LI Xingzhi1 HUANG Jian2* ZHANG Caixia2 LIN Tianxin2 LICENSE Wei2
1 Department of Urology, Inner Mongolia Autonomous Region Hospital, (Hohhot 010017)
2 Department of Urology, Second Affiliated Hospital of Sun Yat-sen University, (Guangzhou 510120, China) Li Xingzhi, Department of Urology, People’s Hospital of Inner Mongolia Autonomous Region
[Abstract] Objective To explore the indications for laparoscopic insertional papillary method ureteral bladder reimplantation, surgical technique and its application effect. Methods From May 2004 to June 2007, 21 patients (25 sides) with lower ureteral lesions were treated by laparoscopic ureteral papillary ureterobladder reimplantation, of whom 14 were male and 7 were female, aged 3.5-52 years, with an average of 32 years. The lesions were located on the left side in 12 cases and on the right side in 5 cases. The lesions were located on the left side in 12 cases and on the right side in 5 cases. 4 cases were bilateral, 11 were end ureteral stenosis, 2 were ureteral endometriosis, 3 were giant ureter, 4 were hydronephrosis with duplicated kidney and ureteral malformation, and 5 were ureterovaginal fistula. Moderate hydronephrosis on 11 sides and severe hydronephrosis on 10 sides. The ureter was dissected at the proximal end of the ureter and sutured externally to form a hemipapillary, and a double J tube was placed under the microscope. In the case of giant ureter, the ureter was pulled out through the abdominal wall trocar, and the F16 catheter was used as a stent to cut and suture the end 1-2 cm to keep the tube shape and externalize to form a papilla, and the double J tube was inserted, and then the ureter was reintroduced into the abdominal cavity. The posterior bladder wall was incised 1 cm, and the ureter was inserted 1.0 cm to 1.5 cm, after making an interrupted anastomosis between the outer muscle layer of the ureter and the whole bladder wall with a 4-0 Dixon thread for 5-6 stitches. Results All 21 cases (25 sides) were completed laparoscopically without intermediate open surgery. Ultrasound and intravenous urography showed that the hydronephrosis disappeared or improved in 19 cases, and postoperative restenosis of the anastomosis disappeared in 1 case after ureteroscopic dissection. Cystography did not show any vesicoureteral reflux, and no complications such as anastomotic fistula occurred. Cystoscopy revealed the insertion of the papilla into the bladder, and papillary spurting was observed. Conclusion Laparoscopic papillary approach to ureteral bladder reimplantation for lower ureteral lesions has the advantages of simple operation, minimal surgical trauma, rapid patient recovery, good anti-reflux effect, and low incidence of anastomotic stricture and anastomotic fistula.
[Keywords]: laparoscopy; insertional papillary approach; ureteral bladder reimplantation
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.
[The numbers of patients with left-side reimplantation were the same as those of patients with left-side reimplantation. 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 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 loss and minimally invasive alternative method for treatment of lower ureteral lesions. [Key Words]: Laparoscopy; “ureteral nipple”; Vesico-ureteral reimplantation From May 2004 to June 2007, 21 patients (25 sides) with uretero-vesical junction lesions were treated by laparoscopic insertional papillary ureterobladder reimplantation with satisfactory results. The following is reported. 1 Data and methods 1.1 Clinical data: From May 2004 to June 2007, 21 patients (25 sides) with lower ureteral lesions were treated by laparoscopic ureteral papillary ureteral bladder reimplantation, of whom 14 were male and 7 were female, aged 3.5-52 years, with an average of 32 years. The lesion was located on the left side in 12 cases and on the right side in 5 cases. 4 cases were bilateral, 11 with end ureteral stenosis, 2 with ureteral endometriosis, 3 with giant ureter, 4 with hydronephrosis of the duplicated kidney, and 5 with ureterovaginal fistula. All 17 patients had a history of low back pain and lumbago, and IVU, ultrasound or MRU showed ureteral outlet obstruction with varying degrees of ureteral dilatation and hydronephrosis. 