腹腔镜离断式肾盂输尿管成形术治疗UPJO肾积水230例经验总结

目的:探讨腹腔镜离断式肾盂输尿管成形术治疗肾盂输尿管连接部梗阻(UPJO)肾积水的临床疗效及总结手术经验。方法:回顾性分析我院2012年10月～2018年10月收治的230例UPJO患者的临床资料。其中先天性UPJO 180例,获得性UPJO 50例,含肾盂输尿管连接部(UPJ)成形术后狭窄10例,输尿管镜下钬激光碎石或经皮肾镜取石术后狭窄30例及球囊扩张术后狭窄10例。采用经腹腹腔镜行离断式肾盂输尿管成形术,术前及术中对体位、Trocar布置、游离和吻合各环节做了细节优化。术后定期随访,分别于拔除双J管后1、3、6、12个月门诊复查B超检查及尿常规,测量肾盂前后径扩张程度及肾实质厚度。结果:所有手术均成功完成,5例中转开放。平均随访时间12(6～36)个月,B超提示肾积水较术前减轻,部分患者ECT及CTU提示肾实质厚度增加,梗阻程度较前减轻,患肾功能不同程度恢复,术前腰背部不适、腹痛及发热等症状主观上明显改善。6例术后出现UPJ再狭窄,3例经输尿管镜检+双J管再置2个月后拔管梗阻缓解,2例行再次腹腔镜肾盂输尿管成形术后改善,1例失访。结论:腹腔镜离断式肾盂输尿管成形术治疗UPJO肾积水安全、有效,术后并发症发生率低,改善肾积水和肾功能结果满意。严格掌握手术适应证、耐心细致的操作和正确处理术中遇到的困难是做好腹腔镜离断式肾盂输尿管成形术的关键。     

经皮腔内顺行球囊扩张结合内切开术治疗肾盂输尿管连接部梗阻

目的观察经皮腔内顺行球囊扩张结合内切开术治疗肾盂输尿管连接部梗阻(UPJO)的疗效。方法回顾分析2010年3月至2012年9月我院采用经皮腔内顺行球囊扩张结合内切开术治疗肾盂输尿管连接部梗阻23例患者的病例资料并行随访。结果患者23例,男性14例,女性9例;年龄21~71岁,平均(39±10.5)岁;左侧10例,右侧13例;原发性UPJO 18例(合并肾结石12例),经皮肾镜碎石术后2例,肾盂输尿管连接部结石开放取石术后1例,开放肾盂成形术后1例,腹腔镜肾盂成形术后1例,狭窄段长度均不超过2cm。所有患者均手术成功,围手术期无严重并发症发生。17例患者纳入随访,其中原发性UPJO患者12例,经皮肾穿刺取石术(PCN)术后患者2例,开放输尿管切开取石术后1例,腹腔镜下肾盂成形术后1例,开放肾盂成形术后1例,术后随访7~31月,未见复发。结论经皮腔内顺行球囊扩张结合内切开术是治疗UPJO安全、有效的手术方式,具有微创、患者耐受度好、术后恢复快的特点,可有选择性地作为治疗UPJO的初始治疗手段。     

腹膜后腹腔镜肾盂成形术治疗肾盂输尿管连接处梗阻的临床价值

目的:探讨腹膜后腹腔镜肾盂成形术治疗输尿管连接部(ureteropelvic junction,UPJ)梗阻的适应证、手术技巧及临床应用价值。方法:回顾分析腹膜后腹腔镜肾盂成形术治疗17例UPJ梗阻患者的临床资料。其中男11例,女6例,22～38岁,高位输尿管开口2例,UPJ完全闭锁4例,单纯重度肾积水7例,异位血管压迫4例,合并肾盂结石3例。结果:17例手术均获成功,手术时间80～240min,平均120min,出血50～130ml,平均85ml,术后平均住院8.5d(7～10d)。围手术期无并发症发生。随访3～12个月,UPJ吻合无狭窄,肾积水、肾功能均获改善。结论:基层医院行腹膜后腹腔镜肾盂成形术是治疗UPJ梗阻有效、安全的术式,可代替开放手术,作为UPJ梗阻患者的首选术式。     

