输尿管支架管和肾盂造瘘管在小儿Anderson—Hynes术中的应用

目的 评估小儿肾盂输尿管连接部狭窄（UPJO）采用离断式肾盂成形术（Anderson-Hynes）后,放置输尿管支架管和肾盂造瘘管对术后疗效的影响.方法 回顾性分析139例因肾盂输尿管连接部狭窄在本院行Anderson-Hynes术,术后放置输尿管支架管和肾盂造瘘管的患儿临床资料,对住院时间、术后并发症及拔管时间等进行分析. 结果 139例患儿行144侧Anderson-Hynes术,其中5例为双侧.术后23例出现并发症：12例（8.3%）血尿、2例尿路感染（1.4%）、1例尿性囊肿（0.7%）、2例（1.4%）暂时性吻合口梗阻、2例（1.4%）尿漏.拔除肾周引流管平均时间4.2d.拔除输尿管支架管平均时间9.6d.拔除肾盂造瘘管平均时间13.3 d.平均住院天数14.8 d.术后随访0.5～24个月,没有发现因吻合口再次梗阻等原因需再次手术的病例.结论 小儿肾盂成形术后使用输尿管支架管和肾盂造瘘管引流,减少了尿漏和吻合口狭窄的可能,也未增加术后尿路及切口感染的机会.     

双肾重度积水17例

目的探讨双侧肾盂输尿管连接部梗阻(UPJO)致双肾重度积水的诊断治疗效果。方法回顾总结本院2008年1月-2009年7月诊治的双侧UPJO致双肾重度积水婴幼儿17例[14例Ⅰ期行双侧离断式肾盂成形术(Anderson-Hynes术),3例Ⅰ期行单侧离断式肾盂成形术+对侧肾造瘘术、Ⅱ期行对侧离断式肾盂成形术],手术年龄(45±11)d,并于术后3个月、6个月、1 a、2 a行彩超、核素肾显像、尿常规等检查及随访。结果 34侧肾脏术后1例单侧肾出现尿外渗,1例单侧肾出现吻合口狭窄,无出血、切口感染等并发症;末次随访(2a)17例患儿尿常规均正常,彩超提示积水均≤2级,相对肾功能(单侧肾小球滤过率/双侧肾小球滤过率)为(47.30±5.18)%,患儿均未出现肾盂、肾盏分离加大情况,肾皮质厚度逐渐增加,肾功能逐渐恢复。结论确诊存在器质性梗阻的双肾重度积水患儿应尽早手术干预,Ⅰ期双侧离断式肾盂成形术不但疗效确切,且避免了患儿二次手术的痛苦,可作为首选术式;同时应加强术后随访。     

腹部小切口手术治疗小儿肾盂输尿管连接部梗阻

目的探讨腹部小切口离断式肾盂成形术治疗小儿肾盂输尿管连接部梗阻的临床疗效。方法2010年12月至2011年12月作者采用腹部小切口腹膜外入路行离断式肾盂成形术,治疗小儿肾盂输尿管连接部梗阻患儿33例,分析其手术入路、临床效果及并发症情况。结果33例均手术成功,平均手术时间（89±37）min,平均出血量（16±12）mL,伤口愈合良好。术后随访3~12个月,无吻合口狭窄、尿瘘、泌尿系感染等并发症,患儿肾盂均不同程度缩小,肾实质增厚。结论腹部小切口离断式肾盂成形术治疗小儿肾盂输尿管连接部梗阻,操作简单,损伤少,并发症少,疗效好,值得临床推广。 Abstract：     

腹膜后腹腔镜下Anderson-Hynes手术

目的 介绍腹膜后腹腔镜肾盂成形术。方法 采用后腹腔途径对5例确诊为肾盂输尿管连接部(UPJ)梗阻的患儿施行腹腔镜离断性肾盂成形术。结果5例手术全部成功，手术时间130～190min。术中出血20～50ml，术后3～24个月B超复查，手术侧肾积水基本消失，3例术后1年IVU检查UPJ吻合口无狭窄，肾盂输尿管排尿功能好。结论后腹腔镜离断性肾盂成形术是治疗UPJ梗阻有效、安全及微创的方法。     

