腹腔镜下Anderson-Hynes肾盂成形术治疗婴儿肾盂输尿管连接处梗阻

Laparoscopic Anderson-Hynes pyeloplasty for ureteropelvic junction obstruction in infants

目的评估腹腔镜下Anderson-Hynes肾盂成形术治疗婴儿肾盂输尿管连接处梗阻(ureteropelvic junction obstruction,UPJO)的可行性、安全性、疗效和优势。方法回顾性分析2008年7月至2013年5月我院经腹腔入路腹腔镜下Anderson-Hynes肾盂成形术治疗UPJO的48例年龄小于12个月婴儿的临床资料,按照简单随机抽样法术中随机采用双J管和支架管两种肾盂尿液引流方式分为内引流组和外引流组,比较2组的手术时间、术中和术后并发症、术后住院时间等。术后经连续B超检测AP值变化,评价2组术后积水缓解情况及再次手术发生率。结果 48例中,1例(2.1%)因术中肠道扩张显露术野困难,被动中转开放手术。47例在腹腔镜下顺利完成离断式Anderson-Hynes肾盂输尿管成形术。外引流组和内引流组平均手术时间分别为82.8、86.4 min,无明显差异(P>0.05)。2组术中均无与气腹相关的并发症,无肠道损伤及相关脏器损伤。2组的11例(23.4%)并发症中7例(14.9%)为轻度ClavienⅠ级,其中外引流组3例暂时性吻合口梗阻,1例引流管堵塞经冲洗后通畅;内引流组1例尿外渗持续引流后治愈,1例术后持续24 h肉眼血尿经止血药物治疗后消失,1例大网膜经脐部穿刺孔脱出于皮下,经镇静后回纳入腹腔及包扎后治愈。另4例(8.5%)为ClavienⅡ级,均发生在内引流组,为尿路感染,经抗感染治愈。外引流组术后住院时间(10.6 d)明显长于内引流组(7.2 d)(P<0.05)。术后随访3个月至2年。术后随访2组疗效差异无统计学意义,无再次手术病例。结论腹腔镜下AndersonHynes肾盂成形术治疗婴儿肾盂输尿管连接处梗阻是安全、有效的可选择方式,远期疗效良好,具有解剖学上的微创优势,采用外引流方式优于内引流。

Objective To evaluate the feasibility, safety, efficacy and advantage of laparoscopic Anderson-Hynes pyeloplasty for the treatment of ureteropelvic junction （UPJ） obstruction in children younger than 1 year. Methods We retrospectively reviewed all infants who underwent transperitoneal laparoscopic Anderson-Hynes pyeloplasty for UPJ obstruction from July 2008 to May 2013 in our hospital （n = 48）. During operation all were drained randomly with double-J sent and ureteral sent as two groups of internal drainage and external drainage with simple random sampling. The operative duration, intraoperative and postoperative com- plications, postoperative hospital stay, and rate of pyeloplasty reoperation were compared between the two groups. We followed the change of anterior-posterior（AP） with ultrasound at regular intervals and analyzed the outcome of two groups after operation. Results Forty-seven infants completed transperitoneal laparoscopic An- derson-Hynes pyeloplasty except one case of intraoperative conversion to open surgery limited to abdominal working space because of intestine dilatation. Median operative time of two groups had no significant difference, 82.8 min and 86.4 min, respectively （P 〉 0. 05 ）. No intraoperative complication about pneumoperitoneum and intestinal tract and other visceral organs was recorded in internal and external drainage groups. In two groups, eleven cases （23.4%） of post-operative complications were renorted, of which seven （ （ 14.9% ） belonged to Clavein I and four （8.5%） belonged to Clavein Ⅱ. The seven Clavein I cases contained 3 cases of anasto- motic obstructions transiently and 1 case of drainage tube jam in the external drainage group, as well as 1 case of urinary extravasation, 1 case of gross hematuria, and 1 case of incisional hernia of omentum cured after heteropathy treatment in the internal drainage group. The four Clavein Ⅱ cases were all found in the internal drainage group, with urinary tract infections accompanied by fever, and were cured after anti-infection treatment. The hospital stay of the external drainage group （ 10.6 d） was significantly longer than the internal drainage group （7.2 d） （P 〈 0. 05 ）. Median follow-up was 14 months （3 to 24 months）. Statistical analysis demonstrated the outcome of two groups had no difference. No case of reoperation was reported. Conclusion Laparoscopic Anderson-Hynes pyeloplasty is a safe, reliable and efficient procedure with an excellent outcome and minimal invasion for infants with UPJ obstruction. The operative way of ureteral sent is superior to the way of double-J sent.