长段输尿管狭窄外科治疗思考：不同自体组织成形术的优劣及微创与开放的抉择

Reflections on the surgical treatment of long-segment ureteral stricture: advantages and disadvantages of various autologous tissue reconstruction techniques and the choice between minimally invasive and open surgery

摘要

输尿管狭窄是泌尿外科常见疾病，治疗方法主要取决于输尿管狭窄的病因、位置、数目和长度等。长段输尿管狭窄的主要治疗术式包括输尿管腔内治疗、肾盂瓣输尿管成形术、肾下盏输尿管吻合术、颊黏膜输尿管成形术、舌黏膜输尿管成形术、膀胱黏膜输尿管成形术、阑尾代输尿管成形术、膀胱瓣代输尿管成形术和回肠代输尿管成形术。虽然开放手术和腹腔镜手术仍然是常用的治疗方法，但机器人辅助手术因其微创、精确的特点，在临床上应用已越来越多。本文结合最新临床进展及本团队（郑州大学第一附属医院泌尿外科）诊疗经验，着重探讨不同自体组织成形术的优劣及在微创与开放术式之间的抉择，以期从临床实用角度系统介绍长段输尿管狭窄的各种外科治疗新方法和新技术。

Abstract

Ureteral stricture is a common urological condition, whose treatment mainly depends on the etiology, location, number, and length of the stricture. For complex long-segment ureteral stricture, the main surgical procedures include endourological treatment, flap pyeloplasty, ureterocalicostomy, buccal mucosal ureteroplasty, lingual mucosal ureteroplasty, bladder mucosal ureteroplasty, appendiceal ureteroplasty, bladder flap ureteroplasty, and ileal ureter substitution ureteroplasty. Although open and laparoscopic surgeries are still prevalent, robotic surgery is gaining popularity due to its minimally invasive nature and precision. Based on the latest clinical advances and diagnostic and therapeutic experience of our team, we will systematically introduce the new surgical techniques and methods for the treatment of long-segment ureteral stricture from a clinical practical perspective. In addition, we will discuss the advantages and disadvantages of different autologous tissue reconstruction techniques, as well as the choices between minimally invasive and open surgery.

关键词

长段输尿管狭窄 / 腹腔镜手术 / 机器人辅助手术 / 尿路重建 / 自体组织成形术

Key words

long-segment ureteral stricture / laparoscopic surgery / robot-assisted surgery / urinary tract reconstruction / autologous tissue reconstruction technique

参考文献

[1] GAO X, CHEN J, WANG W, et al. Step-by-step technique for the endoscopic treatment of ureteric stricture[J]. BJU Int, 2021, 128(6): 692-696.

[2] MOSKOVITZ B, HALACHMI S, NATIV O. A new self-expanding, large-caliber ureteral stent: results of a multicenter experience[J]. J Endourol, 2012, 26(11): 1523-1527.

[3] GAO X, DI X, CHEN G, et al. Metal ureteral stents for ureteral stricture: 2 years of experience with 246 cases[J]. Int J Surg, 2024, 110(1): 66-71.

[4] GAO X, WANG W, LI F, et al. A new technique for the treatment of ureteric stricture after kidney transplantation[J]. BJU Int, 2024, 134(3): 442-448.

[5] CHENG S, LI X, YANG K, et al. Modified laparoscopic and robotic flap pyeloplasty for recurrent ureteropelvic junction obstruction with a long proximal ureteral stricture: the “wishbone” anastomosis and the “ureteral plate” technique[J]. Urol Int, 2021, 105(7-8): 642-649.

[6] LI Z, LI X, FAN S, et al. Robot-assisted modified bilateral dismembered V-shaped flap pyeloplasty for ureteropelvic junction obstruction in horseshoe kidney using KangDuo-surgical-robot-01 system[J]. Int Braz J Urol, 2023, 49(3): 388-390.

[7] 朱照伟, 赵品, 王声政, 等. 腹腔镜或机器人肾盂瓣成形术治疗复杂上段输尿管狭窄[J]. 泌尿外科杂志(电子版), 2023, 15(1): 29-33.

