离断性肾盂成形术治疗小儿先天性肾积水

为探讨小儿先天性肾积水手术治疗方法，对１９８８～１９９５年间１１７例肾积水进行总结。离断性肾盂成形术１１２例、肾盂ＹＶ成形术４例，盂管部纵切横缝１例；离断性肾盂成形术一期治愈９９例（８８．４％），延期拔肾造瘘管１０例（９．０％），手术失败３例（２．６％）。离断性肾盂成形术设计合理，成功率高，优于其它手术方法，应作为小儿先天性肾积水的首选手术方法。     

腹腔镜辅助下离断式反向裁剪肾盂成形术13例

目的探讨腹腔镜辅助下结合放大镜行离断式肾盂成形术可行性。方法肾盂输尿管连接部狭窄13例采用腹膜后小切口，腹腔镜下游离肾周围，肾盂及输尿管上段，将肾盂反向裁剪，放大镜下行肾盂输尿管吻合。结果13例手术均获成功，手术时间100～180min，平均121min，术中出血量30～100ml，平均70ml。12例随访3～20个月，平均12．3月，肾功能恢复良好，肾积水基本消失。结论腹腔镜下离断式反向裁剪肾盂成形术符合解剖生理，临床可行，值得推广。     

小儿后腹腔镜下离断性肾盂成形术

目的 探讨小儿后腹腔镜下离断性肾盂成形术的临床效果.方法 肾盂输尿管连接部梗阻(UPJO)患儿24例.平均年龄7(3～14)岁.经B超、IVU、CT,磁共振水成像检查临床确诊,轻度肾积水4例、中度10例、重度10例.均采用后腹腔镜下离断性肾盂成形术治疗.结果 24例手术均获成功,无中转开放手术.手术时间平均180(150～200)min,出血量平均60(40～100)ml,术后住院平均7(5～9)d.随访平均14(6～24)个月,吻合口无狭窄,肾积水消失18例,肾积水明显减轻6例.结论 后腹腔镜下离断性肾盂成形术治疗小儿 UPJO安全、有效,可以替代开放手术.     

不置支架管的离断性肾盂成形术治疗先天性肾积水

目的：评价不留置支架管作离断性肾盂成形术。方法：1997年1月～1999年12月19例患儿因肾盂输尿管连接处梗阻在本院行未留置支架管的离断性肾盂整形手术。结果：1例术后出现吻合口尿外渗(5．3％)。术后平均住院6．5d，随访3～6个月，患肾形态功能经B超及利尿性动态肾核素扫描证实有不同程度的提高。结论：我们认为不置管的离断性肾盂整形手术可应用于原发性、无其他并发症的单侧肾盂积水，其较短暂的住院时间及相对低廉的医疗费用及术后较少的并发症可作为一种常规的手术方式。     

Laparoscopic dismembered pyeloplasty of a retrocaval ureter: case report and review of the literature

A retrocaval ureter is a rare entity that has traditionally been treated with open pyeloplasty techniques. In this paper, we describe the successful performance of a laparoscopic dismembered pyeloplasty for a retrocaval ureter and present important technical points. In reviewing the available literature about this technique, the laparoscopic approach should be considered to be first-line treatment for this anatomic anomaly due to the good track record, quick convalescence, and relative technical ease.     

Cure du syndrome de Jonction Pyelo-Ureterale par voie laparoscopique : Résultats et clés du succès au cours de la courbe d'apprentissage

ObjectivesWe report our experience of transperitoneal laparoscopic dismembered pyeloplasties describing our step-by-step surgical technique, and we retrospectively analyze the impact on operative times of the learning curve and long term results.Patients and MethodsFrom January 2005 to January 2009, 27 consecutive (15 male and 12 female) patients, a mean age of 32 years (range 13-66 years) with ureteropelvic junction obstruction were managed by laparoscopic pyeloplasty (LP). In the 27 patients who underwent LP, anastomosis was performed with running sutures and we performed intraoperative antegrade stenting.ResultsMean operative time was 175.1 minutes, and mean hospital stay was 3.4 days. A crossing vessel was found in 50% and 5 patients needed pyelolithotomy for concomitant stone disease. There were no major complications. The mean hospital stay was 3, 46 days (range : 2 ?17). Mean follow-up was 15 months (range 6–50 month) with 100% free of obstruction on radiologic imaging.ConclusionsLaparoscopic pyeloplasty is a safe and effective management option for UPJO with excellent short to medium-term results. The antegrade placement of the ureteral stent and the ureteropelvic anastomosis with two running sutures seemed to be tips of success in reducing operative times. Laparoscopic pyeloplasty has now superseded open surgery in our center as the gold standard surgical management for UPJO.     

