Evaluation and outcome of the distal ureteral stump after nephro-ureterectomy in children. A comparison between laparoscopy and retroperitoneoscopy

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• 作者：Maria Escolino ; ^{x.escolino@libero.it" class="auth_mail" title="E-mail the corresponding author} ; Alessandra Farina ; Francesco Turrà ; Mariapina Cerulo ; Rosanna Esposito ; Antonio Savanelli ; Alessandro Settimi ; Ciro Esposito
• 关键词：Nephro-ureterectomy ; Laparoscopy ; Retroperitoneoscopy ; Ureteral stump ; Children
• 刊名：Journal of Pediatric Urology
• 出版年：2016
• 出版时间：April 2016
• 年：2016
• 卷：12
• 期：2
• 页码：119.e1-119.e8
• 全文大小：1257 K

文摘

In children with a poorly functioning kidney due to vesicoureteral reflux (VUR) or ureteropelvic junction obstruction, management is by nephrectomy with total or proximal ureterectomy. The complete removal of all the ureter minimizes the risk of future morbidity associated with the distal ureteral stump (DUS), including febrile urinary tract infections (UTIs), lower quadrant pain and hematuria, the so-called ureteral stump syndrome.

Objective

To assess the outcome of the DUS after nephroureterectomy, we analyzed our recent experience of nephrectomy performed via retroperitoneoscopy and via laparoscopy.

Methods

The records of 21 consecutive patients (median age 3.5 years, range 1–10 years) who underwent nephroureterectomy via laparoscopy or via retroperitoneoscopy were retrospectively reviewed for symptoms caused by DUS and their management. Nephrectomy was undertaken for a poorly functioning dysplastic (4), scarred from VUR (10) or hydronephrotic (7) kidney. In the laparoscopic group (11 pts), 6 cases required nephrectomy for reflux while 5 patients were operated for hydronephrotic or dysplastic non-functioning kidney. In the retroperitoneoscopic group (10 pts), nephrectomy was performed for reflux in 4 cases versus 6 patients affected by hydronephrotic or dysplastic non-functioning kidney. The patients were evaluated using ultrasound (US) to check DUS length and clinically to evaluate symptoms due to a symptomatic DUS.

Results

The average length of surgery was 50 min for laparoscopy and 80 min for retroperitoneoscopy. The average of follow-up was 5 years. The length of DUS after laparoscopic nephrectomy was shorter (range 3–7 mm, statistically significant) than the DUS after retroperitoneoscopy (range 2–5 cm) (p < 0.001). Laparoscopic patients were all asymptomatic. Two patients, after retroperitoneoscopic nephrectomy, presented with recurrent UTIs; a voiding cystography revealed a VUR on the residual DUS and a redo surgery was performed in both the patients to remove the DUS (Figure).

Discussion

Several authors have stated that, in case of subtotal ureterectomy, the incidence of symptomatic DUS after nephrectomy for high-grade vesicoureteric reflux is low. However, in our series, the incidence of symptomatic DUS after nephroureterectomy was not insignificant (2/21, 9.5%). Symptoms related to a refluxing DUS occurred only in patients undergoing retroperitoneoscopic nephroureterectomy, where the DUS was longer than the DUS detected in laparoscopic patients.

Conclusions

Considering that laparoscopy permits removal of all the ureter near the bladder dome, in children with non-functioning kidney due to VUR, it is advisable to always perform a laparoscopic rather than a retroperitoneoscopic nephrectomy to prevent problems related to a symptomatic DUS.