先天性肾盂输尿管连接处梗阻的诊断和治疗

目的 探讨先天性肾盂输尿管连接处梗阻(UPJO)致肾积水的诊断和治疗方法.方法 回顾分析UPJO致肾积水患儿63例的临床资料.患儿均经彩超筛查、静脉肾盂造影(IVP)、磁共振尿路成像(MRU)或电子计算机X射线断层扫描尿路成像(CTU)确诊.单侧肾积水55例中47例行一期离断式肾盂输尿管成形术,切除无蠕动功能的肾盂输尿管狭窄段和大部分扩张的肾盂;5例因重度肾积水先行患肾穿刺造瘘引流3～6个月,其中3例二期行离断性肾盂成形术,另2例因肾脏无功能行肾切除术;3例保守治疗.双侧肾积水8例中3例一期完成双侧肾盂输尿管成形术,5例分次完成.结果 术后B超随访,肾积水均有改善,肾盂前后径缩小,肾实质增厚;IVP均证实肾盂输尿管吻合口通畅.肾脏积水导致肾功能受损者,术后肾动态显像榆查患肾功能均有恢复.结论 彩超为UPJO诊断最常用的筛查方法,IVU、MRU及CTU是确诊UPJO的可靠方法,先天性肾盂输尿管连接部狭窄是造成肾积水的首要原因、肾盂进行性扩张或肾功能损害进行性加重者需行离断性肾盂成形术.     

非钳夹式吻合口缝合法在腹腔镜离断式肾盂成形术中的应用

目的 探讨“非钳夹”式吻合口缝合法在腹腔镜肾盂输尿管成形术治疗小儿肾盂输尿管连接部梗阻(UPJO)的手术技巧、疗效及临床应用价值.方法 2015年1月至2015年4月对我院收治的81例肾盂输尿管连接部梗阻小儿肾积水患儿行“非钳夹”式吻合口缝合法经脐单部位腹腔镜肾盂输尿管成形术,其中男68例,女13例,左侧57例,右侧24例,平均年龄3.5岁(11d至15岁),所有患儿术前均行泌尿系B型超声、MRU及MAG3肾核素扫描等检查明确诊断.采用经脐单部位建立手术操作通道,吻合肾盂输尿管前后壁时,离肾盂输尿管吻合口最低点1.0～1.5 cm处于肾盂瓣及输尿管前后壁分别用4-0慕斯线牵引用于缝合吻合口时钳夹与牵拉用,其余方法基本同普通腹腔镜肾盂输尿管成形术.结果 81例患儿手术均获得成功,无中转开放手术,无术中并发症,有2例大龄右侧病变患儿术中在上腹部增加一5 mmTrocar后完成手术.平均手术时间94(80～150)min、术中平均出血量15(10～50)ml、平均引流管拔除时间5(3～10)d、术后平均住院时间7(5～10)d.术后行超声、放射性核素扫描随访3～6个月,术侧肾实质不同程度增厚,肾盂前后径明显减小或消失,62例形态接近正常,患肾分肾功能不同程度恢复.结论 腹腔镜肾盂输尿管成形术治疗小儿肾积水时采用“非钳夹”式吻合口缝合法安全可行,具有损伤小、恢复快、成功率高等优点,值得临床推广应用.     

小儿先天性肾盂输尿管连接部梗阻诊治265例

目的探讨离断性肾盂成形术在小儿先天性。肾盂输尿管连接部梗阻中的治疗效果。方法总结2006年至2007年收治的265例小儿先天性肾盂输尿管连接部梗阻患儿的临床资料。男226例，女39例。左侧183例，右侧65例，双侧17例。平均年龄4．5岁，其中年龄小于1岁34例。根据症状、超声、静脉尿路造影（IVU）或核磁水成像明确诊断，对重度肾积水患儿行肾核素扫描了解分肾功能。均行腹部横行小切口离断性肾盂成形术（Anderson—Hynes术式）。结果术后随访6个月，以梗阻症状消失、。肾盂变窄或肾实质增厚为治愈标准。病理诊断：肾盂输尿管连接部狭窄并高位输尿管最多见，占93．2％。265例（282侧）一次手术成功率为98．5％。结论新生儿肾积水多为生理性，有白行改善的可能，绝大多数不需要手术治疗。小儿先天性肾盂输尿管连接部梗阻的首要病因是。肾盂输尿管连接部狭窄。有明显梗阻症状、肾盂进行性扩张或。肾功能损害进行性加重者需手术治疗，首选离断性。肾盂成形术。     