后腹腔镜与开放离断肾盂成形术的临床效果比较

目的：通过与开放离断肾盂成形术的效果比较,评价后腹腔镜离断肾盂成形术的临床价值。方法：回顾性分析的腹腔镜离断肾盂成形术56例（A组）及开放离断肾盂成形术10例（B组）的临床资料,就两组手术时间、术中出血量、术后肠道功能恢复时间、术后止疼药用量、术后住院天数,并发症和成功率等指标进行比较。根据数据类型选用X^2检验,成组t检验或Mann-Whitey U检验。结果：A组在术中出血量,术后肠道功能恢复时间,术后止产药用量。术后住院天数方面优于B组,差异有统计学意义（P〈0.01）;并发症和成功率与B组相当,差异无统计学意义（P〉0.05）。结论：后腹腔镜离断肾盂成形术是一种治疗肾盂输尿管连接部梗阻的微阳、安全、有效的方法,但存在较明显的学习期。熟练后可在较短时间内完成手术。     

Laparoscopic Versus Open Pyeloplasty: Comparison of Two Surgical Approaches- A Single Centre Experience of Three Years

UPJO causes hydronephrosis and progressive renal impairment may ensue if left uncorrected. Open pyeloplasty remains the standard against which new technique must be compared. We analyzed the comparison of Laparoscopic and open pyeloplasty in a randomized prospective trial. A prospective randomized study was done from January 2004 to January 2007 in which a total of 28 Laparoscopic and 34 open pyeloplasty were done. All laparoscopic pyeloplasties were performed transperitoneally. Standard open Anderson Hynes pyeloplasty, spiral flap or VY plasty was done depending on anatomic consideration. Patients were followed with DTPA scan at 3 months and IVP at 6 months. Perioperative parameters including operative time, analgesic use, hospital stay, and complication and success rates were compared. Mean total operative time with stent placement in LP group was 244.2 min (188–300 min) compared to 122 min (100–140 min) in open group. Compared to open pyeloplasty the post operative diclofenac requirement was significantly less in LP group (mean107.14 mg) and open group required mean of (682.35 mg) The duration of analgesic requirement was also significantly less in LP group. The post operative hospital stay in LP was mean 8.29 days (7–11) and was significantly less than open group (mean 3.14 Days (2–7 days). Open pyeloplasty has been the gold standard for UPJO repair and achieves success rates exceeding 90%. Laparoscopic pyeloplasty provides a minimally invasive alternative to repair UPJO and has developed world wide as the first minimally option to match success rate of open pyeloplasty. Its potential advantages including less post op pain, shorter hospital stay an improved cosmesis has been proved in some comparative series. The only disadvantage seems to be longer operative time. LP has a minimal level of morbidity and short hospital stay compared to open approach Although Laparoscopic pyeloplasty has the disadvantages of longer operative time and requires significant skill of intracorporeal knotting but it is here to stay and represents an emerging standard of care.     

后腹腔镜下肾盂成形术在小儿肾积水手术中的应用

目的总结后腹腔镜下离断式肾盂成形术治疗小儿肾积水的经验。方法2003年12月至2005年9月收治肾积水患儿21例。男15例,女6例,平均年龄6．3岁。左侧14例,右侧7例。B超、IVU、放射性核素肾图检查均提示梗阻位于肾盂输尿管连接处。均采用后腹腔镜下离断式肾盂成形术。结果21例患儿中手术成功19例,中转开放手术2例。手术时间150～230 min,平均185 min。术中平均出血量＜20ml。术后3个月随访B超或放射性核素肾图,肾积水有明显改善。结论后腹腔镜下肾盂成形术有望成为治疗小儿肾积水的可靠方法,远期效果有待进一步随访。     

Da Vinci robot assisted Anderson-Hynes dismembered pyeloplasty: technique and 1 year follow-up

