腹腔镜重建性手术治疗小儿重复肾畸形合并肾盂输尿管连接部梗阻(附5例报告)
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摘要
目的:总结腹腔镜下行重建性手术治疗重复肾畸形合并UPJO的临床经验。方法:回顾性分析2015年9月-2017年1月收治的5例重复肾畸形合并UPJO患儿临床资料,其中男1例,女4例,中位年龄16.2(3～66)个月。重复肾畸形合并UPJO位于左侧2例,右侧3例。术前所有患儿均行超声、MRU、IVP及肾核素扫描等检查明确重复肾畸形且肾功能良好,术中证实UPJO合并不完全性重复肾输尿管畸形2例,UPJO合并完全性重复肾输尿管畸形3例。手术均经腹腹腔镜建立操作通道,其中行离断式肾盂成形术2例,输尿管-肾盂吻合术2例,离断式肾盂成形术+输尿管-肾盂吻合术1例。结果:5例患儿均在腹腔镜下完成手术,无中转开放手术,无术中术后严重并发症。平均手术时间136.8(100～198)min,平均术中出血量12(5～20)mL,术后平均住院6.2(5～8)d。术后行超声、IVP及肾动态显像检查,所有患儿梗阻均获解除,超声及IVP提示原重复肾积水明显缩小,肾动态显像无梗阻表现。结论:对于不同重复肾输尿管畸形需根据术前影像学检查结合术中探查情况采取相应手术方法,腹腔镜下重建性手术治疗重复肾畸形合并UPJO安全可行。
Objective:To summarize our experience in laparoscopic reconstructive surgery in children with ure?teropelvic junction obstruction(UPJO)associated with duplex anomalies.Methods:The clinical data of 5 patients with UPJO associated with duplex renal anomalies were analyzed retrospectively between September 2015 and Janu?ary 2017 in our institution. There were 1 male and 4 females with a median age of 16.2(range 3 to 66 months)months,2 patients had left hydronephrosis and 3 had right hydronephrosis,who were diagnosed by ultrasonography,IVP,MRU,and 99 mTc DTPA renal scan etc. Intraoperative investigations confirmed that 2 patients had incomplete duplicated systems and 3 patients had complete duplicated systems with UPJO. The trans-peritoneal laparoscopic ap?proach was utilized in all cases. Two patients underwent dismembered pyeloplasty,2 patients underwent pyeloureter?ostomy and one patient underwent dismembered pyeloplasty and pyeloureterostomy.Results:All surgeries were suc?cessfully performed without open conversion. No severe intra-operative and post-operative complications were encoun?tered. The mean operative time was 136.8 min(range 100-198 min)and the mean estimated blood loss was 12.0 mL(range 5-20 mL). The mean postoperative hospital stay was 6.2 days(range 5-8 days). Patients were followed up in our clinic postoperatively. All patients got complete clinical and radiologic resolution. The hydronephrosis was re?duced on ultrasound and IVP,and the anastomosis was patenct on 99 mTc DTPA scans after 6 months postoperation.Conclusions:Different techniques should be adopted according to pre-and intraoperative findings for UPJO in chil?dren with duplex renal anomalies. Laparoscopic reconstructive operation is a feasible option in cases of UPJO with du?plex renal anomalies.
Objective:To summarize our experience in laparoscopic reconstructive surgery in children with ure?teropelvic junction obstruction(UPJO)associated with duplex anomalies.Methods:The clinical data of 5 patients with UPJO associated with duplex renal anomalies were analyzed retrospectively between September 2015 and Janu?ary 2017 in our institution. There were 1 male and 4 females with a median age of 16.2(range 3 to 66 months)months,2 patients had left hydronephrosis and 3 had right hydronephrosis,who were diagnosed by ultrasonography,IVP,MRU,and 99 mTc DTPA renal scan etc. Intraoperative investigations confirmed that 2 patients had incomplete duplicated systems and 3 patients had complete duplicated systems with UPJO. The trans-peritoneal laparoscopic ap?proach was utilized in all cases. Two patients underwent dismembered pyeloplasty,2 patients underwent pyeloureter?ostomy and one patient underwent dismembered pyeloplasty and pyeloureterostomy.Results:All surgeries were suc?cessfully performed without open conversion. No severe intra-operative and post-operative complications were encoun?tered. The mean operative time was 136.8 min(range 100-198 min)and the mean estimated blood loss was 12.0 mL(range 5-20 mL). The mean postoperative hospital stay was 6.2 days(range 5-8 days). Patients were followed up in our clinic postoperatively. All patients got complete clinical and radiologic resolution. The hydronephrosis was re?duced on ultrasound and IVP,and the anastomosis was patenct on 99 mTc DTPA scans after 6 months postoperation.Conclusions:Different techniques should be adopted according to pre-and intraoperative findings for UPJO in chil?dren with duplex renal anomalies. Laparoscopic reconstructive operation is a feasible option in cases of UPJO with du?plex renal anomalies.