后腹腔镜离断式肾盂成形术治疗肾内型肾盂输尿管连接部梗阻的探讨

目的:探讨后腹腔镜离断式肾盂成形术治疗肾内型肾盂输尿管连接部梗阻(ureteropelvic junction obstruction,UPJO)的手术技巧与临床效果。方法:2008年3月至2014年10月为6例肾内型UPJO患者行后腹腔镜离断式肾盂成形术。患者先取截石位,患侧输尿管逆行置入6Fr输尿管支架,经后腹膜腹腔镜下于肾下极腰大肌前缘间隙找到输尿管,沿输尿管向近端分离至肾门,紧贴肾盂表面钝性剥离肾窦,显露肾内型肾盂与输尿管连接部,行腹腔镜离断式肾盂成形术。结果:6例手术均顺利完成,无中转开放手术。手术时间145~260 min,平均(185.0±48.3)min;术中出血量30~100 ml,平均(52.0±21.5)ml;住院9~21 d,平均(13.0±3.6)d。6例术后随访6~24个月,平均(18.0±4.6)个月,肾盂输尿管连接部吻合口无狭窄,肾积水得到改善。结论:后腹腔镜离断式肾盂成形术是治疗肾内型UPJO有效、安全的手术方式,近期随访临床效果满意。     

后腹腔镜肾盂成形术治疗肾盂输尿管连接部梗阻的临床价值

目的探讨后腹腔镜肾盂成形术治疗肾盂输尿管连接部（UPJ）梗阻的适应证选择、手术技巧及临床应用价值。方法回顾性分析经后腹腔镜肾盂成形术治疗的13例UPJ梗阻患者的临床资料。患者中男7例，女6例，年龄11—47岁。钬激光腔内切开失败1例，高位输尿管开口1例，狭窄段〉2cm或UPJ完全闭锁3例，单纯重度肾积水4例，异位血管压迫2例，合并肾盂结石2例。结果13例手术均获成功。手术时间120～200min，平均175min；出血量60～110ml，平均75ml。术后平均住院时间7．5d（5～8d）。围手术期无并发症。随访3—19个月，UPJ吻合口无狭窄，肾积水、肾功能均得到改善。结论后腹腔镜肾盂成形术是治疗UPJ梗阻的有效、可行的微创手术。可以替代开放手术，成为腔内切开治疗失败、高位输尿管开口、异位血管压迫或伴有重度肾积水、结石的UPJ梗阻患者的首选术式。     

腹腔镜肾盂成形术治疗输尿管连接处梗阻疗效观察

目的：评价腹腔镜肾盂成形术治疗肾盂输尿管连接处梗阻（UPJ0）的临床疗效及其可行性。方法：对50例UPJO均有不同程度肾盂积水患者分别使用Anderson—Hynes、FoleyY—V成形术、Fenger成形术及Hellstrom成形术进行治疗。结果：50例手术均获成功,无一例中转开放手术。手术时间2．5～4．5h,出血量35～88ml。40例术后随访6～24个月,IVP检查UPJ吻合口未见狭窄,肾盂输尿管排尿功能好,手术侧肾盂积水明显减轻或基本消失。结论：腹腔镜肾盂成形术具有术中创伤小、术后恢复快、疼痛减轻的优点,效果优于开放手术,是既安全又有效的微创手术方法。     

