腹腔镜经膀胱内外2种途径修复儿童输尿管膀胱连接部畸形效果评价

Evaluation on the laparoscopic repair in children with ureterovesical junction malformation through internal or external bladder

目的评价腹腔镜经膀胱内外2种途径修复儿童输尿管膀胱连接部畸形的治疗特点。方法收集2018年2月至2019年8月郑州大学第一附属医院收治的29例儿童肾积水合并输尿管扩张病例,其中男17例,女12例,均经术前检查确诊,输尿管膀胱连接部狭窄15例,输尿管反流12例,单输尿管开口异位2例。21例经气膀胱腹腔镜Cohen术式治疗,单侧17例,双侧4例,包含5例输尿管膨出,输尿管裁剪8例;8例经腹腔镜Lich-Gregoir术式治疗,单侧7例,双侧1例,共裁剪4例,其中1例为重复肾合并上位输尿管髂血管外异位,1例合并双侧隐睾,1例合并单侧隐睾。对于所有输尿管裁剪的患儿给予输尿管内支架管植入,导尿管术后1周拔出,留置输尿管内支架术后6周左右全身麻醉下经膀胱镜拔出。结果29例肾积水合并输尿管扩张患儿均在腹腔镜下完成操作,无中转开放手术,无输血。气膀胱经腹腔镜组21例,单侧平均耗时1.8 h,双侧平均耗时2.8 h,腹腔镜Lich-Gregoir组8例,单侧平均耗时1.7 h,双侧耗时3 h。平均随访9个月(4~20个月),所有患儿术后4个月排尿性膀胱尿道造影(VCUG)复查证实仅有1例出现膀胱输尿管反流Ⅲ级,其余均无膀胱输尿管反流,肾积水程度均减轻。1例双侧Lich-Gregoir患儿术后出现短期尿潴留,留置导尿1周后症状消失,1例气膀胱Cohen组患儿术后出现血尿时间4 d,之后逐渐消失。2组患儿手术时间和术后恢复无明显差异,腹腔镜Lich-Gregoir组术后住院时间略长于气膀胱经腹腔镜组。结论对于输尿管膀胱连接部畸形患儿,经腹腔镜Lich-Gregoir术式适用于输尿管开口异位、输尿管过度扩张、合并腹腔内其他畸形、输尿管迂曲不明显者,气膀胱腹腔镜Cohen术适用于输尿管迂曲明显者、合并输尿管膨出且有排尿困难者。2种术式均安全有效,但在选择时需权衡利弊,择优采用。

Objective To evaluate the therapeutic characteristics of laparoscopic repair in children with ure-terovesical junction malformation through internal or external bladder.Methods From February 2018 to August 2019,29 cases of hydronephrosis combined with ureter expansion treated in the First Affiliated Hospital of Zhengzhou University,with 17 boys and 12 girls confirmed through the preoperative examinations.Inspection results revealed 15 cases of ureteropelvic junction obstruction,12 cases of vesicoureteral reflux,and 2 cases of single ectopic ureter.Totally,21 cases were treated by pneumovesical laparoscopic Cohen means,including 17 unilateral cases and 4 bilateral cases,5 cases of ureterocele,and 8 cases of ureteral clipping.A total of 8 cases were treated by laparoscopic Lich-Gregoir surgical treatment,including 7 unilateral cases and 1 bilateral case.Meanwhile,4 cases of ureteral clipping were performed among them.There was 1 case of duplex kidney with the ectopic upper ureter outside iliac blood vessels,1 case of bilateral cryptorchidism and 1 case of unilateral cryptorchidism.Ureteral stents were implanted for those with ureteral tailoring.The catheters were removed 7 days after operation,and the indwelling ureteral stents were removed by cystoscope under general anesthesia after about 6 weeks.Results All the cases with hydronephrosis and ureteral dilatation were completed in laparoscopic surgery,without open surgery or blood transfusion,21 cases were treated by pneumovesical laparoscopic Cohen means,with the average time being 1.8 hours in unilateral side and 2.8 hours in bilateral sides.At the same time,8 cases were treated by laparoscopic Lich-Gregoir means,with the unilateral average time being 1.7 hours and bilateral time being 3.0 hours.All cases were followed up at an average month of 9(4-20 months),and all children underwent voiding cystourethrography 4 months after the operations.The voiding cystourethrogram(VCUG)of all the cases was confirmed successfully,with only 1 case of vesicoureteral reflux in levelⅢ,and their hydronephrosis were relieved.There was no vesicoureteral reflux in the others.The short-term urinary retention occurred in 1 patient with bilateral ureteral reimplantation in Lich-Gregoir group,and the symptom disappeared after 1 week of indwelling catheterization.Among them,1 patient in Cohen group had hematuria that disappeared gradually for 4 days after surgery.There were no significant differences in operation time and postoperative recovery between the two groups.The length of hospital stay in laparoscopic Lich-Gregoir group was slightly longer than that in pneumovesical laparoscopic Cohen group.Conclusions As for children with ureterovesical junction malformation,laparoscopic Lich-Gregoir surgery is suitable for the ectopia of ureter opening,overexpansion of ureter,and other abdominal malformation complicated and expansive ureter without tortuosity.Pneumovesical laparoscopic Cohen surgery is suitable for hydronephrosis and ureteral expansion with ureterocele,especially with the symptom of dysuria,and ureteral tortuosity obviously.The two ways are safe and reliable,and the advantages and disadvantages should be weighed before being chosen.