereexcluded. Surgicalproceduresincludeddirectureteroneo— 温星桥,等.盆腔恶性肿瘤术后输尿管下段梗阻的腔镜手术治疗1229 cystostomy,ureteroneocystostomyusingpsoashitchor Boaribladderflap,retrogradeplacementofureter stentunderureteroscope,andpercutaneous nephrostomy. Theendourologicoperationswereselected accordingtothepatients'generalcondition,defect lengthoftheureter,andtheseverityof hydronephrosis.Afterresectionoftheconstrictivepart oftheureter,directureteroneocystostomyunder laparoscopewasconducted.Whentheureterwastoo shortfordirectureteroneocystostomy.Boaribladder flaporpsoashitchprocedureswereconductedto createatension.freeanastomosisE73.Inthepatients withadvancedtumors,whowereextremelyold,or hadahighsurgicalriskandcouldtolerateinternal stentdrainagewell,placementofureterstentunder ureteroscopewasperformed【8].Whenretrogradestent insertionfailed,thepatientswerereferredto percutaneousnephrostomy. Thelaparoscopicoperationswereperformedvia transperitonealrouteinmostpatients.Aftersettingup thepneum0perit0neum,thelaparoscopicinstruments wereusedtodissectandexposethedistalobstructive ureter,preservingasheathof3—4mmthickin periureteraltissue.Thestricturepartoftheureterwas incised.anda6一IOFcatheterwasinsertedasan internalstent.Absorbablesuturewasusedtofinish theanastomosis.AUtheureteralanastomoseswere freeoftension.Drainageinductiontubeswere routinelyplacedbesidetheanastomoticstoma. 1.4Follow—up Thepatientswereinterviewedpostoperatively evcry3months.Examinationofurinetest,detection oftheserumlevelofcreatine,andB—uhrasonography wereperformedroutinelyatthefollow—upobservation. Atthethirdmonthafteroperation,IVUwas performedwhenitcanbetoleratedbythepatient, nuclearrenalscanningwasperformedtoassessthe renalfunctionoftheipsilateralkidney. 2RESULTS Inthisgroup,25patientsunderwent laparoscopicureteroneocystostomy(including12 underwentdirectureteroneocystostomy,6usedpsoas hitch,and7usedBoariflap);18underwentdilation orplacementofureterstentunderureteroscope;3 underwentpercutaneousnephrostomyafterthefailure ofstentplacementforrapidlyrelievingureteral obstruction. Themeanoperatingtimewas82.5min(range, 30—140min).ThemeanbloodlOSSwas45.5ml (range,5—180m1).Nobloodtransfusionwasneeded. Allprocedureswereperformedsuccessfullywithout anyconversiontoopensurgicaloperation.Nosevere complicationswereencountered. Themedianfollow—uptimewas18.2months (range,3monthsto6.5years).Forty—two(91.3%) patientswerealiveattheendoffollow—up.N0 strictureintheanastomoticstomawasrecorded, whichwasconfirmedbyIVUatthe6thmonthafter operation. Ofthe46patients,39(84.8%)hadrecovered normalrenalfunctionafteroperation,7(15.2%)had hydronephrosisreliefandrenalfunctionimprovement, whichwasconfirmedbyB.uhrasonographyandIVU. Nuclearrenalscanningshowedthatthemean postoperativeglomerularfihrationrate(GFR)ofthe kidneyattheobstructivesidewassignificantlyhigher thanthepreoperativelevel(37.6ml/minvs.21.3ml/ min.P<0.O5). 3DISCUSSION Endourologictechniquesaresafeandfeasible mini.invasiveoptionsfortreatingdistalureteral obstructioninthepatientswithahistoryofoperation orradiotherapyforpelvicmalignancies.Inthisstudy, alltheprocedureswereperformedsuccessfully withoutanyconvemiontoopensurgicaloperation.No severecomplicationswereencountered.Asweknow, theextrinsicureteralobstructioninthepatientswith historyofpelvicmalignanciesishardtobemanaged. Theurologistsshouldbalancethepatient'slife quality,renalpreservationandtheriskof complications.Withskillfulexperience,endoumlogic techniques,suchaslaparoscopy,ureteroscopy,and percutaneousnephrostomy,provideotheroptionswith theadvantagessuchaslesstrauma,mini—invaslveand shortrecoverytimeforthepatients. 1230温星桥,等.盆腔恶性肿瘤术后输尿管下段梗阻的腔镜手术治疗 Laparoscopicoperationsbecomeanimportant partofmodemurologicpractice,andplayimportant rolesinablativeproceduresandreconstruction operations.Laparoscopicureteroneocystostomywas firstdescribedbyEhrlichetal[.anditsfirst performanceinanadultwasreportedbyReddyet a1.[subsequently.Itisdescribedforavarietyof conditions,includingendometriosis,stricturedueto animpactedcalculus,andureteralinjuryduring laparoscopichysterectomy.Nezhateta1.LllJreporteda seriesof6patientswhounderwentlaparoscopic vesical—psoashitchforinfiltrativeureteral endometriosisandconcludedthattheprocedureis safeandeffective,withtheknownbenefitsof laparoscopy.Inourexperience,successfulureteral reconstructionreliesonpreservationofadequate vascularperfusionandconstructionofatension—free anastomosis.Theprocedurechoiceisdetermined traditionallydependonthestricturelength.Boariflap andpsoashitchproceduresarebestsuitedforthe stricturewithalengthexceeding6am.The cystostomyshouldbemadelaterallyafterfillingthe bladderandensuringthattheanastomosiscanbe accomplishedwithouttension.Thebloodsupplyofthe uretershouldbemonitoredintheprocedureof dissection.Weprefertoplacetheinternalstentswith largediameter,suchas6Fand10F,intheureterfor betterinduction.Therequirementsforsuccessful completionincludeknowledgeofanatomy,askillful andexperiencedlaparoscopicsurgeon,and,lastbut notleast,gooddexterityintheintracoporeal laparoscopicsuturingtechnique. Forthepatientswithadvancedtumors,orhavea highsurgicalriskandtoleratesinternalstentdrainage well,retrogradedilationorplacementofureterstent underureteroscopearegoodchoicesforattenuating theobstructioninamini—invasiveway.Despite significantimprovementsinendourologicdevicesand materials,endourologicureteralstentingmay occasionallybeachallengingprocedure,evenfor experiencedurologists.Percutaneousnephrostomyis anotherchoiceincasesoftransurethralprocedure failure【.However,itisassociatedwithahigh incidenceofaccidentaltubedislodgement,andthus mayreducethepatients'qualityoflife.Additional researchbyourgroupisongoingtoassessthe efficiencyandlong—termresultsofpercutaneous nephrostomyinthesepatients.Itshouldbenotedthat endourologicoperationcouldnottreatallkindsof distalureteralobstruction.Whenthepatienthas severetissuesca~ingoradherenceinthepelvis, traditionalopenoperationmaybeabetterchoice. 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