根治性膀胱切除联合尿流改道术后良性输尿管回肠吻合口狭窄的治疗分析

Treatment of benign uretero-ileal anastomotic stricture after radical cystectomy and urinary diversion

摘要

目的 回顾性对照研究分析（机器人辅助）腹腔镜下输尿管回肠吻合口狭窄切除+再植术及经皮肾镜顺行内镜下狭窄球囊扩张+置管术处理根治性膀胱全切+尿流改道术后输尿管回肠吻合口狭窄的疗效与安全性，为治疗良性输尿管回肠吻合口狭窄提供新的思路。 方法 收集并回顾性分析2014年10月至2023年12月于浙江省人民医院63例实行机器人辅助与普通腹腔镜下根治性膀胱切除+尿流改道术后发生良性输尿管回肠吻合口狭窄患者的临床资料。患者用回肠膀胱术（Bricker术）或原位回肠新膀胱的尿流改道方式。根据良性输尿管回肠吻合口狭窄治疗方式的不同将患者分成2组，组1为内镜下治疗组（27例），由内镜下球囊扩张或联合内镜下钬激光切开组成；组2为腹腔镜输尿管再植组（36例），由机器人辅助腹腔镜输尿管再植与普通腹腔镜再植组成。比较2组的基础资料、围手术期情况、手术疗效与安全性进行分析。 结果 2组患者在性别、年龄、体质指数、狭窄长度、术前肌酐值、术前尿素值、术前血红蛋白、术前患侧肾小球滤过率（glomerular filtration rate，GFR）以及肾积水程度均无统计学差异（P>0.05）。在2组患者术中和术后资料中，内镜下治疗在手术时间［（97±31） min vs.（185±36） min，t=-2.641，P=0.000］、术后住院时间［（5.9±1.9） d vs.（8.1±3.1） d，t=-3.144，P=0.000］以及术后进食时间［（1.7±0.8） d vs.（2.9±1.3） d，t=-4.320，P=0.000］上均少于腹腔镜再植（P<0.05）。在术中及术后有无输血上，2组无明显统计学差异（P>0.05）。在2组治疗方式术后临床疗效的比较上，术后放置D-J管的平均时间［（6.1±2.0）月 vs.（4.0±3.5）月，t=2.824，P=0.010］、术后吻合口狭窄复发率（P=0.020）和患肾GFR上升率（P=0.000），腹腔镜再植组均优于内镜治疗组。 结论 对于根治性膀胱切除联合尿流改道术后发生良性输尿管回肠吻合口狭窄的治疗，针对不同的狭窄段输尿管长度，相比内镜下治疗，腹腔镜再植均能较好的解决良性输尿管回肠吻合口狭窄的问题，有更高的狭窄治愈率及肾功能改善率。

Abstract

Objective To investigate the efficacy and safety of robot-assisted laparoscopic uretero-ileal anastomotic stricture resection+replantation versus percutaneous nephroscopic balloon dilatation+catheterization in the treatment of uretero-ileal anastomotic stricture after radical cystotomy and urine diversion through a retrospective control study，and to provide new ideas for the treatment of benign uretero-ileal anastomotic stricture. Methods A retrospective analysis was performed for the clinical data of 63 patients who experienced benign uretero-ileal anastomotic stricture after robot-assisted or conventional laparoscopic radical cystectomy and urinary diversion in Zhejiang Provincial People’s Hospital from October 2014 to December 2023，and the patients underwent either Bricker procedure or in situ ileal neobladder urinary diversion. According to the treatment method for benign uretero-ileal anastomotic stricture，the patients were divided into group 1（27 patients receiving endoscopic balloon dilatation or combined endoscopic holmium laser incision） and group 2（36 patients receiving robot-assisted or conventional laparoscopic ureteral reimplantation）. The two groups were compared in terms of basic data，perioperative conditions，surgical outcome，and safety. Results There were no significant differences between the two groups in sex，age，body mass index，length of stricture，preoperative creatinine，preoperative urea，preoperative hemoglobin，preoperative glomerular filtration rate（GFR） of the affected side，and degree of hydronephrosis（P>0.05）. In terms of the intraoperative and postoperative data of the two groups，compared with laparoscopic reimplantation，endoscopic treatment had significantly shorter time of operation[（97±31） min vs.（185±36） min，t=-2.641，P=0.000]，length of postoperative hospital stay [（5.9±1.9） d vs.（8.1±3.1） d，t=-3.144，P=0.000]，and time to postoperative first eating [（1.7±0.8） d vs.（2.9±1.3） d，t=-4.320，P=0.000]. There was no significant difference in blood transfusion between the two groups during and after surgery（P>0.05）. As for the comparison of clinical outcome after surgery between the two groups，compared with the endoscopic treatment group，the laparoscopic reimplantation group had a significantly shorter mean time of D-J tube placement [（6.1±2.0） months vs.（4.0±3.5） months，t=2.824，P=0.010]，a significantly lower recurrence rate of anastomotic stricture（P=0.020），and a significantly better increase in GFR of the affected kidney（P=0.000）. Conclusion For the treatment of benign uretero-ileal anastomotic stricture after radical cystotomy and urine diversion and based on the length of the ureter with stricture，compared with endoscopic treatment，laparoscopic reimplantation can better address the problem of benign uretero-ileal anastomotic stricture，with higher cure rate of stricture and improvement rate of renal function.

关键词

根治性膀胱切除术 / 良性输尿管吻合口狭窄 / 内镜治疗 / 输尿管再植

Key words

radical cystectomy / benign ureteral anastomotic stricture / endoscopic treatment / ureteral reimplantation