经膀胱内腹腔镜手术治疗膀胱输尿管连接处疾病

Intravesical laparoscopic procedure for patients with vesicoureteral malformations under pneumovesicum

目的探讨经膀胱内腹腔镜治疗膀胱输尿管连接处疾病的手术技巧及适应证。方法回顾分析30例患儿，男19例，女11例。年龄4个月～7岁。单侧输尿管末端狭窄18例（其中输尿管囊肿3例、伴发结石2例），原发性膀胱输尿管反流12例（双侧4例）。在膀胱镜引导下，经膀胱顶置入5mm目镜鞘管并固定，建立CO2气膀胱，两侧放置3～5mm操作鞘管。术式同开放手术，术后留置导尿5～7d。结果29例在CO2气膀胱下完成手术，1例中转开放手术。所有病例手术时间57～260min。术后轻度血尿6例，均在2d内消失。术后随访3～26个月，21根恢复正常，9根较术前明显缩小，3根输尿管直径大于2．0cm者，术后未裁剪部分输尿管扩张无缓解。无输尿管反流。结论CO2气膀胱下经膀胱内腹腔镜治疗膀胱输尿管连接处疾病是一种安全有效的手术，容易学习，具有微创优势，但是，输尿管末端结石或扩张直径大于2．0cm者，不宜首选该术式，术中注意避免输精管损伤。

Objective To report our experience on intravesical laparoscopic Cohen ureteral reimplantation under pneumovesicum for patients with vesicoureteral malformations. Methods Thirty cases with vesicoureteral malformations were analyzed retrospectively, including 19 boys and 11 girls aging from 4 months to 7 years. Of all the patients, 18 were diagnosed with the unilateral vesicoureteral junction obstruction （3 complicated with ureterocele and 2 with calculus）, and 12 were diagnosed with primary vesicoureteral reflux （VUR, 4 in bilateral sides）. The operative procedure was as follows： a 5ram port was inserted into the bladder under cystoscopic guidance. After the bladder was insufflated with CO2, 2 more working ports were inserted on both sides of the lateral bladder wall. The following laparoseopic procedures were similar as the open technique, followed by bladder drainage with a urethral catheter for five to seven days postoperatively. Results Of all the patients, 29 underwent complete laparoscopic procedures, while only 1 was converted to the open procedure. The mean operating time ranged from 57 to 260 rains. Six patients got postoperative hematuria which persisted for only 2 days. All patients were followed up for 3 to 26 months. Twenty-one ureters achieved a normal diameter, and other 9 achieved a shorter diameter compared to the preoperative ones. However, the diameter of 3 dilated ureters did not get short after operation. No postoperative VUR was noted. Conclusions The intravesical laparoscopic procedure for ureteral reimplantation is safe, effective and minimally invasive. The technique can be learned easily with routine laparoscopic surgical techniques under pneu- movesicum. However, the procedure is not the first choice for patients with calculus at the terminal end of ureters or with a preoperative diameter more than 2cm. Attention should be paid to avoid injuring the spermatic ducts.