In experienced hands, laparoscopic pyeloplasty is an effective alternative treatment for symptomatic ureteropelvic junction obstruction (UPJO). Although laparoscopic surgery can clearly benefit patients, laparoscopic pyeloplasty using conventional instrumentation is complex. The purpose of this report is to evaluate the feasibility of robot assisted laparoscopic surgery. Eleven pyeloplasties for UPJO were performed via a laparoscopic transperitoneal approach exclusively with the da Vinci Surgical System. The mean procedure time was 197 min (range 110–310 min). All operations were completed laparoscopically with no intraoperative complications and negligible blood loss. All patients recovered rapidly after surgery with excellent functional results at the 1 year follow-up. Our initial experience suggests that robot assisted Anderson-Hynes pyeloplasty is a safe and effective alternative to conventional laparoscopic surgery. In our opinion, robot assisted surgery will allow urologists to perform complex procedures with greater precision, confidence, and better results, as well as enable them to adapt the whole spectrum of laparoscopic procedures to their field.     

Patch grafting the renal pelvis and ureteropelvic junction

Summary Lyophilized dura mater (Lyodura) and autogenous free peritoneum were compared in the replacement of the partially resected renal pelvis and ureteropelvic junction (UPJ) in the pig. The Lyodura and peritoneum grafts were both progressively resorbed, and replaced by fibroblasts which formed a mature scar lined by transitional epithelium, but without smooth muscle regeneration. Lyodura was found to be superior to free peritoneum with a longer time before resorption of the graft, less intense inflammatory reaction, absence of metaplastic bone formation, less risk of urine leak and greater ease of surgical manipulation.Supported by the University Urological Research Foundation     

Laparoscopic Pyeloplasty in the Animal Model

Purpose:

Laparoscopic pyeloplasty has been associated with long operative times. This study proposed to evaluate the feasibility of two different laparoscopic techniques for the performance of pyeloplasty repair of secondary ureteropelvic junction (UPJ) obstruction.

Materials and Methods:

Sixteen female Yucatan mini-pigs underwent general anesthesia for cystoscopy, retrograde pyelography, urine culture and a baseline renal scan. Unilateral UPJ obstruction was created by ligating the UPJ over a 5F catheter. Six weeks later a laparoscopic pyeloplasty was performed utilizing an intracorporeal suturing technique and the Lapra-Ty suture clip or the Endostitch device with intracorporeal knot tying. Four control animals underwent only cystoscopy and in/out ureteral catheterization. In the study animals the ureteral stent was maintained for six weeks and at six weeks, three months and six months post-pyeloplasty the animals underwent the previously mentioned studies. At six months post-pyeloplasty the animals were euthanized and the UPJ was calibrated. Histopathology was obtained on the ureter below the anastomosis, at the anastomosis, above the anastomosis and on a renal biopsy.

Results:

All planned laparoscopic pyeloplasties were completed. However, the stricture model was too severe in that most animals developed 40-45% decrease in renal function in the kidney following ipsilateral UPJ ligation. There was no significant difference between the two pyeloplasty techniques with respect to operative time to perform the pyeloplasty (mean of 40 minutes), post-pyeloplasty ureteral caliber (7.5-8.0 F), serum creatinine or healing scores at, above or below the anastomosis.

Conclusion:

Laparoscopic pyeloplasty can be performed equally successfully with the Endostitch device and intracorporeal knot tying or with the intracorporeal suturing technique and Lapra-Ty clips. The resultant pyeloplasty is also equivalent for the two techniques.     

改良腹腔镜肾盂成形术

目的探讨一种改良的腹腔镜肾盂成形术.方法肾盂输尿管连接部梗阻32例,经腹腔镜下游离肾盂及部分输尿管上段,然后扩大经肾盂输尿管连接部的切口至2.5～3 cm,采用开放手术方式进行肾盂输尿管成形操作.结果32例手术均获成功.术中证实肾下极异位血管压迫1例,原发管腔狭窄31例.手术时间40～70 min,平均52 min;术中出血量20～30 ml,平均23 ml.无手术并发症.27例随访7～15个月,平均9.6月,腰部胀痛消失,静脉肾盂造影(intravenous pyelography,IVP)检查吻合口均无梗阻,B超肾集合系统分离术前2.0～4.2 cm,平均2.8 cm,术后17例降至1.0～2.3 cm,平均1.5 cm,余10例无分离.结论改良的腹腔镜肾盂成形术简化了腹腔镜操作,缩短了手术时间,值得临床推广应用.     

