吲哚菁绿在复杂上尿路修复手术中的应用

doi:10.19723/j.issn.1671-167X.2020.04.010

摘要/Abstract

摘要：

目的: 探讨吲哚菁绿(indocyanine green,ICG)在复杂上尿路修复手术中的使用方法及应用价值。方法: 回顾性分析2019年5月至10月收治的7例复杂输尿管狭窄患者的资料,其中男性6例,女性1例,平均年龄47岁(24~57岁)。右侧输尿管狭窄5例,其中3例为上段狭窄,2例为放疗所致多处长段狭窄;左侧输尿管狭窄2例,其中1例为肾盂输尿管连接处狭窄,1例为上段狭窄。3例为初次修复手术,4例为二次手术。7例患者均行经腹途径的腹腔镜手术,吲哚菁绿溶液于术中经肾造瘘管注入患侧输尿管,通过近红外光腹腔镜辅助辨认输尿管狭窄段。7例患者中,2例行北京大学泌尿外科研究所(Institute of Urology, Peking University,IUPU)改良回肠代输尿管术,2例行输尿管狭窄段切除再吻合术,2例行阑尾补片右侧输尿管成形术,1例行舌黏膜补片左侧输尿管成形术。结果: 7例手术均顺利完成,无中转开腹手术,均使用近红外光ICG显影腹腔镜辅助完成输尿管狭窄段的定位及分离。平均手术时长187 (135~300) min,平均分离病变输尿管时间为18 (15~27) min,平均术中出血量50 (15~200) mL。1例回肠代输尿管患者术后出现发热,抗生素治疗后好转。7例患者术后平均住院日7 (6~10) d,所有患者均无Clavien-Dindo Ⅲ~Ⅳ级并发症出现。平均随访时间9 (6~11)个月,未见吲哚菁绿毒副反应,所有患者均于术后2个月内顺利拔除D-J管及肾造瘘管,复查泌尿系B超未见明显肾积水,泌尿系CT成像(computed tomography urography,CTU)示尿路通畅且肾功能良好。结论: 在近红外光腹腔镜下使用吲哚菁绿,可在复杂上尿路修复手术中辅助术者快速辨认出输尿管及其狭窄段,有利于减少手术误损伤,更好地保护输尿管血液供应,使用方法简便、安全,值得临床推广。

关键词: 吲哚菁绿, 近红外光腹腔镜, 输尿管狭窄, 上尿路修复

Abstract:

Objective: To evaluate the clinical application of indocyanine green (ICG) visualization by near infrared fluorescence laparoscopy (NIFL) in complex upper urinary tract reconstructions surgery. Methods: This was a retrospective study of 7 patients who underwent complex surgeries of ureteral reconstruction between May 2019 and October 2019. There were 6 males and 1 female with the age ranging from 24 to 57 years (median age was 47 years). There were 5 cases of right ureteral strictures, of which 3 were proximal ureteral strictures and 2 were multiple and long ureteral strictures caused by radiotherapy. There were 2 cases of left ureteral strictures, of which 1 was ureteropelvic junction stricture and 1 was proximal ureteral stricture. There were 4 cases of secondary repair operations and 3 cases of primary operations. All the patients underwent laparoscopic surgery via the abdominal approach. ICG was injected into the ureter via nephrostomy tube during the operations, and the diseased ureter was identified by NIFL. Among the patients, 2 cases underwent IUPU (Institute of Urology, Peking University) modified ileal ureter replacement, 2 cases underwent ureteroureterostomy, 2 cases underwent appendiceal onlay flap ureteroplasty, and 1 case underwent lingual mucosa onlay flap ureteroplasty. Results: All the operations were successfully completed without open conversion. The localization and separation of ureteral lesions were completed under NIFL. The mean operative time was 187 (135-300) min. The duration of ureteral separation was 15-27 min, and the mean time was 18 min. The estimated blood loss was 15-200 mL, the mean estimated blood loss was 50 mL. There was one patient with ileal ureter replacement who had fever after surgery and responded well to antibiotics. The mean (range) length of postoperative hospital stay was 7 (6-10) days and no postoperative complications of a high grade (Clavien-Dindo Ⅲ and Ⅳ) occurred. Up to now, the mean follow-up duration was 9 (6-11) months, and no indocyanine green toxicity occurred. All D-J stents and nephrostomy were removed successfully 2 months after the operation. Ultrasound showed no obvious hydronephrosis, and CTU (computed tomography urography) showed that the urinary tract was unobstructed and the kidney function was normal. Conclusion: The application of ICG in the complex upper urinary tract reconstructive surgery is a safe and easy method to help surgeon to identify the ureter which may reduce the risk of iatrogenic damage and protect the ureteral blood supply.

Key words: Indocyanine green, Near-infrared fluorescence laparoscopy, Ureteral stricture, Upper urinary tract reconstruction

中图分类号:

R693.5

黄炳伟,王杰,张鹏,李喆,毕泗成,王强,岳才博,杨昆霖,李学松,周利群. 吲哚菁绿在复杂上尿路修复手术中的应用[J]. 北京大学学报（医学版）, 2020, 52(4): 651-656.

Bing-wei HUANG,Jie WANG,Peng ZHANG,Zhe LI,Si-cheng BI,Qiang WANG,Cai-bo YUE,Kun-lin YANG,Xue-song LI,Li-qun ZHOU. Application of indocyanine green in complex upper urinary tract repair surgery[J]. Journal of Peking University (Health Sciences), 2020, 52(4): 651-656.

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Cases	Gender	Age/years	Injury etiology	Stenosis location	Stenosis length/cm	Preoperative nephrostomy	Nephrostomy indwelling/months
1	Female	54	Holmium laser lithotripsy	Multiple segments		Yes	7.0
2	Male	57	Radiotherapy	Multiple segments		Yes	12.0
3	Male	28	Holmium laser lithotripsy	Proximal	2.0	Yes	1.0
4	Male	47	Rectal cancer operation	Proximal	2.5	Yes	1.0
5	Male	27	Pyeloplasty failed	Proximal	0.5	Yes	1.0
6	Male	24	Pyeloplasty failed	Proximal	1.5	Yes	4.0
7	Male	49	Holmium laser lithotripsy	Proximal	4.0	Yes	6.0
Mean		47			2.0		4.5

Cases	Operations	Operation time/min	Estimated blood loss/mL	Exposure time of ureteral stenosis/min	Early postoperative complications	Postoperative hospital stay/d
1	Ileal ureter replacement	300	200	17	Fever	10
2	Ileal ureter replacement	180	50	15	None	9
3	Appendiceal onlay flap ureteroplasty	150	15	18	None	6
4	Tongue mucosal onlay flap ureteroplasty	240	20	27	None	8
5	Ureteroureterostomy	140	15	16	None	6
6	Ureteroureterostomy	135	20	15	None	6
7	Appendiceal onlay flap ureteroplasty	160	50	20	None	7
Mean		187	50	18		7