关键词: 肾移植, 移植, 自体, 输尿管损伤, 医源性疾病, 腹腔镜检查

Abstract:

Objective：To evaluate the safety and efficacy of retroperitoneal laparoscopic nephrectomy with autotransplantation in cases of severe iatrogenic proximal ureteral damage. Methods: From July 2011 to March 2015, two patients, aged 44 (female) and 54 years (male), underwent retroperitoneal laparoscopic nephrectomy and autotransplantation for treatment of severe iatrogenic proximal ureteral injuries. Both injuries were proximal ureteral avulsion during ureterolithotomy with the holmium laser for ureteral calculi. computed tomography angiography (CTA) and computed tomography urography (CTU) was performed in both patients before operation. A 3-port retroperitoneal technique was used for the patients placed in a lateral decubitus position. A retroperitoneal laparoscopic nephrectomy with autotransplantation approach was used in both the patients, and the kidneys were removed to the right iliac fossa. Case 1’s kidney was removed through the right Gibson incision, while Case 2’s kidney was removed through the left lumbar incision. The renal artery and renal vein were ligated using the Hem-o-lok. The kidneys were taken out quickly from the patients and infused with 4 ℃ kidney preserving fluid immediately.  Results: The retroperitoneal laparoscopic nephrectomy with autotransplantations was performed 4 hours in Case 1 and 2 years in Case 2 after atrogenic proximal ureteral injuries. Case 2 was associated with dense perinephric and perihilar fibrosis. The procedures were successful, with immediate return of renal function in both the patients. After ex vivo graft preparation, ureteral and vessel length and quality were adequate for transplantation in both the cases. A direct ureterovesical anastomosis was performed in both patients. In the 2 patients, the warm ischemia time was 3 and 5 minutes, the total operation time 185 and 246 minutes, and the estimated blood loss 70 and 200 mL, respectively. No perioperative complications occurred. At the end of the follow-up, the transplanted kidneys were functional, and the patients had returned to their normal activity. Conclusion: Retroperitoneal laparoscopic nephrectomy with autotransplantation is an excellent alternative to nephrectomyor bowel interposition in patients with proximal urete-ral loss. This procedure is associated with acceptable morbidity and preserves the renal function. This report supports the safety and efficacy of retroperotoneal laparoscopic nephrectomy with autotransplantation in experienced hands.

Key words: Kidney transplantation, Transplantation, autologous, Ureteral injury, Iatrogenic disease, Laparoscopy