腹腔镜气膀胱改良乳头式输尿管膀胱再植术的临床研究

Pneumovesicoscopic modified orthotopic nipple ureteral reimplantation

目的介绍腹腔镜气膀胱改良乳头式输尿管膀胱再植术的手术方法,通过与开放手术和Cohen术的比较探讨这种术式的安全性、可行性。方法回顾性分析山东大学齐鲁医院小儿外科2010年1月至2019年3月实施腹腔镜气膀胱改良乳头式输尿管膀胱再植术的病例资料,包括临床效果、膀胱造影检查结果、并发症等,与开放手术和Cohen术式对比,分析优缺点及应用前景。共收集到179例患儿资料,分三组进行比较。开放手术组63例,其中男44例,女19例。年龄<6个月32例,6个月至1岁23例,>1岁8例。左侧30例,右侧17例,双侧16例。输尿管末端狭窄58例,膀胱输尿管反流4例,狭窄伴反流1例,合并肾积水53例,泌尿系统感染33例,输尿管开口异位7例,输尿管末端囊肿3例。气膀胱Cohen组55例,其中男38例,女17例,年龄<6个月10例,6个月至1岁5例,>1岁40例。左侧27例,右侧13例,双侧15例。输尿管末端狭窄50例,膀胱输尿管反流3例,狭窄伴反流2例,合并肾积水44例,出现泌尿系统感染症状38例,输尿管末端囊肿3例,输尿管开口异位2例。气膀胱改良乳头式再植组61例,其中男36例,女25例,年龄<6个月22例,6个月至1岁28例,>1岁11例。左侧33例,右侧19例,双侧9例。输尿管末端狭窄50例,膀胱输尿管反流7例,狭窄伴反流4例;均出现肾积水,出现泌尿系统感染症状56例,输尿管末端盲端1例,输尿管开口异位不与膀胱相通2例,开口膀胱憩室1例。结果三组均无死亡病例,气膀胱Cohen组有2例中转开放,气膀胱改良乳头式再植均在腹腔镜下顺利完成;气膀胱Cohen组与气膀胱改良乳头式再植组之间,手术时间[(97.2±49.4)min比(77.4±37.0)min,P>0.05]、出血量[(3.7±1.5)ml比(2.9±1.8)ml,P>0.05]及住院时间[(6.8±2.3)d比(6.2±1.3)d,P>0.05]的差异均无统计学意义,抗反流效果相当,术后未见严重并发症,肾盂及输尿管积水均有明显减轻。气膀胱的两组手术时间略长于开放手术(P<0.05),血量明显减少(P<0.05),住院时间明显缩短(P<0.05),并发症少。结论腹腔镜气膀胱改良乳头式输尿管膀胱再植术符合生理特点,抗反流效果可靠,是治疗输尿管末端狭窄以及反流引起巨输尿管的一种应用前景广阔的术式。

Objective To introduce pneumovesicoscopic orthotopic modified nipple ureteral reimplantation for megaureter and to compare its safety,feasibility and application with open or pneumovesicoscopic Cohen cross-trigonal ureteral reimplantation.Methods From January 2010 to March 2019,retrospective analysis was performed for clinical data of retrograde cystography and complications during pneumovesicoscopic orthotopic modified nipple ureteral reimplantation.The potential advantages and disadvantages were compared with open or pneumovesicoscopic Cohen cross-trigonal ureteral reimplantation.One hundred and seventy-nine cases were reviewed and analyzed in 3 groups.In open group,there were 44 boys and 19 girls.The age was under 6 months(n=32),6 months to 1 year(n=23)and older than 1 year(n=8).The sideness was left(n=30),right(n=17)and bilateral(n=16).There were primary obstructive megaureter(POM,n=58),vesicoureteral reflux(VUR,n=4)and POM&VUR(n=1).And the outcomes were hydronephrosis(n=53),infection(n=33),ectopic ureteral orifice(n=7)and ureter cyst(n=3);In pneumovesicoscopic Cohen group,there were 38 boys and 17 girls.The age was under 6 months(n=10),6 months to 1 year(n=5)and above 1 year(n=40).The sideness was left(n=27),right(n=13)and bilateral(n=15).There were POM(n=50),VUR(n=3)and POM&VUR(n=2).And the outcomes were hydronephrosis(n=44),infection(n=38),ectopic ureteral orifice(n=2)and ureter cyst(n=3);In pneumovesicoscopic modified nipple group,there were 36 boys and 25 girls.The age was under 6 months(n=22),6 months to 1 year(n=28)and older than 1 year(n=11).The sideness was left(n=33),right(n=19)and bilateral(n=9).There were POM(n=50),VUR(n=7)and POM&VUR(n=4).And the outcomes were hydronephrosis(n=61),infection(n=56),ectopic ureteral orifice(n=3)and ureteral caecum(n=1).Results All cases of ureteral reimplantation were performed successfully.Pneumovesicoscopic operations were performed with only 2 cases of Cohen procedure converting into open surgery.No significant differences existed between pneumovesicoscopic Cohen procedure and pneumovesicoscopic orthotopic modified nipple procedure in operative duration(97.2±49.4 vs 77.4±37.0 min,P>0.05),volume of blood loss(3.7±1.5 vs 2.9±1.8 ml,P>0.05)and hospitalization stay(6.8±2.3 vs 6.2±1.3 days,P>0.05)with an equivalent postoperative antireflux efficacy and without severe complications.As compared with open surgery,pneumovesicoscopy offered longer operative duration(P<0.05),less volume of blood loss(P<0.05),shorter hospitalization stay(P<0.05)and fewer complications.Conclusions Pneumovesicoscopic orthotopic modified nipple ureteral reimplantation is an anatomic orthotopic ureteral reimplantation with remarkable antireflux and clinical efficacies.It is an alternative treatment for refluxing and obstructed megaureter.