腹腔镜与输尿管软镜联合定位治疗复杂输尿管狭窄的疗效分析

doi:10.19723/j.issn.1671-167X.2025.04.025

摘要/Abstract

摘要：

目的: 探讨双镜联合(腹腔镜/机器人辅助腹腔镜联合一次性输尿管软镜)术中定位技术在复杂输尿管狭窄重建手术中的安全性及临床疗效。方法: 回顾性分析2023年1月至2024年11月北京大学人民医院收治的21例复杂输尿管狭窄患者的资料，所有病例均采用双镜联合技术进行术中定位与重建。患者入组标准为狭窄长度≥ 2 cm、多发性狭窄或医源性狭窄或放疗后狭窄。术前均行泌尿系增强CT检查以及利尿肾动态显像检查，明确狭窄部位及肾功能。术中根据狭窄位置采用免分腿斜仰卧位(中上段狭窄)或仰卧截石位(中下段狭窄)，通过腹腔镜光源与输尿管软镜协同定位狭窄段，结合狭窄长度及吻合张力选择舌黏膜补片成形、膀胱瓣代输尿管或端端吻合等重建方式。术后随访患者，评估症状缓解、肾积水程度及再狭窄情况。结果: 21例患者中男性10例，女性11例，平均年龄(44.1±13.3)岁，狭窄长度(4.81±4.33) cm，病因包括结石相关狭窄(15例)、妇科术后损伤(1例)、放疗后狭窄(1例)、先天性因素(4例)。52.4%(11/21)的患者术中发现狭窄范围与术前影像学判断存在差异。术后随访2~21个月[平均(10.76±6.81)个月]，所有患者均症状消失，肾积水较术前显著改善，总有效率为100%。1例患者术后出现漏尿，经保守治疗缓解，1例患者支架取出后因结石梗阻行输尿管镜碎石术，无中转开放手术或严重并发症。结论: 双镜联合技术通过术中实时光源定位与腔内直视探查，显著提高了复杂输尿管狭窄段的定位精度，减少了正常输尿管过度切除风险，同时优化了体位设计，降低了操作难度，此项技术可精准指导重建策略的选择，术后再狭窄率低，是复杂输尿管狭窄治疗的安全、有效手段。

关键词: 输尿管狭窄, 输尿管成形术, 输尿管镜, 腹腔镜检查, 机器人手术

Abstract:

Objective: To evaluate the safety and efficacy of a dual-endoscopic technique combining laparoscopy/robot-assisted laparoscopy with disposable flexible ureteroscopy for intraoperative localization and reconstruction in complex ureteral strictures. Methods: A retrospective analysis was conducted on 21 patients with complex ureteral strictures (stenosis length ≥2 cm, multiple strictures, or iatrogenic strictures, or radiation-induced strictures) treated at Peking University People' s Hospital between January 2023 and November 2024. All the patients underwent dual-endoscopic procedures using laparoscopy (n=17) or da Vinci robotic-assisted laparoscopy (n=4) combined with disposable flexible ureteroscopy. Preoperative evaluation included contrast-enhanced CT urography and diuretic renography. Intra-operatively, stricture localization was achieved by synchronizing laparoscopic light sources with ureteroscopic visualization. Surgical positions were optimized: non-split-leg oblique supine position for mid-upper strictures and lithotomy position for mid-lower strictures. Reconstruction strategies (lingual mucosa graft, bladder flap augmentation, or primary anastomosis) were selected based on stricture length and tension. Postoperative outcomes were assessed via symptom resolution, hydronephrosis improvement (ultrasonographic renal pelvis diameter), and stent-free patency. Results: The cohort included 10 males and 11 females [mean age (44.1±13.3) years]. Etiologies included lithogenic strictures (71.4%, 15/21), post-gynecologic surgery injury (4.8%), radiation-induced fibrosis (4.8%), and congenital factors (19.0%). Intraoperative findings revealed discrepancies in stricture localization compared with pre-operative imaging in 52.4% (11/21) of cases, necessitating extended resection or modified reconstruction. Mean stricture length was (4.81±4.33) cm. Postoperative complications included transient urinary leakage (1 case) and secondary ureteral obstruction due to stone migration (1 case), both resolved without sequelae. At a mean follow-up of (10.76±6.81) months (range 2-21), hydronephrosis significantly improved in all the patients (100% efficacy), with no recurrence of strictures or symptom recurrence. Conclusion: The dual-endoscopic technique enhances intraoperative precision in complex ureteral stricture management by integrating real-time luminal visualization with extraluminal anatomical guidance. This approach minimizes excessive resection of healthy ureter, optimizes reconstruction strategies, and reduces postoperative recurrence. The modified positioning protocol further improves ergonomic efficiency, making it a reliable and adaptable option for challenging ureteral pathologies.

Key words: Ureteral stricture, Ureteroplasty, Ureteroscopes, Laparoscopy, Robotic surgical procedures

中图分类号:

R699.4

王焕瑞, 赖世聪, 胡浩浦, 丁泽华, 徐涛, 胡浩. 腹腔镜与输尿管软镜联合定位治疗复杂输尿管狭窄的疗效分析[J]. 北京大学学报（医学版）, 2025, 57(4): 784-788.

Huanrui WANG, Shicong LAI, Haopu HU, Zehua DING, Tao XU, Hao HU. Efficacy analysis of laparoscopy combined with flexible ureteroscope in the treatment of complex ureteral stricture[J]. Journal of Peking University (Health Sciences), 2025, 57(4): 784-788.

图/表 3

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参考文献 20

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Variables	Data (n=21)
Gender (male/female), n	10/11
Age/years, ${\bar x}$±s	44.1±13.3
Causes of stenosis, n
Calculus	15
Injury	1
Radiotherapy	1
Congenital factors	4
Location of stenosis, n
Left/right side	9/12
Upper/middle/lower segment	4/12/5
Length of stenosis/cm, ${\bar x}$±s	4.81±4.33
Reconstruction methods, n
Pyeloplasty	4
Ureteroneocystostomy	2
Bladder flap ureteroplasty	4
Lingual mucosal graft ureteroplasty	6
Appendix graft ureteroplasty	2
Ureteroureterostomy	1
Ileal segment replacement of ureter	1
Renal pelvis flap + ureteroneocystostomy	1
Surgical approaches, n
Laparoscopy	17
da Vinci robot-assisted laparoscopy	4