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。     

输尿管镜下钬激光内切开与离断性肾盂成形术治疗UPJ狭窄的疗效评价

目的 探讨经尿道输尿管镜下钬激光内切开术与离断性肾盂成形术治疗UPJ狭窄的疗效评价.方法 回顾性分析本院2009年～2012年期间收治的120例肾盂输尿管连接部狭窄患者,均经过彩超,肾分泌造影,MRI水成像或逆行造影等明确诊断,患者分为两组,输尿管镜下钬激光内切开术组(58例)和离断性肾盂成形术组(62例),术后所有患者输尿管内留置Fr7号双J管内引流,每3个月行超声、排泄性尿路造影检查.结果 输尿管镜钬激光内切开组手术时间(50.6±15.6)min、术后住院时间(7.5±2.5)d、平均出血量10ml,明显优于开放肾盂成形组(120.6±26.4) min、术后住院时间(16.5±3.6)d、平均出血量200ml(P＜0.05),两组病人术后每3个月复查泌尿系彩超及静脉肾盂造影,随访6～18个月,平均12个月,术后两组肾积水疗效评价,输尿管钬激光内切开组:40例治愈,16例好转,2例手术失败,改行离断性肾盂成形术治愈;开放肾盂成形术组:35例治愈,20例好转,7例无效.结论 肾盂输尿管连接部狭窄的部分病例选择输尿管镜下钬激光内切开术治疗的手术效果可达到开放手术水平、在手术时间、术中出血量、术后住院时间等方面明显优于开放手术组,输尿管镜下钬激光内切开术是一种安全、有效、术后恢复快、创伤小的治疗方法.     

后腹腔镜离断式肾盂成形术(附25例报告)

目的:探讨后腹腔镜离断式肾盂成形术的临床应用价值。方法:回顾性分析经后腹腔镜肾盂成形术治疗的25例肾盂输尿管连接部梗阻(UPJO)患者的临床资料。其中男16例,女9例,年龄18～43岁,平均32岁。左侧14例,右侧11例。所有患者术前经静脉肾盂造影(IVP)、逆行肾盂造影(RP)或磁共振水成像(MRU)确诊。结果:25例手术均获成功。手术时间120～160 min,平均135 min;术中出血量50～100 ml,平均75 ml,无一例输血;术后住院时间5～8天,平均7.3天。术后尿漏1例。随访3～18个月,25例行IVP检查均显示UPJ吻合口无狭窄,肾积水明显改善。B超检查显示肾盂扩张积水消失20例,轻度3例,中度2例。结论:后腹腔镜离断式肾盂成形术安全、有效,充分体现了腹腔镜手术的微创优势,可以替代开放性手术,成为治疗UPJO的首选方法。     

俯卧位背侧入路后腹腔镜肾盂成形术治疗肾盂输尿管连接部梗阻的临床价值

目的：探讨俯卧位背侧入路后腹腔镜肾盂成形术治疗肾盂输尿管连接部梗阻（UPJO）的临床应用价值。方法：回顾性分析18例UPJO患者的临床资料。其中男12例,女6例,年龄18～65岁,平均31岁。所有患者行肾脏超声、静脉肾盂造影或多层螺旋CT尿路成像和逆行造影检查,其中2例行逆行造影证实迷走血管压迫,8例无症状患者行同位素肾图证实上尿路梗阻。结果：18例均在后腹腔镜下顺利完成手术。手术时间85～205min,平均125min;术中出血量35～80ml,平均54ml;术后住院6～12天,平均8．7天。围手术期未出现并发症。术后4～6周拔除双J管。随访时间9～20个月,平均14．7月,17例痊愈,总治愈率（94．4％）。1例发生再狭窄,二次行开放手术治愈。结论：俯卧位背侧入路后腹腔镜离断性肾盂成形术治疗UPJ0安全可行。经背侧入路后腹腔镜手术的成功实施为临床手术路径的研究提供一种新的思路。     

Ureteropelvic junction obstruction: does CT angiography allow better selection of therapeutic modalities and better patient outcome?

PURPOSE: To determine whether preoperative helical CT angiography (CTA) with three-dimensional (3D) reconstructed images improves outcome in patients with ureteropelvic junction obstruction (UPJO) by identifying crossing vessels that may lead to surgical failure. PATIENTS AND METHODS: Twenty-five patients with UPJO underwent imaging with CTA to identify crossing vessels. Patients with crossing vessels or severe hydronephrosis underwent laparoscopic dismembered pyeloplasty. In the absence of crossing vessels, and with >25% renal function on MAG-3 scan, the patient underwent an endopyelotomy. Procedures were assessed as successful by resolution of patient symptoms as well as relief of obstruction on renal scintography. RESULTS: Twenty-seven procedures (14 laparoscopic dismembered pyeloplasties [9 in the setting of a crossing vessel], 11 ureteroscopic endopyelotomies, and two antegrade endopyelotomy procedures) were performed. Follow-up ranged from 2.4 to 40 months (mean 21.6 months). Twenty-three of the primary procedures (92.0%) were successful. Primary laparoscopic pyeloplasty was successful in 100% of patients, while primary endopyelotomy had a success rate of 83.3%. Both secondary procedures were successful rendering the patients unobstructed and pain free. No complications occurred. The sensitivity and specificity of CTA in determining crossing vessels was 78% and 40%, respectively. CONCLUSIONS: Helical CT angiography with 3D reconstructed images provides valuable preoperative information in patients with UPJO scheduled for surgical intervention. This study may be used in selecting patients for proper operative intervention according to the anatomy of crossing vessels to attain high treatment success rates.     

