后腹腔镜积水无功能肾切除术(附5例报告)

【摘要】 目的 探讨后腹腔镜积水无功能肾切除术的手术方法和效果。方法 对5例积水无功能肾患者行后腹腔镜积水无功能肾切除术。腰部3个Trocar穿刺入路,手指法建立后腹膜气腹,游离出部分病变肾脏后先肾脏切开一小口,吸净积水肾内的积水,然后再游离肾脏,暴露肾蒂后,用钛夹或Hem o lock夹闭肾蒂并切断,将积水无功能肾切除并置入标本袋后取出。结果 5例手术均获得成功,手术时间为150~300 min,平均为170 min。术中出血10~80 ml,平均30 ml。引流管于术后2~3 d拔除,无大出血、感染、腹膜破裂、腹腔脏器损伤等并发症。结论 后腹腔镜积水无功能肾切除术是一种微创、安全、有效、恢复快的术式,必将成为此类疾病治疗的首选方法。

【关键词】后腹腔镜;积水无功能肾;肾切除术

Retroperitoneo scopic nephrectomy on the treatmet of non functioning kidney with hydronephrosis

(Report of 5 cases)

ZHENG Hao,LI Huai fu,ZHENG Xiao qing,et al.Department of Urology,the Fifth Affiliated Hospital of Sun Yat sen University,Zhuhai,519000,China

【Abstract】 Objective To evaluate the operation method and results of retroperitoneoscopic nephrectomy on the treatment of non functioning kidney with hydronephrosis.Methods Retroperitoneoscopic nephrectomy was performed in 5 cases with nonfunctioning kidney with hydronephrosis.The retroperitoneal cavity were established with the fingers separating method.Afterwards,3 Trocars were inserted through lumbar ports,the kidney was liberated partially,and made a small hole,the intrarenal fluid was drawn out.Then the kidney was liberated fully,the renal pedicle were exposed,and blocked with titanium clips or Hem o lok and then cut off,the non functioning kidney was taken out in a specimen bag.Results The 5 operations were successful.The mean operative time was 170 min(150 300 min),and blood loss was 30 ml(10 80 ml).Drainage tube was removed 2 3 days after operation,we have not found any massive hemorrhage,infection,peritoneum rupture,intraabdominal visceral injury,and other severe complications.Conclusion Retroperitoneoscopic nephrectomy for non functioning kidney with hydronephrosis is proved to be minimal invasive,safe,effective,and rapid recovery.It would become the first choice for this kind of disease.

【Key words】Retroperitoneoscopic;Non functioning kidney with hydronephrosis;Nephrectomy

我院2005年2月至2009年11月期间对5例积水无功能肾疾病患者行后腹腔镜下积水无功能肾切除术,效果良好,现报告如下。

1 资料与方法

1.1 临床资料 本组5例,男2例,女3例。年龄18~57岁,平均36.2岁。左侧3例,右侧2例。术前常规检查心、肺、肾、肝功能等,均无明显手术禁忌证。常规行血、尿生化检查及B超、IVU、CT检查、ECT检查。术前尿路造影患肾均不显影,对侧肾脏显影良好。逆行尿路造影检查证实为单纯肾盂输尿管连接部(UPJ)梗阻3例,输尿管上段结石并肾积水2例。放射性核素肾检查示积水侧肾脏肾小球滤过率(GFR)0~10 ml/min。血清Cr、BUN均正常。

1.2 手术方法 全部病例均采用后腹腔径路,气管插管全身麻醉,留置导尿,健侧卧位。首先于腋中线与髂嵴交界处上方2横指处(C点)斜行切开皮肤约1.5 cm,用中弯钳垂直体表穿过腹前外侧壁肌层及腰背筋膜,撑开后用示指在腹膜外间隙向四周分离出一定的空间,然后在腋后线与肋弓交界处(A点)及腋前线与肋弓下缘交界处(B点)斜形切开皮肤约0.5 cm和1.0 cm,在示指的指引下,分别置入5 mm和10 mm Trocar。再在C点处置入10 mm Trocar。冲入CO2气体,建立气腹,气腹压12~14 mm Hg(1 mm Hg=0.133 kPa)。置入30°腹腔镜,在电视监视下用吸引器和超声刀沿腰大肌向上扩大腹膜后间隙,然后切开肾周筋膜,游离肾脏,暴露部分肾脏后即在肾脏皮质菲薄处表面做一小切口,通过该切口将肾脏内积水吸净,注意抽吸肾内积水时速度不要太快。完成后腹膜后间隙明显增大,有利于之后的肾脏游离及肾蒂的显露和处理。此时用无损伤钳提起已游离的肾实质,使之与周围组织保持一定的张力,再用超声刀游离肾脏,完全游离肾脏及显露肾蒂后,用钛夹分别夹闭肾蒂血管和输尿管后切断,切除的肾脏用标本袋装好后由穿刺孔取出。观察创面无出血后,置入引流管,排空气体后,拔除Trocar,缝合各穿刺口。