引文
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[8] FERNBACH SK,ZAWIN JK,LEBOWITZ RL.Complete duplication of the ureter with ureteropelvicjunction obstruction of the lower pole of the kidney:imaging findings. AJR Am J Roentgenol,1995,164(3):701-704.
[9] AVLAN D,GüNDOGDU G,DELIBAS A,et al.Pyeloureterostomy in the management of the lowerpole pelvi-ureteric junction obstruction in incompleteduplicated systems. Urology,2010,76(6):1468-71.
[10] HORST M,SMITH GH. Pelvi-ureteric junction ob?struction in duplex kidneys. BJU Int, 2008,101(12):1580-1584.
[11] Bove P,Ong AM,Rha KH,et al. Laparoscopicmanagement of ureteropelvic junction obstruction inpatients with upper urinary tract anomalies. J Urol,2004,171(1):77-79.
[12] SAHAI A,RAGHURAM S,MINARIK L,et al.Laparoscopic pyeloplasty and pyelopyelostomy forureteropelvic junction obstruction in a duplicated col?lecting system. Urology,2006,67(1):E9-E11.
[13] AVLAN D,GUNDOGDU G,DELIBAS A,et al.Pyeloureterostomy in the management of the lowerpole pelvi-ureteric junction obstruction in incompleteduplicated systems. Urology,2010,76(6):1468-1471.
[14] LIU W,ZHANG LJ,MA R,et al. The morpholo?gy and treatment of coexisting ureteropelvic junctionobstruction in lower moiety of duplex kidney. Int JSurg,2016,34:23-27.
[15] METZELDER ML,PETERSEN C. Laparoscopicpyeloplasty is feasible for lower pole pelvi-uretericobstruction in duplex systems. Pediatr Surg Int,2007,23(9):907-909.
[2] HO DS,JENKINS GR,WILLIAMS M,et al.Ureteropelvic junction obstruction in upper and lowermoiety of duplex renal systems. Urology,1995,45(3):503-506.
[3] GONZALEZ F,CANNING DA,HYUN G,et al.Lower pole pelvi-ureteric junction obstruction in du?plicated collecting systems. BJU Int,2006,97(1):161-165.
[4] RUBENWOLF P,ZIESEL C,BEETZ R,et al.Presentation,management and long-term outcomeof ureteropelvic junction obstruction in duplex kid?neys. J Urol,2015,194(2):427-432.
[5] CAO HL,ZHOU HX,LIU K,et al. A modifiedtechnique of paraumbilical three-port laparoscopicdismembered pyeloplasty for infants and children. Pe?diatr Surg Int,2016,32(11):1037-1045.
[6] VANDERBRINK BA,CAIN MP,GILLEY D,etal. Reconstructive surgery for lower pole ureteropel?vic junction obstruction associated with incompleteureteral duplication. J Pediatr Urol,2009,5(5):374-377.
[7]马洪,方勇,王鑫,等.小儿膀胱镜输尿管插管逆行造影检查术在肾输尿管先天畸形诊断中的价值.实用儿科临床杂志,2009,24(11):817-818,826.
[8] FERNBACH SK,ZAWIN JK,LEBOWITZ RL.Complete duplication of the ureter with ureteropelvicjunction obstruction of the lower pole of the kidney:imaging findings. AJR Am J Roentgenol,1995,164(3):701-704.
[9] AVLAN D,GüNDOGDU G,DELIBAS A,et al.Pyeloureterostomy in the management of the lowerpole pelvi-ureteric junction obstruction in incompleteduplicated systems. Urology,2010,76(6):1468-71.
[10] HORST M,SMITH GH. Pelvi-ureteric junction ob?struction in duplex kidneys. BJU Int, 2008,101(12):1580-1584.
[11] Bove P,Ong AM,Rha KH,et al. Laparoscopicmanagement of ureteropelvic junction obstruction inpatients with upper urinary tract anomalies. J Urol,2004,171(1):77-79.
[12] SAHAI A,RAGHURAM S,MINARIK L,et al.Laparoscopic pyeloplasty and pyelopyelostomy forureteropelvic junction obstruction in a duplicated col?lecting system. Urology,2006,67(1):E9-E11.
[13] AVLAN D,GUNDOGDU G,DELIBAS A,et al.Pyeloureterostomy in the management of the lowerpole pelvi-ureteric junction obstruction in incompleteduplicated systems. Urology,2010,76(6):1468-1471.
[14] LIU W,ZHANG LJ,MA R,et al. The morpholo?gy and treatment of coexisting ureteropelvic junctionobstruction in lower moiety of duplex kidney. Int JSurg,2016,34:23-27.
[15] METZELDER ML,PETERSEN C. Laparoscopicpyeloplasty is feasible for lower pole pelvi-uretericobstruction in duplex systems. Pediatr Surg Int,2007,23(9):907-909.