5 cases of ureterocystic fistula were confirmed by IVU. 1.2 Surgical method: Patients were intubated with tracheal intubation compounded with general anesthesia in supine, head-down and foot-up position. The ureter was left in place and was clamped. A 1-cm incision was made at the inferior umbilical rim, and a pneumoperitoneal needle was inserted into the abdominal cavity and filled with CO2 at an air pressure of 15 mmHg (1 mmHg = 0.5 mmHg). After establishing a pneumoperitoneum with a flow rate of 40 L/min, the pneumoperitoneum needle was withdrawn and a 10-mm Trocar (point A) was punctured through the incision and a 30° laparoscope was placed. After establishing the pneumoperitoneum, the pneumoperitoneum needle was withdrawn, and 10mm Trocar was punctured from the incision at 1/3 (point B) and 2/3 (point C) of the left anterior superior iliac spine line, 10mm Trocar was punctured at the midpoint of the umbilicus and right anterior superior iliac spine line (point D), and 10mm Trocar was punctured at 1/3 (point B) and 2/3 (point C) of the umbilicus and right anterior superior iliac spine line for right ureteral surgery, respectively. The working channel and pneumoperitoneum were established by puncturing 10 mm and 5 mm Trocar at the midpoint of the line between the umbilicus and the left anterior superior iliac spine (point D). The sigmoid colon was retracted on the left side, and the iliac vessels could be directly revealed on the right side, and the peristaltic or milky white striped ureter could be seen at the bifurcation of the iliac vessels. The ureter was opened along its course, and the free ureter was exposed, and the stone was removed at the same time if it was complicated by a stone. In the case of giant ureter, the ureter was pulled out through the trocar, the stent was cut and sutured with the F16 catheter, and the ureter was reintegrated into the abdominal cavity, and the open end of the ureter was cut into an oblique mouth and sutured outward to form a papilla. The bladder is filled, the bladder wall is incised longitudinally on the lateral posterior wall of the bladder about 1.0 cm, the urine is aspirated, the proximal segment of the ureter is fully freed, the ureter is inserted into the bladder 1.0 cm to 1.5 cm without significant tension or torsion, the ureter is interrupted with 3 stitches of 4-0 Dixon wire and the double J tube is placed under the scope The remaining part of the ureter was anastomosed to form an insertional papillary anastomosis, and the ureteral bladder anastomosis was completed, the wound was flushed, and a drainage tube was placed to end the procedure. Results: 21 cases (25 sides) were completed laparoscopically without intermediate open surgery. The operation time ranged from 60 to 180 min, averaging 136 min; intraoperative bleeding ranged from 20 to 50 ml, averaging 32 ml; hospitalization ranged from 9 to 15 d, averaging 12 d; follow-up ranged from 3 to 36 months, averaging 15 months; ultrasound and intravenous urography showed that the hydronephrosis disappeared or improved in 19 cases; postoperative restenosis of the anastomosis disappeared in 1 case after ureteroscopic dissection. The cystogram did not show the occurrence of vesicoureteral reflux, and no complications such as anastomotic fistula occurred. Cystoscopy revealed the insertion of the papilla into the bladder, and papillary spurting was observed. Table 1 Analysis of hospitalization time, operation time, bleeding volume, and follow-up time of 25 patients/side lesion Number of cases/side Length of hospitalization (d) Operative time (min) Bleeding volume (ml) Follow-up time (m) Ureteral stricture 11 12.00±1.78 134.62±31.25 33.85±6.60 10.92±6.60 Giant ureter 3 12.25±1.50 133.75±21.36 30.00±8.17 24.00±8.04 Repetitive renal ureteral malformation 4 10.67±2.08 161.67± 7.64 31.67±2.89 17.00±1.00 Ureterovaginal fistula 5
15.00±1.00 133.75± 31.25 25.44±3.96 30.00±1.00 Endometriosis 2 11.67±2.08
135.62±21.25 26.54±5.96 10.00±2.00 Total (Total) 25 12.00±1.84 136.19±29.44 32.14±9.29 15.19±8.64