腹腔镜下双侧Anderson—Hynes肾盂输尿管成形术治疗UPJ0所致肾积水

Simultaneous bilateral laparoscopic Anderson-Hynes pyeloplasty for ureteropelvic junction obstruction

目的分析腹腔镜双侧Anderson-Hynes。肾盂输尿管成形术治疗儿童双侧先天性肾盂输尿管连接处梗阻（ureteropelvic junction obstruction，UPJ0）导致的肾积水的可行性、安全性、疗效和优势。方法双侧UPJO所致肾积水15例（30侧）。其中男13例，女2例。年龄1岁～13岁5个月，中位年龄5岁。临床表现为术前伴腰痛7例，伴尿路感染2例，双侧腹部包块4例，单侧腹部包块4例，其中单侧巨大肾积水2例。均采用经脐部（2孔）和脐部与剑突下连线中点（1TL）两部位放置穿刺鞘管，一次性腹腔镜下双侧Anderson-Hynes肾盂输尿管成形术。手术均由同一医生完成。术后随访12-24个月，连续B型超声检测AP值变化，必要时IVu，尿常规评估疗效。分析中转开放率、手术时间、术中出血量、术后住院时间、并发症及术后肾积水缓解程度、再手术率。结果15例手术均获成功，无中转开放，无添加鞘管或切口。手术时间（180±60）min，术中出血量（21．6±13．9）ml，术后住院天数（10．1±2．0）d。术中发现单侧重复肾Y形输尿管1例，双侧输尿管息肉1例，单侧输尿管息肉1例，双侧迷走血管压迫1例。1例于术后3d因单侧支架管堵塞而尿外渗至肠动力性降低，术后通过禁食及胃肠减压后自行治愈。3例术后24h后仍有明显肉眼血尿，通过延长止血药的使用血尿消失，无明显高碳酸血症、内环境紊乱等CQ气腹相关并发症，无其他胃肠动力减弱或机械性梗阻病例发生。无CtavienⅢ级手术并发症。术后12个月10例20侧（66．7％）获得随访，在20侧患肾中，10侧（50％）肾积水完全缓解，10侧（50％）部分缓解。术后24个月14侧（70％）获得完全缓解，6侧（30％）部分缓解，无再次手术病例。结论经脐部（2孔）和脐部与剑突下连线中点（1孔）两部位鞘管穿刺，腹腔镜下双侧Anderson-Hynes肾盂输尿管成形术治疗儿童UPJ0安全有效，术后效果良好，具有微创优势。

Objective To evaluate the feasibility, safety, efficacy and advantages of simultaneous bilateral laparoscopic Anderson-Hynes pyeloplasty in the treatment of ureteropelvic junction obstruction （UPJO）. Methods We retrospectively reviewed 15 patients undergoing simultaneous bilateral laparoseopic Anderson-Hynes pyeloptasty （2 umbilical trocars and 1 trocar placed put in midpoint between umbilicus and xiphoid process） for UPJO by the same surgeon. The median age was 5 （1-14） years. The clinical manifestations included loin pain （n = 7） ,urinary tract infections （UTI,n = 2） ,bilateral loin mass （n = 4）, unilateral loin mass （n = 4） and giant hydronephrosis （n = 2）. The follow-up period was 12-24 months. Type B ultrasonography was employed for tracking the severity of hydronephrosis,intravenous urography （IVU） for UPJO when necessary and urinalysis for urinary tract infection. The conversion rate, operative duration, blood loss volume, length of hospitalization, complications, reintervention rate and level of hydronephrosis remission were evaluated. Results All procedures were completed successfully. Neither conversion into open surgery nor extra trocar or incision was required. The operative duration was （180 ± 60） min, blood loss volume （21.6 ± 13.9） ml and length of hospitalization （10. 1± 2. 0） days. Intraoperative observations revealed incomplete ureteral duplication （n = 1）, bilateral ureteral polyps （n = 1）, unilateral ureteral polyps （n = 1） and bilateral aberrant vessels （n = 1 ）. One case of temporary ileus resulted from urinary extravasation through a drainage tube jam without urinary tract infection at Day 3 after procedure. It achieved a remission after fasting and gastrointestinal decompression. Three cases of hematuria at 24 h disappeared when hemostatics was enhanced. Neither hypercapnia nor internal environment disturbance occurred. No reduced gastrointestinal motility or mechanical obstruction complications were observed. There was no occurrence of Clavien III complication. Ten （66. 7%） cases were followed after 12 months. Among 10 cases, complete and partial remission rate were 50%（10 kidneys） and 50% （10 kidneys）. At 24 months after procedure, the above ratios were 70% （14 kidneys） and 30 % （6 kidneys） respectively. No secondary surgical intervention was required. Conclusions Simultaneous bilateral laparoscopic Anderson-Hynes pyeloplasty is both safe,mini-invasive and effective with excellent outcomes.