儿童单侧UPJO腹腔镜下肾盂输尿管成形术后吻合口暂时性梗阻的危险因素分析

目的探讨腹腔镜肾盂输尿管成形术后发生吻合口暂时性梗阻的危险因素。方法收集本院泌尿外科2007年7月至2015年6月实施腹腔镜肾盂输尿管成形术患儿的临床资料,共360例。按照是否发生吻合口暂时性梗阻分为两组,比较两组术后发生吻合口暂时性梗阻与年龄、体重、性别、术侧、术前积水程度、有无息肉、病变段输尿管长度及引流方式的相关性。结果 360例中,术后发生吻合口暂时性梗阻24例(占6.7%),两组在年龄、引流方式上比较,差异有统计学意义(P0.05)。多因素分析表明,年龄72个月、肾造瘘管外引流以及输尿管支架管外引流可增加吻合口暂时性梗阻的发生率,是术后发生吻合口暂时性梗阻的独立危险因素。结论年龄与外引流是术后吻合口暂时性梗阻的危险因素。术中应避免肾盂内血凝块存留,适当延长外引流时间,以减少或避免因水肿所致吻合口暂时性梗阻的发生风险。     

小儿先天性肾盂输尿管连接处梗阻的微创治疗研究进展

小儿先天性肾积水主要是由先天性。肾盂输尿管连接处梗阻（ureteropelvic junction obstrction，UPJO）引起，发病率报道不一，一般为0．13％-0．16％，目前公认最合理的手术方法是离断式肾盂输尿管成形术（Anderson—Hynes术），此术式裁剪肾盂，切除了肾盂输尿管狭窄处及肌细胞发育异常的部位，吻合口宽阔、低位、漏斗形，使连接部蠕动能力恢复，     

婴幼儿肾盂输尿管连接处梗阻所致肾积水的诊断与治疗

目的 探讨婴幼儿肾盂输尿管连接处梗阻(UPJO)所致肾积水的诊断与治疗方法.方法 回顾性分析近10年收治的小于3岁婴幼儿UPJO所致肾积水46例51只患肾的临床资料.结果 术前均行B超检查,提示UPJO诊断者共46例51只肾.46例均行静脉尿路造影(IVU),其中16例16只肾影像明确肾盂输尿管连接处迂曲狭窄;对未显影的16例和虽肾盂显影而输尿管未显影的14例再采用膀胱镜检,此30例中25例30只肾成功输尿管逆行插管造影而确诊;另5例根据IVU及B超检查疑诊而手术.所有患肾均行离断式肾盂输尿管成形术(Anderson-Hynes术),术后恢复好,均I期成功.术后均获得B超随访,积水消失或不同程度改善,肾盂前后径缩小,肾实质增厚;26例28只肾术后获得IVU随访,均证实肾盂输尿管吻合口通畅,且术后肾盂显影时间明显较术前提前.结论 B超、IVU及必要的膀胱镜检输尿管逆行插管造影是诊断婴幼儿肾积水的有效可靠的方法;婴幼儿肾积水宜早诊治;离断式肾盂输尿管成形术仍是治疗婴幼儿患者最好的术式;除脓肾外,都应保留患肾.     

经结肠旁入路腹腔镜下Anderson-Hynes肾盂输尿管成形术

目的 探讨经腹腔结肠旁腹腔镜下Anderson-Hynes肾盂输尿管成形术的技巧、安全性及适应证.方法 2006年3月至2008年6月在我院采取经结肠系膜入路行Anderson-Hynes肾盂成形术32例,其中男18例,女14例.年龄8个月～16岁,平均年龄5.5岁.左侧17例,右侧11例,双侧4例,共36侧.肾盂输尿管连接处狭窄24侧,狭窄伴肾结石6侧(其中多发结石3例),输尿管息肉6侧.右侧经结肠肝曲对系膜缘,左侧经结肠系膜侧行Anderson-Hynes肾盂输尿管成形术,术后B超或IVU随访.结果 30例顺利完成手术,学习期间中转开放2例(5.9%).手术时间53～158 min,单侧平均82 min,双侧平均时间107 min.术中失血15～40 ml.术后双"J"管堵塞2例(6.3%).1例多发结石术中残留结石1枚,在拔出双"J"管后.自行排出.术后随访6～26个月,无肾积水临床症状,影像学无梗阻及结石复发.结论 经腹腔结肠旁人路腹腔镜下Anderson-Hynes肾盂输尿管成形术是一种安全、有效、微创的手术,而且容易学习,可以作为肾盂输尿管成形术首选术式.但是,在学习阶段.巨大肾积水、肾盂多发结石不宜首选该术式.     