2 结果

本组病例均经后腹腔镜顺利完成手术。2例输尿管上段结石一并去除。术中出血量10~80 ml,平均30 ml。手术时间150~300 min,平均170 min。术中引流肾积水量1500~4500 ml。术后常规放置引流管,于术后2~3 d拔除,术后2~3 d下床活动,术后1~2 d拔除导尿管。术后均未出现出血、感染、腹腔脏器损伤等并发症。术后病理为压迫性肾小球萎缩改变。

3 讨论

造成积水无功能肾的原因主要有先天性肾盂输尿管交界处狭窄、输尿管结石、后腹膜纤维化、肾活动过度致输尿管成角、异位血管压迫输尿管等[1]。一般认为患肾分肾功能低于总肾功能10%即有肾切除的指征。传统开放式积水无功能肾切除术是一种成熟有效的治疗积水无功能肾的方法,但手术切口较大,导致手术创伤较大,出血较多,患者术后恢复时间较长。1991年Clayman等率先报道了腹腔镜肾切除术以来[2],该技术很快普及并在很多医院成为治疗肾脏疾病标准手术方式[3,4]。随着腹腔镜技术在泌尿外科的应用,腹腔镜下积水无功能肾切除术已成为一种创伤小、术后恢复快的新的治疗方法。

后腹腔镜下切除积水无功能肾具有一定的难度,主要是积水肾体积大,后腹膜腔空间小,术中游离肾脏较困难[5,6]。另外准确有效地控制肾蒂血管是腹腔镜手术的关键,高江平等认为按照位置、牵拉、隆起、搏动和纤维等五步骤可快速寻找到肾血管[7]。目前对肾积水分度尚无统一客观指标,当成人肾积水容量>1000 ml或小儿>24 h尿液总量时,称为巨大肾积水[8]。本组应用后腹腔镜下肾切除术治疗积水无功能肾5例,疗效满意。作者的体会:①患肾因体积较大,为一具有弹性的水囊,影响视野及患肾的游离,故在游离出部分肾实质后即可在肾实质菲薄处切开一小口,将吸引器置入抽吸肾内积水。高旭等认为对于巨大肾积水,手术中应分步放出肾内积水,利用剩余的积液在肾脏内形成的张力以利于进一步分离[9],但分次放液需间断封闭和打开放液的切口,增加不必要的手术步骤;②当肾积水量巨大时,抽吸肾内积水时不要太快,以防突然的后腹腔内压减低可能导致回心血量不足,引起心肺循环系统衰竭;③在吸净肾内积水后,肾脏塌陷,后腹腔空间显露好,但因肾脏塌陷,可能增加肾脏游离的困难,此时用无损伤钳提起塌陷的肾脏,使之与周围组织保持一定的张力,以利于患肾的游离;④游离肾脏时应用钝性加锐性的方法,在临近肾蒂时可看见局部有动脉搏动,此时小心钝性暴露肾蒂血管,逐条显露然后分别用钛夹或Hem o lock夹闭再剪断。肾蒂的处理方法有多种,如钛夹、腔内直线切割器、Hem o lock等,其中钛夹有潜在脱落的风险,腔内直线切割器安全可靠,但价格昂贵[10],应用Hem o lock处理肾蒂血管,增加了手术的安全性[11];⑤如为输尿管结石引起的积水无功能肾,则应将结石及以上的输尿管一并切除;⑥据Gill报道术中并发症主要是血管损伤和脏器撕裂[12]。本组病例在良好的手术视野及小心细致的手术操作下,未发生血管损伤和脏器撕裂等并发症。

总之,我们认为后腹腔镜下积水无功能肾切除术是一种安全、微创、有效、恢复快的术式,必将成为此类疾病治疗的首选方法。

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