Acucise endopyelotomy: A technique with limited efficacy for primary ureteropelvic junction obstruction in adults

AIM: To retrospectively evaluate the ef fi cacy of Acucise endopyelotomy in a series of patients with primary ureteropelvic junction obstruction (UPJO). METHODS: Twenty-four patients with a symptomatic primary UPJO underwent Acucise endopyelotomy. Patients with high-grade hydronephrosis and/or poor renal function were excluded. Patients were followed by ultrasound imaging, intravenous urography, diuretic renography, and clinical review. RESULTS: The overall success rate was 58% (14/24 patients), with a median follow up of 32 months. Of the ten patients in whom Acucise endopyelotomy failed, seven underwent open pyeloplasty, one required nephrectomy, and two received a permanent ureteral stent. A poor outcome was noted in patients without perioperative extravasation. CONCLUSIONS: Our experience with Acucise endopyelotomy indicates that the success rate is lower than initially reported. Larger studies are needed to clarify the role of Acucise endopyelotomy in comparison with other techniques.     

Percutaneous endopyelotomy for secondary ureteropelvic junction obstruction: prognostic factors affecting late recurrence

OBJECTIVE: To determine prognostic variables which influence late recurrence after initially successful percutaneous endopyelotomy for secondary ureteropelvic junction obstruction (UPJO). MATERIAL AND METHODS: Between July 1987 and March 2002, 67 patients with secondary UPJO were treated with percutaneous endopyelotomy at our center. Long-term follow-up data were available for 50 patients with initially successful results (42 after a single treatment and eight after repeated endopyelotomy). Follow-up excretory urography and diuretic renal scans were performed for objective evaluation. Late recurrence was diagnosed if obstruction developed after > 1 year of follow-up. Univariate (Kaplan-Meier method) and multivariate (Cox regression model) analyses of pre-, peri- and postoperative factors were carried out for detection of significant variables affecting the late recurrence rate. RESULTS: The follow-up period ranged from 1.27 to 13.85 years (mean 6 +/- 4.3 years). Late recurrence of UPJO was observed in seven cases (14%): 4/42 initially successful cases (9.5%) and 3/8 cases of repeated endopyelotomy (37.5%). In univariate analysis, the significant factors were severity of stenosis at the UPJ (p = 0.04), preoperative serum creatinine (p = 0.04), repetition of endopyelotomy (p = 0.03) and development of postoperative complications (p = 0.02). In multivariate analysis, all of the above factors, with the exception of severity of stenosis at the UPJ, were independent significant factors affecting late recurrence. CONCLUSIONS: As late recurrence was observed in 14% of cases after percutaneous endopyelotomy, long-term follow-up is needed, especially in patients with elevated preoperative serum creatinine, those in whom postoperative complications developed and those in whom a first attempt at endopyelotomy failed.     

顺行经皮肾微造瘘与逆行经输尿管镜钬激光肾盂内切开术治疗肾盂输尿管连接部狭窄疗效比较

目的比较顺行经皮肾微造瘘(antegrade mini-invasive percutaneous nephrostomy,MPCN)和逆行经输尿管镜(retrograde ureteroscopy,RUS)行钬激光肾盂内切开术治疗肾盂输尿管连接部狭窄(ureteropelvic junction obstruction,UPJO)的疗效。方法48例UPJO患者按照治疗方法分为MPCN组(28例)和RUS组(20例)。结果MPCN组无一例中转开放,平均手术时间(52.3±12.7)min、术中出血量(32.1±17.9)ml、术后住院时间(6.3±1.3)d、恢复工作时间(43.2±5.2)d、并发症发生率17.9%(5/28),随访治疗有效率为89.3%(25/28)。RUS组有4例中转开放或顺行腔内手术,平均手术时间(36.2±7.8)min、术中出血量(9.4±7.3)ml、术后住院时间(4.0±1.3)d、恢复工作时间(37.7±5.3)d、并发症发生率18.7%(3/16),随访治疗有效率56.2%(9/16)。两组并发症发生率比较差异无统计学意义(P>0.05),但手术时间、术中出血量、术后住院时...     

