Brown James A, Strup Stephen E, Chenven Eric, Bagley Demetrius, Gomella Leonard G
Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
Urology. 2005 Dec;66(6):1192-6. doi: 10.1016/j.urology.2005.06.086.
To review our experience with various techniques used to manage the distal ureter during hand-assisted laparoscopic nephroureterectomy and to evaluate the surgical outcomes, including pathologic margin status and the incidence of disease recurrence.
We retrospectively analyzed 55 hand-assisted laparoscopic nephroureterectomies performed to treat transitional cell carcinoma (TCC), with the distal ureter managed as follows: cystoscopic disarticulation in 16 patients, stapled division in 7, open distal ureterectomy in 3, and hand-assisted laparoscopic extravesical en bloc distal ureterectomy with bladder cuff in 29. The cystotomy was not closed in 7 patients.
The coexistence of renal pelvic and ureteral tumors was common but in 27% of cases was not recognized preoperatively. One outer and four distal ureteral margins were positive for tumor (n = 2) or carcinoma in situ (n = 3). Two (29%) of the seven cystotomies that were not closed and only 1 (2%) of the 42 that were closed demonstrated extravasation. The operative time was 60 to 90 minutes longer and the estimated blood loss, open conversion rate, and indwelling catheterization time were two to three times greater for the cystoscopic ureteral disarticulation cohort. The stapled division cohort had a greater positive margin rate (29%) than the other cohorts (10% or less). With a mean follow-up of 24 months, 19 patients had developed bladder cancer, 1 prostate cancer, 1 an extravesical malignancy with synchronous liver metastasis, and 4 distant recurrence (lung in 2 and the retroperitoneum and spine in 1 each).
The results of our study have shown that distal ureteral tumors have the greatest likelihood for a positive margin. Cystoscopic ureteral disarticulation increased the operative time and estimated blood loss. Cystotomy closure reduced the extravasation rate. We favor hand-assisted laparoscopic en bloc distal ureterectomy followed by cystotomy closure to minimize the risk of distal ureteral or extravesical recurrence.
回顾我们在实施手辅助腹腔镜肾输尿管切除术时处理远端输尿管所采用的各种技术的经验，并评估手术结果，包括病理切缘情况和疾病复发率。
我们回顾性分析了55例因治疗移行细胞癌（TCC）而实施的手辅助腹腔镜肾输尿管切除术，远端输尿管的处理方式如下：16例患者采用膀胱镜下离断术，7例采用吻合器离断术，3例采用开放性远端输尿管切除术，29例采用手辅助腹腔镜膀胱外整块远端输尿管切除术并保留膀胱袖口组织。7例患者未缝合膀胱切开处。
肾盂和输尿管肿瘤共存情况常见，但27%的病例术前未被识别。1例输尿管外切缘及4例远端输尿管切缘存在肿瘤（2例）或原位癌（3例）阳性。7例未缝合膀胱切开处中有2例（29%）发生渗漏，而42例缝合膀胱切开处的患者中仅1例（2%）发生渗漏。膀胱镜下输尿管离断术组的手术时间长60至90分钟，估计失血量、开放手术转换率和留置导尿时间是其他组的两到三倍。吻合器离断术组的切缘阳性率（29%）高于其他组（10%或更低）。平均随访24个月时，19例患者发生膀胱癌，1例发生前列腺癌，1例发生膀胱外恶性肿瘤并伴有同步肝转移，4例发生远处复发（2例肺部转移，1例腹膜后转移，1例脊柱转移）。
我们的研究结果表明，远端输尿管肿瘤切缘阳性的可能性最大。膀胱镜下输尿管离断术增加了手术时间和估计失血量。缝合膀胱切开处可降低渗漏率。我们倾向于采用手辅助腹腔镜整块远端输尿管切除术并随后缝合膀胱切开处，以将远端输尿管或膀胱外复发风险降至最低。