肾盂输尿管连接部梗阻的开放手术治疗

目的 探讨肾盂输尿管连接部梗阻(UPJO)的临床特点和诊治方法.方法 UPJO患者222例.男155例,女67例.平均年龄29(13～75)岁.病程6个月～4.5年,平均27个月.临床表现为腰腹部胀痛173例、尿路感染19例、腹部包块12例、肉眼血尿7例,体检B超检查发现11例.其中肾盂输尿管连接部狭窄185例、肾盂输尿管高位连接18例、纤维条索或迷走血管压迫19例.患者均行B超检查,提示不同程度肾积水;IVU检查215例,其中肾积水轻度29例、中度115例、重度61例,患肾不显影10例;逆行肾盂造影检查37例及CT尿路造影检查19例,均提示肾盂输尿管连接部狭窄.222例均手术,其中离断性肾盂成形术191例、纤维条索或迷走血管切断19例、患肾无功能行肾切除12例.结果 191例行离断性肾盂成形术者随访6个月～8年,平均38个月,B超及IVU检查提示患侧肾实质明显增厚,尿路通畅.肾积水完全消失127例,轻度肾积水58例、中度积水6例;患者腰腹胀痛,腹部包块,尿路感染及肉眼血尿症状消失;7例术前SCr为146～203μmol/L者术后复查均<133μmol/L.结论 离断性肾盂成形术为UPJO病例的标准术式,疗效确切.     

腹腔镜辅助腹部小切口肾盂成形术(附38例报告)

目的:探讨腹腔镜辅助技术应用于小儿肾盂输尿管连接部狭窄(UPJO)的方法。方法:采用腹腔镜辅助小切口经腹腔进行离断性肾盂成形术。结果:手术均获成功。手术时间50~80m in,平均65m in;术中出血量20~50m l,平均35m l;术中、术后均无输血,未发生明显的并发症。结论:腹腔镜辅助小切口离断性肾盂成形术具有损伤小、术后康复快和住院时间短等优点,有良好的临床应用前景。     

小儿腹腔镜肾盂成形术的护理

目的探讨小儿后腹腔镜肾盂成形术的护理要点。方法对15例肾盂输尿管连接部梗阻的患儿行腹腔镜肾盂成形术,观察患儿的术前准备、术后护理及随访的手术效果。结果所有手术均取得成功,术中无并发症发生,患儿均治愈出院。随访5-12个月,超声示患儿肾积水均不同程度减轻或消失。结论结合小儿的生理特点,术前对患儿进行耐心细致的心理护理及充分的准备、术后做好饮食指导、管道护理及并发症的观察是保证手术疗效的关键。     

再行腹腔镜肾脏手术的可行性

目的：探讨既往有肾脏手术史者再行腹腔镜肾脏手术的可行性。方法：4例肾积水患者均有经腰切口肾脏手术史，其中2例经腹入路行腹腔镜肾切除，1例经腹膜后入路行腹腔镜肾切除，1例经腹膜后入路行腹腔镜肾盂成形术。结果：4例腹腔镜手术均获得成功，无术中及术后并发症发生。经腹入路手术时间平均2．5h，术中出血量约50ml，经腹膜后入路腹腔镜肾切除术手术时间3h，腹腔镜肾盂成形术手术时间4．5h，出血量80～100ml。结论：对于既往有肾脏手术史者，虽然因瘢痕粘连增加了手术难度，但随着腹腔镜手术经验的积累和手术技能的提高，再行腹腔镜肾脏手术是可行的。     