The role of Acucise endopyelotomy in the treatment of ureteropelvic junction obstruction

OBJECTIVE: Open surgical pyeloplasty has been the gold standard for the correction of ureteropelvic junction obstruction (UPJO). Endourological management of UPJO has gained increased acceptance, with reported success rates of 57-87%. It has been suggested that Acucise endopyelotomy (AE) should be the procedure of choice for patients with UPJO. The aim of this study was to assess the effectiveness of AE in the treatment of UPJO and the factors contributing to surgical outcome. MATERIALS AND METHODS: Forty-two patients (34 primary, 8 secondary UPJO) underwent AE between June 1995 and December 1999. Presenting symptoms were; pain 34 (80.9%), UTI 10 (23.8%) and haematuria 5 (11.9%). Preoperative evaluation included ultrasound and/or intravenous urogram with diuretic renography. Hydronephrosis was graded in 36 patients. Of these 4, 14, 9 and 9 had grade I, II, III and IV hydronephrosis, respectively. Twenty-four patients were stented prior to endopyelotomy and one required nephrostomy. Overall (true) success was defined as clinically pain free and radiologically no evidence of obstruction on diuretic scan. RESULTS: The average operating time was 45 min and mean hospital stay was 2.7 days. Mean follow-up was 27 months (range 6-55). The objective success rate was 52% and the subjective success rate was 64%. A total of 19 patients (45.2%) had long lasting clinical and radiographic treatment success. Three (7%) patients required nephrectomy and five (12%) underwent open pyeloplasty. Success rate for grade I/II hydronephrosis was 55.5% and only 27.7% with grade III/IV hydronephrosis. Normal renograms were found in 12 (48%) of those with perioperative extravasation compared to three (25%) without. Only one of the eight patients with secondary UPJO had a normal post-operative renogram. Size or type of stent used had no effect on surgical outcome. The substandard results were noted in patients with grade III/IV hydronephrosis, poor pre-operative renal function, secondary UPJO and without perioperative extravasation. CONCLUSIONS: Acucise endopyelotomy is a safe and minimally invasive procedure for the management of UPJO. Although the results of AE are suboptimal, its lower degree of invasiveness makes it reasonable choice for first-line treatment. Careful selection of patients will improve the results of AE, although multicentre randomized trials are needed to make a valued comparison with other techniques.     

Ureteroscopic endopyelotomy with the Holmium:YAG laser. mid-term results

OBJECTIVE: Various modalities ranging from acucise balloon to endoincision with electrocautery, cold knife, and lasers have been used to treat ureteropelvic junction obstruction (UPJO). We assessed the intermediate effectiveness of endopyelotomy with the holmium(Ho):YAG laser. PATIENTS AND METHODS: Between November 1994 and May 1998, 20 patients with 16 primary and 4 secondary symptomatic UPJO were treated. All patients were evaluated clinically and radiologically before and after the procedure at 3 months, and yearly thereafter. The mean follow-up was 34 months (12-38 months). RESULTS: A total of 22 procedure were performed on 20 patients with an average operating time of 44.3 min and mean hospital stay of 1.9 days. All patients were stented after the procedure for 6 weeks. Complication included urinoma (1) and guidewire fracture in 1 patient. 15 patients had a successful outcome determined by a diuretic renography and/or Whitaker test. Three patients with poor preoperative renal function (<25%) had an unsatisfactory outcome. There were 2 failures and they were treated with nephrectomy (1) and open pyeloplasty (1). CONCLUSIONS: A controlled, precise, safe and almost 'bloodless' endopyelotomy can be performed with the holmium laser. Success rate tends to be poor in patients with poor renal function.     