Laparoscopic management of ureteropelvic junction obstruction in pediatric patients: A new approach to crossing vessels,crossing vein division,and upward transposition of the crossing artery

ObjectiveTo demonstrate the role of the laparoscopic approach for management of primary ureteropelvic junction obstruction (UPJO) using two different techniques in the pediatric age group.Material and methodsFrom April 2005 to October 2008, 63 pediatric patients underwent treatment of primary UPJO via a laparoscopic approach. Dismembered pyeloplasty was elected in 56 renal units while nine patients were managed by upward transposition of accessory renal artery after division of accessory renal vein. No JJ stent was required in these nine patients.ResultsMean age of patients was 61 (2–180) months. Mean operative time was significantly lower in those managed by transposition of aberrant vessels compared with dismembered pyeloplasty. The mean hospital stay was 6.4 (2–14) days for the dismembered technique and 2.1 (1–4) days for the vascular transposition approach. Significant improvement of obstruction was achieved in all of the patients who underwent the modified Hellstrom technique and in 92.81% of the renal units undergoing dismembered pyeloplasty.ConclusionThe technique of laparoscopic transposition of crossing renal artery without violating collecting system may have a role in minimally invasive management of UPJO in selected pediatric patients. Further research with larger samples and a longer follow-up period is required.     

腹腔镜辅助经腹路径双侧肾盂成形术的临床应用

目的 探讨腹腔镜辅助经腹路径肾盂成形术在儿童双侧肾盂输尿管连接部梗阻中的应用.方法 2007年2月至2011年1月,收治12例双侧肾盂输尿管连接部梗阻肾积水患儿,男8例,女4例;年龄2～10岁,平均年龄4.9岁;12例均采用腹腔镜辅助经腹路径肾盂成形术.结果 12例手术成功11例,中转开放手术1例.手术时间120 170 min,平均140 min;术中出血20～50 ml,平均25ml.无严重围手术期并发症发生.全部获得随访,术后B超随访肾积水明显改善.结论 腹腔镜辅助经腹路径肾盂成形术治疗双肾盂输尿管连接部梗阻创伤小,安全,有效,有很好的应用前景.

Abstract：

Objective To study the application of transperitoneal laparoscopy-assisted dismembered pyeloplasty in children with bilateral ureteropelvic junction obstruction (UPJO). Methods From Feb,2007 to Jan 2011 ,a total of 12 children with bilateral UPJO underwent transperitoneal laparoscopy-assisted dismembered pyeloplasty. Among them, there were 8 boys and 4 girls. The ages ranged from 2 to 10 years(mean,4. 9 years). Results Eleven operations were completed successfully, 1 case was converted to open surgery. The operation time was 120～170 min (mean: 140 min); The estimated intraoperative blood loss was 20～50ml (mean:25 ml). No serious perioperative complication occurred.The twelve cases wer followed up, Ultrasound examinations after the procedure showed the hydronephrosis was improved. Conclusions The application of transperitoneal laparoscopy-assisted dismembered pyeloplasty with bilateral UPJO is a minimally invasive,safe and effective procedure for treating bilateral UPJO.     

