Picard Jonathan, Abaza Ronney
Department of Urology, University of Toledo College of Medicine, Ohio, USA.
JSLS. 2009 Jul-Sep;13(3):411-5.
Laparoscopic ureteral surgery is becoming increasingly common; however, advanced laparoscopic skills are required due to the precise suturing involved. Because of the size of the ureter and need for careful mucosal apposition to prevent stricturing, there is less room for error than with larger lumens, as in pyeloplasty. We sought to identify whether the presence of a stent is beneficial or a hindrance in performing ureteroureterostomy both for the novice and more experienced laparoscopist.
Eight ureteroureteral anastomoses were performed on each ureter of a 50 kg female pig for a total of 16 anastomoses. Eight were performed with a stent in place, and 8 were performed without a stent. An equal number with and without a stent were performed by a novice and an experienced laparoscopist. Anastomoses were graded by time to complete and quality of the anastomosis. Quality was graded by the presence and size of defects and patency of the lumen.
The overall times required for ureteral division and spatulation, initial stitch placement, completion of the anastomosis, and total time for the stented vs. nonstented procedures were 4.3 vs. 2.2 minutes (P=0.05), 4.2 vs. 4.4 minutes (P=0.16), 10.4 vs. 13.5 (P=0.22) minutes, and 18.3 vs. 20.1 minutes (P=0.49), respectively. For stented and nonstented ureters, 3 vs. 5 anastomoses were found to have no or very small gaps, 5 vs. 1 anastomosis were found to have large gaps, and 0 vs. 2 anastomoses were found to have occluded lumens, respectively.
For both the novice and experienced surgeon, presence of a stent did not affect the overall time to complete a ureteroureteral anastomosis despite the significantly longer time needed to divide and spatulate the ureter. There were no occlusions when the ureteral stent was placed prior to suturing, which may indicate a reduced risk of "back-walling" the ureter.
腹腔镜输尿管手术正变得越来越普遍；然而，由于涉及精确缝合，需要先进的腹腔镜技术。由于输尿管的尺寸以及需要仔细对合黏膜以防止狭窄，与肾盂成形术等较大管腔手术相比，出错空间更小。我们试图确定对于新手和经验更丰富的腹腔镜手术医生而言，放置支架对输尿管输尿管吻合术是有益还是有阻碍。
对一头50千克雌性猪的每条输尿管进行8例输尿管输尿管吻合术，共16例吻合术。8例在放置支架的情况下进行，8例在未放置支架的情况下进行。新手和经验丰富的腹腔镜手术医生进行的有支架和无支架的手术数量相等。吻合术根据完成时间和吻合质量进行分级。质量根据缺陷的存在和大小以及管腔通畅情况进行分级。
输尿管离断与切开、最初缝线放置、吻合完成以及有支架与无支架手术的总时间分别为4.3分钟对2.2分钟（P = 0.05）、4.2分钟对4.4分钟（P = 0.16）、10.4分钟对13.5分钟（P = 0.22）以及18.3分钟对20.1分钟（P = 0.49）。对于有支架和无支架的输尿管，分别有3例对5例吻合术无间隙或间隙非常小，5例对1例吻合术有大间隙，0例对2例吻合术管腔闭塞。
对于新手和经验丰富的外科医生，尽管输尿管离断与切开所需时间明显更长，但支架的存在并不影响完成输尿管输尿管吻合术的总时间。在缝合前放置输尿管支架时未出现管腔闭塞情况，这可能表明输尿管“后壁化”风险降低。
