李星智1 黃健2* 張彩霞2 林天歆2 許可慰2
1 內蒙古自治區醫院泌尿外科，（呼和浩特市 010017）
2中山大學第二附屬醫院泌尿外科，（廣州 510120）內蒙古自治區人民醫院泌尿外科李星智
[摘要] 目的 探討腹腔鏡下插入式乳頭法輸尿管膀胱再植術的適應證、手術技巧及其應用效果。方法 2004年5月～2007年6月,應用腹腔鏡行輸尿管乳頭法輸尿管膀胱再植術治療輸尿管下段病變患者21例（25側），其中男14例,女7例，年 齡3.5～52歲,平均32歲。病變位於左側12例,右側 5例。雙側4例，11側為輸尿管末端狹窄, 2側輸尿管子宮內膜異位症。3側為巨輸尿管,4側為重複腎輸尿管畸形積水。5側為輸尿管陰道瘻。中度腎積水11側，重度腎積水10側。腹腔鏡下游離輸尿管，在入膀胱處切斷，輸尿管近側斷端剖開1cm,外翻縫合形成半邊乳頭，鏡下置入雙J管。巨輸尿管者將輸尿管經腹壁套管拉出，用F16導尿管做支架裁剪縫合，末端1-2cm保持管狀並外翻形成乳頭，插入雙J管，然後將輸尿管重新回納腹腔。膀胱後壁切開1cm，將輸尿管插入1.0cm～1.5cm，用4-0 Dixon線將輸尿管外膜肌層與膀胱壁全層作間斷吻合5-6針後。結果
21例（25側）均腹腔鏡下完成，沒有中轉開放手術。手術時間60～180min,平均 136min;術中出血20～50ml,平均32ml；住院9～15d，平均12d；隨訪3～36個月,平均15個月。B超和靜脈尿路造影顯示,腎輸尿管積水消失或好轉19例,術後吻合口再狹窄1例，行輸尿管鏡內切開後積水消失。膀胱造影檢查未見膀胱輸尿管反流發生,沒有發生吻合口瘻等併發症。膀胱鏡檢查可見插入膀胱內的乳頭，並觀察到乳頭噴尿。結論 腹腔鏡下乳頭法輸尿管膀胱再植術治療輸尿管下段病變具有操作簡單、手術創傷小、患者恢復快、抗反流效果好、吻合口狹窄及吻合口瘻的發生率低的優點。
[關鍵詞]: 腹腔鏡；插入式乳頭法；輸尿管膀胱再植術
laparoscopic uretero C vesical anastomosis by means of “ureteral nipple ”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,科應用腹腔鏡插入式乳頭法輸尿管膀胱再植術治療輸尿管膀胱交界處病變患者21例（25側）,效果滿意。現報告如下。
1 資料與方法
1.1 臨床資料：2004年5月～2007年6月,應用腹腔鏡行輸尿管乳頭法輸尿管膀胱再植術治療輸尿管下段病變患者21例（25側），其中 男14例,女7例，年齡3.5～52歲,平均32歲。病變位於左側12例,右側 5例。雙側4例，11側為輸尿管末端狹窄, 2側輸尿管子宮內膜異位症。3側為巨輸尿管,4側為重複腎輸尿管畸形積水。5側為輸尿管陰道瘻。中度腎積水11側，重度腎積水10側。17例患者均有腰痛腰痠病史,IVU、B超或MRU均提示輸尿管出口梗阻,有不同程度的輸尿管擴張和腎積水。5例輸尿管膀胱瘻均為IVU證實。
1.2手術方法:患者氣管插管複合全身麻醉,仰臥、頭低腳高位。留置尿管,予以夾閉。臍下緣切開1cm,插氣腹針至腹腔,充CO2,氣壓15mmHg(1mmHg=0.133kPa),流量40L/min，建立氣腹後，退出氣腹針,從該切口穿刺10mm Trocar(A點),放入30°腹腔鏡,左側輸尿管病變在腹腔鏡監視下分別於臍與左髂前上棘連線中外1/3(B點)、2/3(C點)處穿刺10mm、 5mm Trocar,臍與右髂前上棘連線中點處(D點)穿刺10mm Trocar,右側輸尿管手術者分別於臍與右髂前上棘連線中外1/3(B點)、2/3(C點)處穿刺10mm、5mm Trocar,臍與左髂前上棘連線中點處(D點)穿刺10mm Trocar。完成工作通道及氣腹建立。左側牽開乙狀結腸,右側可直接顯露髂血管,於髂血管分叉處可見蠕動或呈乳白色條索狀輸尿管,循其走行開啟盆側腹膜,暴露遊離輸尿管至膀胱壁段,輸尿管狹窄者遊離至狹窄上方，異位開口分離至盆底，於該處離斷輸尿管,併發結石者同時取石,殘端用Hem-O-lok夾閉。巨輸尿管者將輸尿管經套管拉出，用F16導尿管做支架裁剪縫合，將輸尿管重新回納腹腔，輸尿管開口端剪成斜口外翻縫合形成乳頭。充盈膀胱，於膀胱側後壁縱行切開膀胱壁約1.0cm，吸盡尿液，充分遊離輸尿管近段,在無明顯張力和扭轉情況下,將輸尿管插入膀胱1.0cm～1.5cm，用4-0Dixon線將輸尿管膀胱間斷吻合3針後,鏡下置入雙J管,吻合餘下部分，形成插入式乳頭法吻合，完成輸尿管膀胱吻合,沖洗傷口,放置引流管，結束手術。
結果：21例（25側）均腹腔鏡下完成，沒有中轉開放手術。手術時間60～180min,平均 136min;術中出血20～50ml,平均32ml；住院9～15d，平均12d；隨訪3～36個月,平均15個月。B超和靜脈尿路造影顯示,腎輸尿管積水消失或好轉19例,術後吻合口再狹窄1例，行輸尿管鏡內切開後積水消失。膀胱造影檢查未見膀胱輸尿管反流發生,沒有發生吻合口瘻等併發症。膀胱鏡檢查可見插入膀胱內的乳頭，並觀察到乳頭噴尿。
表1 25例/側患者住院時間、手術時間、出血量、隨訪時間分析
病變
例數/側
住院時間（d）
手術時間（min）
出血量（ml）
隨訪時間（m）
輸尿管狹窄
11
12.00±1.78
134.62±31.25
33.85±6.60
10.92±6.60
巨輸尿管
3
12.25±1.50
133.75±21.36
30.00±8.17
24.00±8.04
重複腎輸尿管畸形
4
10.67±2.08
161.67± 7.64
31.67±2.89
17.00±1.00
輸尿管陰道瘻
5
15.00±1.00
133.75±31.25
25.44±3.96
30.00±1.00
子宮內膜異位症
2
11.67±2.08
135.62±21.25
26.54±5.96
10.00±2.00
合計（Total）
25
12.00±1.84
136.19±29.44
32.14±9.29
15.19±8.64
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