Objective: To evaluate the feasibility and clinical value of suprapubic-assisted laparoendoscopic single-site surgery (SA-LESS) in nephroureterectomy using method of transvaginal natural orifice specimen extraction (NOSE) (SA-LESS+TV-NOSE NU). Methods: Four patients (three cases of renal pelvic carcinoma and one case of ureteral carcinoma) undergoing SA-LESS+TV-NOSE NU were enrolled between April 2015 and January 2016. After general anesthesia, the patients were placed in the lithotomy position with the affected side elevated by 60°. Two trocars were inserted at the medial margin of umbilicus, and the third one was inserted into abdominal cavity at the superior margin of pubic symphysis. The operation was performed under a direct vision with a 5.4 mm 0° flexible-tip laparoscope. Firstly, the distal ureter was isolated completely and blocked by a Hem-O-lok clip. Then, the laparoscopic nephrectomy was performed according to the standard method. Finally, the bladder cuff excision was executed and the incision was sutured. The intact specimen was placed inside a homemade bag and removed through the incision at posterior vaginal fornix. Results: All the procedures were successfully performed. The median operative time was 150 (range: 120 to 210) minutes, and the median estimated blood loss was 180 (range: 80 to 350) ml. No major perioperative complications occurred. The mean visual analogue score (VAS) of 24 hours and 48 hours after operation were 3.25 (range: 2 to 5) and 2.25 (range: 2 to 3). All the patients resumed ambulation on postoperative day 1. Pelvic drainage tube was removed on postoperative day 2-4. On postoperative day 7, urethral catheter was removed. The patients were discharged on postoperative day 7-9. During the follow-up of 20-29 months, the patient recovered well with no case of incisional hernia and pelvic, abdominal infections. The vaginal fornix incision healed well, and the umbilical and suprapubic puncture scars were not obvious. All the patients completed the patient-assessed acromegaly symptom questionnaire PASQ. The average PSAQ score of 3 months after surgery was 34.5. Three of them restarted their sex lives, with an average female sexual function index score of 16.0, which was not significantly different with that of preoperation (15.6). There was no tumor recurrence, metastasis and implantation in all cases. Conclusion: SA-LESS+TV-NOSE NU is safe and feasible for upper tract urothelial carcinoma with faster postoperative recovery, less pain, shorter hospitalization time, better cosmetic results, and does not cause negative effect on the female sexual function.
目的： 探讨标本经阴道取出的耻骨上辅助单孔腹腔镜上尿路全切术（SA-LESS+TV-NOSE NU）的可行性及临床应用价值。 方法： 2015年4月至2016年1月间赣南医学院第一附属医院泌尿外科，对3例肾盂癌和1例输尿管癌施行SA-LESS+TV-NOSE NU。全麻，截石位，患侧垫高约60°。于脐内侧缘分别置入10、5 mm两个套管，自患侧耻骨联合上方置入一5 mm套管。耻骨上套管置入5.4 mm 0°远端可弯曲腹腔镜，脐部套管置入操作器械。先游离患侧输尿管下段，远端予Hem-O-lok夹闭；再切除肾脏；向下行输尿管末端膀胱袖套状切除，缝合膀胱切口；标本装袋，切开阴道后穹窿并扩大切口，将标本完整取出。 结果： 本组4例手术均顺利完成。中位手术时间150（120~210）min，中位失血量180（80~350）ml。均未输血，术中无严重并发症。术后24、48 h中位视觉模拟疼痛评分分别为3.25分（2~5分）、2.25分（2~3分）；均于术后第1天下床活动，第2~4天拔除腹腔和盆腔引流管，第7天拔除导尿管，第7~9天出院。随访20~29个月，患者均恢复良好，无切口疝及盆腔、腹腔感染等并发症发生。脐部、耻骨上穿刺孔瘢痕不明显，术后3个月PSAQ中位评分34.5分；3例术前有夫妻性生活患者术后3个月恢复性生活，术前女性性功能指数问卷中位评分（15.2分）与术后（14.8分）相比差异无统计学意义。4例均未发现肿瘤种植、复发或转移。 结论： SA-LESS+TV-NOSE NU安全可行；患者术后疼痛轻、恢复快、住院时间短；该术式美容优势明显，疗效确切，且不影响术后性功能，值得临床选用。.
Zhonghua yi xue za zhi. 2019 Sep 24 [Epub]
H Xu, G X Zhang, X F Zou, X N Wang, G Q Wu, W Xia, Y H Yuan, R H Xiao, Y T Wu, Y F Liao, B Jiang, H M Chen, Q L Liu, T P Xie
Department of Urology, First Affiliated Hospital of Gannan Medical University; Institute of Urology, Gannan Medical University, Ganzhou, Jiangxi 341000, China.