后腹腔镜与开放肾盂成形手术的疗效比较

目的比较后腹腔镜与开放肾盂成形术的疗效。方法后腹腔镜手术于全麻下取健侧卧位，腋中线髂棘上、腋前线、腋后线与肋缘交界线分别置入trocar，必要时髂嵴水平腋前线加置trocar。腰大肌内侧剪开肾脂肪囊并找到输尿管，锐性分离输尿管旁组织显露肾盂，弧形裁剪多余肾盂，切除狭窄段输尿管，可吸收线吻合。肾盂输尿管并放置双J输尿管导管。开放性肾盂成形术于硬膜外或全麻下取健侧卧位，第12肋下腰部切口，腰大肌前方推开腹膜找到肾脏及输尿管。充分显露肾盂输尿管连接部，离肾实质约2cm处环形切断肾盂，切除狭窄段输尿管，可吸收线吻合肾盂输尿管并放置双J输尿管导管。结果后腹腔镜组手术时间（156．9±69．2）min明显长于开放组（111．9±78．1）min（t=2．514，P=0．014），术中出血量35（20～70）ml、术后止痛药用量（0．7±0．3）d、术后住院时间（8．5±6．1）d优于开放组110（60～175）ml、（1．3±0．5）d、（15．5±10．8）d（t=7．502，P=0．000；t=-5．842，P=0．000；t=-3．193，P=0．002）。后腹腔镜组术后尿漏（3例vs3例）、切口感染（0例vs1例）、肾盂输尿管连接部再狭窄（1例vs0例）及肾积水改善与开放手术组无统计学意义（X^2=0．000，P=1．000；X^2=0．000，P=1．000;X^2=0．000，P=1．000；X^2=5．192，P=0．182）。结论后腹腔镜肾盂成形术与开放肾盂成形术相比，出血少、术后恢复快、术后近期疗效相当。     

腹腔镜手术治疗肾盂输尿管连接处梗阻(附26例报告)

目的:探讨腹腔镜离断肾盂成形术的操作方法和临床效果。方法:26例诊断为肾盂输尿管连接部梗阻(uretero-pelvic junction obstruction,UPJO)患者经腹腔途径行腹腔镜肾盂成形术。结果:25例手术成功,手术时间70~210min,平均126min;出血40~100ml,平均60ml;平均住院8d。术后6~12个月经B超、IVP检查,手术侧肾积水减轻或消失,肾盂输尿管连接部(ureteropelvic junction,UPJ)吻合口无狭窄,肾盂、输尿管排尿功能良好。结论:腹腔镜离断肾盂成形术创伤小,患者恢复快,安全可靠,是治疗UPJO的有效微创手术之一,值得临床推广应用。     

腹腔镜与开放性离断式肾盂成形术的疗效比较

目的比较腹腔镜与开放性离断式肾盂成形术治疗肾盂输尿管连接部梗阻（UPJO）的手术疗效。方法采用经腹腔途径腹腔镜下离断式肾盂成形术38例（A组）。男21例，女17例。年龄8～67岁，平均34岁。病变位于左侧23例，右侧15例。重度肾积水21例，中度17例。经腹膜后开放性离断式肾盂成形术40例（B组）。男18例，女22例。年龄9～63岁，平均32岁。左侧26例，右侧14例。重度肾积水22例，中度18例。对2组的手术时间、术中出血量、术后恢复、临床疗效及并发症进行比较研究。结果A组手术均获成功，无中转开放手术者，手术时间（137．1±30．5）min，术中出血量（143．8±45．2）ml，术后止痛药应用时间（O．8±0．2）d，术后住院时间（7．1±1．2）d，恢复工作时间（24．3±5．6）d。术后发生漏尿1例，经B超引导下肾盂穿刺造瘘3d后痊愈。术后随访6～36个月，吻合口无狭窄，肾积水减轻，中度肾积水12例、轻度积水15例、肾积水消失11例。B组手术时间（135．2±34．6）min，术中出血量（245．3±80．9）ml，术后止痛药应用时间（1．5±0．5）d，术后住院时间（10．3±2．6）d，恢复工作时间为（43．2±11．4）d。发生漏尿2例，分别引流5d和8d治愈；切口感染2例，经换药加抗生素治疗2周后好转；1例腹膜后血肿形成者经再次手术清除腹膜后血肿、止血后于术后第21天出院。术后随访6～36个月，1例吻合口狭窄伴重度积水，其余肾积水减轻（中度肾积水9例、轻度积水16例、肾积水消失14例）。2组手术时间比较差异无统计学意义（P＞0．05），术中出血量、术后止痛药应用时间、术后住院时间、恢复工作时间比较差异均有统计学意义（P＜0．01）。结论腹腔镜与开放性离断式肾盂成形术相比，手术时间相当，前者出血少、创伤小、痛苦轻、并发症少、术后恢复快，术后长期疗效相当。