气膀胱腹腔镜Cohen术与Politano-Leadbetter术在儿童输尿管膀胱再植中的疗效比较

Efficacy comparison between pneumovesicoscopic Cohen and Politano-Leadbetter technique in transvesicoscopic ureteral reimplantation in children

目的比较气膀胱腹腔镜Cohen术与Politano-Leadbetter术治疗儿童膀胱输尿管连接部梗阻(VUJO)的手术疗效。方法回顾性研究。收集2017年1月至2021年12月安徽省儿童医院泌尿外科行手术治疗的48例VUJO患儿病例资料,按时间先后分为气膀胱腹腔镜Cohen术式组(C组)(28例)和气膀胱腹腔镜Politano-Leadbetter术式组(P组)(20例)。比较2组患儿手术时间、术后保留导尿管时间、血尿时间、住院时间及手术前后肾积水、输尿管扩张、肾功能改善情况等相关资料。计数资料采用χ^(2)检验或Fisher's确切概率法比较,计量资料采用t检验比较。结果48例患儿均由同一手术医师顺利完成手术,无中转开放手术,C组6例巨输尿管患儿行输尿管裁剪,P组2例肾盏输尿管结石患儿术后无残留。C组与P组手术时间比较[(136.5±35.4)min比(165.8±33.2)min],差异有统计学意义(t=-3.154,P=0.002)。术后随访(10.3±2.6)个月,C组和P组术后2个月内分别有8例、6例出现尿路感染,均予抗感染保守治疗后好转,拔除D-J管后感染控制,术后6个月复查静脉肾盂造影显示输尿管走行通畅。C组术后6个月复查超声肾盂前后径较术前明显减小[(1.62±0.54)cm比(2.55±1.24)cm,t=-5.027,P=0.001];输尿管最大直径较术前明显减小[(0.95±0.27)cm比(1.51±0.52)cm,t=-8.495,P<0.001];肾皮质厚度较术前明显增加[(1.47±0.25)cm比(0.86±0.46)cm,t=2.028,P=0.004];利尿肾图显示分肾功能较术前明显提高[(46.27±2.16)%比(41.83±3.04)%,t=1.647,P=0.030]。P组术后6个月复查超声肾盂前后径较术前明显较小[(1.48±0.82)cm比(2.68±1.41)cm,t=-2.740,P=0.003];输尿管最大直径较术前明显减小[(1.05±0.46)cm比(1.36±0.27)cm,t=-1.635,P=0.040];肾皮质厚度较术前增加[(1.38±0.33)cm比(0.74±0.39)cm,t=9.073,P<0.001];利尿肾图显示分肾功能较术前明显提高[(45.18±3.35)%比(39.55±2.49)%,t=1.277,P=0.030]。Politano-Leadbetter术较Cohen术后肾盂前后径恢复更好[(1.48±0.82)cm比(1.62±0.54)cm,t=-1.748,P=0.030]。结论气膀胱腹腔镜Politano-Leadbetter术建立了较长的黏膜下隧道,不改变输尿管走形及开口位置,治疗VUJO合并肾盏、输尿管结石效果确切,术后肾积水恢复较Cohen术更好,但手术难度大、时间长,手术医师可根据自身经验选择合理术式。

Objective To compare the efficacy of pneumovesicoscopic Cohen and Politano-Leadbetter procedures in the treatment of vesicoureteral junction obstruction(VUJO)in children.Methods The data of 48 children with VUJO who underwent operations in the Department of Urology,Anhui Provincial Children's Hospital from January 2017 to December 2021 were retrospectively analyzed.According to the operation time,the patients were divided into the pneumovesicoscopic Cohen group(group C)(28 cases)and pneumovesicoscopic Politano-Leadbetter group(group P)(20 cases).The operation time,postoperative urinary catheterization duration,hematuria duration,hospitalization time,and the improvement of hydronephrosis,ureteral dilatation,and renal function after surgery were compared between the 2 groups.The enumeration data were compared by the χ^(2) test or Fisher's exact probability method.The measurement data were compared by the t-test.Results All the 48 children were successfully operated on by the same surgeon,without conversion to open surgery.Six cases in the group C had a megaureter and underwent ureter tailoring.Two cases in the group P had calyceal and ureteral calculi,which were all removed after operation.There was a statistically significant difference in the operation time between group C and group P[(136.5±35.4)min vs.(165.8±33.2)min,t=-3.154,P=0.002].The patients were followed up for(10.3±2.6)months after operation.There were 8 cases and 6 cases of urinary tract infection in group C and group P within 2 months after the operation,respectively.They all improved after conservative anti-infection treatment,and the infection was well controlled after removal of the D-J tube.Besides,their intravenous pyelography 6 months after operation showed that the ureter was unobstructed.In group C,6 months after the operation,the anterior and posterior diameters of the renal pelvis[(1.62±0.54)cm vs.(2.55±1.24)cm,t=-5.027,P=0.001]and the largest diameter of the ureter[(0.95±0.27)cm vs.(1.51±0.52)cm,t=-8.495,P<0.001]were significantly decreased,compared with those before operation.However,the renal cortex thickness was increased significantly[(1.47±0.25)cm vs.(0.86±0.46)cm,t=2.028,P=0.004],and the renal function(as indicated by the diuretic nephrogram)was notably improved[(46.27±2.16)%vs.(41.83±3.04)%,t=1.647,P=0.030].In group P,6 months after operation,the anterior and posterior diameters of the renal pelvis[(1.48±0.82)cm vs.(2.68±1.41)cm,t=-2.740,P=0.003]and the maximum diameter of the ureter[(1.05±0.46)cm vs.(1.36±0.27)cm,t=-1.635,P=0.040]were significantly smaller than those before operation.However,the renal cortical thickness was increased[(1.38±0.33)cm vs.(0.74±0.39)cm,t=9.073,P<0.001],and the renal function(as indicated by the diuretic nephrogram)was significantly improved[(45.18±3.35)%vs.(39.55±2.49)%,t=1.277,P=0.030].Politano-Leadbetter surgery outperformed Cohen surgery in promoting the recovery of the anterior and posterior diameters of the renal pelvis[(1.48±0.82)cm vs.(1.62±0.54)cm,t=-1.748,P=0.030].Conclusions Pneumovesicoscopic Politano-Leadbetter operation can establish a longer submucosal tunnel without changing the ureteral shape and opening position,having good effects in treating VUJO combined with calyceal and ureteral calculi.Pneumovesicoscopic Politano-Leadbetter operation can also better improve postoperative recovery from hydronephrosis than Cohen operation.However,the pneumovesicoscopic Politano-Leadbetter operation is more difficult and requires longer time.The surgeon should choose a reasonable operation based on his/her own experience.