Retroperitoneoscopic pyeloplasty for ureteropelvic junction obstruction (UPJO): solving the technical difficulties

OBJECTIVES: To evaluate our current practice in retroperitoneoscopic pyeloplasty in patients with ureteropelvic junction obstruction (UPJO). Special interest was paid to technical difficulties associated with the retroperitoneoscopic approach. METHODS: Our retroperitoneoscopic approach for pyeloplasty is explained step for step including the most technically challenging part: the ureteropelvic anastomosis. RESULTS: Within 49 months a total of 47 retroperitoneoscopic pyeloplasties we performed at our institution. Before pyeloplasty an endopyelotomy had failed in five patients (11%). We did not necessarily perform a ventral transposition of the anastomosis in cases with a crossing vessel. Two (4%) conversions to open surgery were required because of scarring after previous endopyelotomy and massive obesity resulting in a limited working space. There were no intraoperative complications. A recurrence of UPJO was observed in 2% (n = 1). CONCLUSION: Functional results after retroperitoneoscopic pyeloplasty are excellent and comparable to those of open surgery. However, special knowledge of retroperitoneoscopy is necessary to provide the patient with a safe and effective minimally invasive alternative to open pyeloplasty.     

微创经皮肾穿刺钩状电刀顺行肾盂内切开治疗肾盂输尿管连接部梗阻

目的：探讨微创经皮肾穿刺（mini-PCN）钩状电刀顺行肾盂内切开治疗肾盂输尿管连接部梗阻（UPJO）的方法和疗效。方法：在C臂X线机的辅助下，采用mini—PCN技术，用F2钩状电刀顺行肾盂内切开治疗原发性及继发性UPJO患者15例。结果：15例患者均手术成功，术后症状缓解，无大出血、肾周感染等并发症。拔除双J管后1个月及3个月复查B超及静脉肾盂造影（IVP），提示肾积水消失或较术前明显减少，UPJO狭窄段消失。2例拔除双J管后6个月UPJO复发，改行开放手术治愈。结论：采用mini—PCN钩状电刀顺行肾盂内切开治疗UPJO具有操作简便、损伤小、恢复快、效果佳、价格低廉等优点。     

Endopyelotomy versus redo pyeoloplasty for management of failed pyeloplasty in children: A single center experience

PurposeWe compared endopyelotomy to redo pyeloplasty for the treatment of failed pyeloplasty in children to identify factors that may have an impact on outcome and favor one procedure over the other.MethodsOf 43 patients with recurrent UPJO, EP was performed in 27 and RP was performed in 16. Age, gender, side, presentation of secondary UPJO, hospital stay, complications and success rates were compared. Success was defined as radiographic relief of obstruction as determined by ultrasound or diuretic renography at latest follow-up.ResultsMean (Range) patient age was 7.2 years (range 6 months to 17 years) in EP (group 1) while 7.4 (range 6 months to 17 years) in RP (group 2). EP technique consisted of retrograde cold-knife in 17 patients, retrograde holmium laser in 8 and antegrade cold-knife in 2. RP was performed in 16 patients. All the patients with failed EP had a stricture greater than 15 mm. Mean length of the narrowed ureteral segment was 17.8 mm in the failed EP group vs 10 mm in the successful group (p < 0.001). Mean Hospital stay was 1 day for the EP group and 5 days for the RP group (p < 0.001). Mean follow-up was 17 months (range 12 to 43) after EP and 21 months (12 to 51) after RP. There was no statistical significance between both groups regarding the postoperative degree of hydronephrosis, parenchymal thickness, split renal functions and renal drainage. The overall success was (86%); the success was nonsignificantly higher in RP (93.8%) vs (81.5%) in EP.ConclusionIn selected children, retrograde endopyelotomy is safe and may give comparable short-term outcomes as open redo pyeloplasty for correction of secondary UPJO after failed pyeloplasty. Narrowed ureteral segment greater than 15 mm and preoperative grade 4 hydronephrosis were factors significantly associated with a poor outcome after EP.A Level-of-Evidence rating for classifying study qualityLEVEL III Retrospective comparative study.