二次肾盂成形术在复发性肾盂输尿管连接部梗阻中的研究进展

Advance in re-do pyeloplasty for the management of recurrent ureteropelvic junction obstruction after surgery

肾盂输尿管连接部梗阻(ureteropelvic junction obstruction,UPJO)是一种常见的引起肾积水的上尿路梗阻性疾病。开放肾盂成形术是UPJO治疗的标准术式,但目前已逐渐被腹腔镜肾盂成形术等微创术式取代,且其成功率与开放肾盂成形术接近[1-2]。以往研究报道,肾盂成形术(包括开放和腹腔镜)有2.5%~10%的失败率[3-5]。

Ureteropelvic junction obstruction(UPJO)is characterized by decreased flow of urine down the ureter and increased fluid pressure inside the kidney.Open pyeloplasty had been regarded as the standard management of UPJO for a long time.Laparoscopic pyeloplasty reports high success rates,for both retroperitoneal and transperitoneal approaches,which are comparable to those of open pyeloplasty.However,open and laparoscopic pyeloplasty have yielded disappointing failure rates of 2.5%-10%.The main causes for recurrent UPJO are severe peripelvic and periureteric fibrosis due to urinary extravasation,ureteral ischemia,and inadequate hemostasis.In addition,failing to diagnose lower pole crossing vessels before or during the primary procedure is also responsible for recurrent UPJO.In addition,poor preoperative split renal function,hydronephrosis,presence of renal stones,patient age,diabetes,prior endopyelotomy history,and retrograde pyelography history were considered as predictors of pyeloplasty failure.The failure is usually defined by persistent pain,persistent radiographic obstruction(infection or stones),continued decline in split renal function,or a combination of the above.And the failure of pyeloplasty often occurs in the first 2 years after the surgery.The available options for managing recurrent UPJO with a salvageable renal unit include endopyelotomy,re-do pyeloplasty,stent implantation,percutaneous nephrostomy,ureterocalicostomy,and nephrectomy.Re-do pyeloplasty has such merits as high successful rates and rare complications,compared with endopyelotomy or ureterocalicostomy.And some investigators think that re-do pyeloplasty should be regarded as the gold standard for secondary therapy if feasible.Open pyeloplasty can enlarge the operating field,facilitate the exposure of the ureteropelvic junction,reduce the difficulty of operation,and thus reduce the occurrence of complications.There are no significant differences among the success rates of re-do pyeloplasty under open approach,traditional laparoscopy and robot-assisted laparoscopy,according to previous reports.However,traditional laparoscopic and robot-assisted pyeloplasty give advantages of cosmetology,small trauma,less postoperative pain,speedy recovery and shorter hospitalization,fewer complications and lower recurrent rates.If the primary pyeloplasty is an open operation in retroperitoneal approach,the traditional laparoscopic and robotic operation with retroperitoneal approach should be considered for secondary repair.The cause of recurrent UPJO should be evaluated before surgery and identified intraoperatively to minimize the possibility of recurrence.