[8] 李志华, 熊盛炜, 杨昆霖, 等. 机器人辅助腹腔镜肾盂瓣和舌黏膜补片输尿管成形术治疗复发性肾盂输尿管连接部梗阻的临床应用总结[J]. 现代泌尿外科杂志, 2022, 27(2): 124-129.

[9] XIE B, WANG X, ZENG X, et al. Ureterocalicostomy for complex upper ureteral stricture: a narrative review of the current literature[J]. Int Urol Nephrol, 2024, 56(6): 1899-1909.

[10] MITTAL S, AGHABABIAN A, EFTEKHARZADEH S, et al. Robot-assisted laparoscopic ureterocalicostomy in the setting of ureteropelvic junction obstruction: a multi-institutional cohort[J]. J Urol, 2022, 208(1): 180-185.

[11] 江羽, 王毅, 张志强, 等. 腹腔镜颊黏膜输尿管成形术治疗输尿管狭窄的临床应用[J]. 中华泌尿外科杂志, 2021, 42(4): 263-267.

[12] YOU Y, GAO X, CHAI S, et al. Oral mucosal graft ureteroplasty versus ileal ureteric replacement: a meta-analysis[J]. BJU Int, 2023, 132(2): 122-131.

[13] 陈敏杰, 高小峰. 自体补片技术治疗输尿管狭窄的研究进展[J]. 中华泌尿外科杂志, 2023, 44(7): 555-558.

[14] 王建黎, 李兵. 自体组织在输尿管修复重建手术中的应用[J]. 临床泌尿外科杂志, 2020, 35(8): 615-623.

[15] 沈天一, 汤昊, 张征宇, 等. 机器人下自体口腔颊黏膜移植治疗输尿管长段狭窄4例报告[J]. 微创泌尿外科杂志, 2021, 10(4): 217-220.

[16] 应沂岑, 杜毅聪, 李志华, 等. 机器人辅助腹腔镜下颊黏膜补片输尿管成形术治疗复杂输尿管狭窄[J]. 北京大学学报(医学版), 2024, 56(4): 640-645.

[17] LIANG C, WANG J, HAI B, et al. Lingual mucosal graft ureteroplasty for long proximal ureteral stricture: 6 years of experience with 41 cases[J]. Eur Urol, 2022, 82(2): 193-200.

[18] YANG K, FAN S, WANG J, et al. Robotic-assisted lingual mucosal graft ureteroplasty for the repair of complex ureteral strictures: technique description and the medium-term outcome[J]. Eur Urol, 2022, 81(5): 533-540.

[19] XIONG S, WANG J, ZHU W, et al. Onlay repair technique for the management of ureteral strictures: a comprehensive review[J]. Biomed Res Int, 2020, 2020: 6178286.

[20] WANG J, XIONG S, FAN S, et al. Appendiceal onlay flap ureteroplasty for the treatment of complex ureteral strictures: initial experience of nine patients[J]. J Endourol, 2020, 34(8): 874-881.

[21] ZHANG G, ZHAO J, ZHAO G, et al. Laparoscopic ureteral reimplantation with a boari flap for long-segment ureteric avulsion or ureteric strictures: our experience[J]. Int Urol Nephrol, 2022, 54(8): 1865-1870.

[22] YANG K, WANG X, XU C, et al. Totally intracorporeal robot-assisted unilateral or bilateral ileal ureter replacement for the treatment of ureteral strictures: technique and outcomes from a single center[J]. Eur Urol, 2023, 84(6): 561-570.

[23] KAPOGIANNIS F, SPARTALIS E, FASOUIAKIS K, et al. Laparoscopic and robotic management of ureteral stricture in adults[J]. In Vivo, 2020, 34(3): 965-972.

[24] YANG K, PANG KH, FAN S, et al. Robotic ureteral reconstruction for benign ureteral strictures: a systematic review of surgical techniques, complications and outcomes: robotic ureteral reconstruction for ureteral strictures[J]. BMC Urol, 2023, 23(1): 160.