改良“双瓣法”肾盂成形术与传统肾盂成形术治疗儿童特殊类型肾积水的效果比较

Comparison of modified"double flaps"pyeloplasty and traditional pyeloplasty in the treatment of special types of hydronephrosis in children

目的比较改良"双瓣法"肾盂成形术与传统肾盂成形术治疗儿童特殊类型肾积水(伴小肾盂或上段输尿管狭窄长度较长)的效果。方法回顾性分析解放军总医院第七医学中心2018年6月至2019年6月采用手术治疗的39例特殊类型肾积水患儿的临床资料。男33例,女6例;中位年龄为12.0(4.5,63.5)个月。左侧22例,右侧17例。患儿存在血尿、腰痛或反复泌尿系感染等症状,术前影像学检查显示存在输尿管梗阻,肾盂前后径<2.5cm(小肾盂)或上段输尿管狭窄长度为2.0~4.0cm。39例中19例采用改良"双瓣法"肾盂成形术,为改良"双瓣法"手术组;20例采用传统离断式Anderson-Hynes肾盂成形术,为传统手术组。改良"双瓣法"手术组术中将肾盂裁剪形成上下两瓣,下瓣与劈开的输尿管吻合,上瓣进行覆盖,从而实现输尿管长度与口径部分延长。两组患者中位年龄[12.0(6.0,44.0)个月与12.0(4.8,62.8)个月]、术前肾盂前后径[(2.8±0.8)cm与(2.6±0.6)cm]、术前患侧分肾功能[(36.7±5.1)%与(36.0±6.8)%]的差异均无统计学意义(P>0.05)。分析两组手术相关指标及术后随访情况,比较两组疗效。结果本研究39例手术均顺利完成,无中转开腹手术。改良"双瓣法"手术组和传统手术组手术时间分别为(142.6±9.6)min和(124.5±8.6)min,术中吻合时间分别为(56.1±7.2)min和(47.6±4.8)min,两组差异均有统计学意义(P<0.05)。39例均获随访,术后随访时间(27.7±2.5)个月。改良"双瓣法"手术组术后2例发热,为泌尿系感染,予抗生素治疗后好转。传统手术组出现2例发热,为泌尿系感染,予抗生素治疗后好转;另2例术后1年余出现腰痛症状,B超检查发现患儿肾积水逐渐增多,予行改良"双瓣法"肾盂成形术后好转。改良"双瓣法"手术组与传统手术组并发症发生率(2/19与4/20)及短期手术成功率(19/19与18/20)差异均无统计学意义(P>0.05)。结论改良"双瓣法"肾盂成形术治疗肾积水的手术时间和术中吻合时间相对传统方式较长,但在伴有小肾盂或上段输尿管狭窄长度较长的特殊类型肾积水患者中,对于减少并发症有一定的应用价值。

Objective To compare the efficacy of modified"double flaps"pyeloplasty and traditional dismembered pyeloplasty in the treatment of special types of hydronephrosis with small pelvis and long proximal ureteral stricture in children.Methods The data of 39 children with special types of hydronephrosis treated in Seventh Medical Center,General Hospital of PLA from June 2018 to June 2019 were retrospectively analyzed.Among them,33 were boys and 6 were girls.The median age of the patients was 12.0(4.5,63.5)months.Nine of them had left hydronephrosis and four children had right hydronephrosis.These patients with small pelvis existed the characteristics that the anteroposterior diameter of pelvis was smaller than 2.5 cm and these patients existed the symptom of hematuria,flank pain or recurrent urinary tract infection with the imaging revealing ureteral obstruction.The length of proximal ureteral stenosis ranged from 2.0 to 4.0 cm.Among 39 cases,19 cases were operated with modified"double flaps"pyeloplasty,which was the modified"double flaps"pyeloplasty group.20 cases were operated with traditional Anderson-Hynes pyeloplasty,which was traditional pyeloplasty group.The technique of modified"double flaps"pyeloplasty mainly included that the renal pelvis was cut into double flaps,the inferior flap was anastomosed with the spatulated ureter and the superior was covered,so that the length and caliber of the ureter were partial extended.The median age of two groups were 12.0(6.0,44.0)months and 12.0(4.8,62.8)months respectively,the anterior and posterior diameter of renal pelvis were(2.8±0.8)cm and(2.6±0.6)cm respectively,and split renal function were(36.7±5.1)%and(36.0±6.8)%respectively.There were no statistically significant differences in above parameters between the two groups(P>0.05).The clinical efficacy of the two groups were compared by collecting and comparing the operation related data and postoperative follow-up data.ResultsThe operation of 39 children in this study was successfully completed without conversion to open surgery.The operation time of"double flap"pyeloplasty group and traditional pyeloplasty group were(142.6±9.6)min and(124.5±8.6)min respectively,and the intraoperative anastomosis time were(56.1±7.2)min and(47.6±4.8)min respectively.There were significant difference in operation time and intraoperative anastomosis time between the two groups(P<0.05).Thirty-nine children were followed up normally without loss.The mean follow-up time was(27.7±2.5)months after surgery.In the"double flaps"pyeloplasty group,2 cases suffered with fever who were diagnosed as urinary tract infection and improved after antibiotic treatment.In the traditional pyeloplasty group,2 cases suffered with fever who were diagnosed as urinary tract infection and improved after antibiotic treatment.Two children had flank pain during follow-up to more than one year and the examination revealed that the anteroposterior diameter of the renal pelvis gradually increased.So surgery were performed again and the two children recovered.There were no significant differences in complication rate(2/19 and 4/20)and short-term surgical success rate(19/19 and 18/20)between the two groups(P>0.05).ConclusionsThe operation time and anastomosis time of the modified"double flap"technique for treating hydronephrosis are longer than those of the traditional method.But in the treatment of special types of hydronephrosis with small renal pelvis or long proximal ureteral stricture,it may have application prospects in reducing complications.