Laparoscopic pyeloplasty is feasible for lower pole pelvi-ureteric obstruction in duplex systems

Exclusive lower pole pelvi-ureteric junction obstruction (PUJO) in double collecting systems in children is a rare condition requiring reconstructive surgery. We report on the feasibility of laparoscopic transabdominal dismembered pyeloplasty in two cases. Two children with duplicated collecting systems presented with hydronephrosis of lower pole moiety due to exclusive PUJO. Isotope renography revealed impaired drainage of affected lower kidney pole. A four-trocar transabdominal technique was used. No stent was used in one patient with bilateral duplication (male, 6 years) while a 4 Fr. double-J stent was placed laparoscopically in another with unilateral duplication (male, 9 months). Both patients had uneventful laparoscopic transabdominal dismembered pyeloplasty. The operation time was 115 and 155 min, respectively, and was comparable to our previously reported patient series undergoing laparoscopic pyeloplasty for singular collecting systems. After a mean follow-up of 21 months (range 12-42), both patients were asymptomatic and showed improved pelvi-ureteric drainage on isotope renography and improved hydronephrosis on ultrasound scan. Laparoscopic transabdominal dismembered pyeloplasty is safe and effective in children with rare lower pole PUJO in double collecting systems.     

Tansanastomotic stents for dismembered pyeloplasty in children

 Among pediatric urologists, there is a debate whether to drain the upper system after pyeloplasty in children. In a prospective, randomized clinical study we compared the early and late results of patients operated upon for ureteropelvic junction obstruction (UPJO) with or without a transanastomotic stent. Anderson-Hynes pyeloplasty was performed in 31 children during a 5-year period. In 15 a transanastomotic stent with multiple holes was used; the upper system was not drained in 16. A Penrose drain was placed in the perinephritic area in all patients. Patients were evaluated in regard to the time of removal of the stent and the Penrose drain, duration of urine leakage, and duration of hospital stay in the early postoperative period, and favorable or unfavorable outcome during follow-up. The statistical analysis showed no significant difference in regard to the removal time of the stent and Penrose drain, duration of drainage, duration of hospitalization, and early or late complications between the groups. Although stenting does not increase morbidity, we believe that pyeloplasty can be performed in children without upper-tract drainage. A feeding tube with multiple holes at the tip is recommended. Accepted: 21 March 2001     

小儿输尿管息肉致梗阻性肾积水

目的探讨小儿输尿管息肉致梗阻性肾积水的临床特点及诊治方法。方法回顾分析1987～2005年收治33例小儿输尿管息肉致梗阻性肾积水的临床资料，男32例，女1例，左侧27例，右侧5例，双侧1例。就诊年龄5～14岁，平均9岁，病程1个月至5年，平均1年7个月，发病年龄4～12岁，平均7岁。结果33例患儿行手术治疗，手术及术后病理证实肾脏积水为输尿管息肉造成梗阻所致，术后6～12个月行IVP检查，肾积水缓解或减轻，腹痛症状消失，随访6个月至18年未见息肉复发。结论输尿管息肉致梗阻性肾积水以男孩多见，且以学龄儿童为主，多发生在左侧，临床表现和其他原因引起的肾积水类似，但腹痛较剧烈，积水多不重。治疗根据息肉的位置及大小决定手术方案，包括息肉段输尿管切除＋肾盂输尿管吻合，及息肉段输尿管切除＋输尿管一输尿管吻合。     

One-trocar-assisted pyeloplasty: An attractive alternative to open pyeloplasty

Background:

To survey the effects of one-trocar-assisted pyeloplasty (OTAP) in the treatment of ureteropelvic junction obstruction (UPJO) in kids.

Materials and Methods:

Forty-four children (±3.5 years) were submitted to OTAP procedure. A flank incision under the XII rib was made, the Gerota''s fascia was achieved and a balloon Hasson trocar with an operative telescope inserted for retroperitoneal access. The renal pelvis and ureter were isolated and exteriorised. Forty-two patients underwent Anderson-Hynes dismembered and one Fenger pyeloplasty. One patient was converted to an open procedure. Two patients presented an aberrant crossing vessel. In all patients, a double J stent was positioned. The operative time and length of stay (LOS) were evaluated. Renal scan and ultrasound (US) were utilised to evaluate the results from 6 to 12 months.

Results:

OTAP was successful in all but 1 patient. Mean operative time and LOS were 128 min and 3,5 days. We had four operative complications (9.09%). The US and a nuclear scan confirmed the resolution of the UPJO in all patients except one with the Fenger pyeloplasty who had an open Anderson-Hynes.

Conclusions:

The combination of retroperitoneoscopic and open procedures for dismembered pyeloplasty offers a simple, time-saving method in a minimally invasive fashion with low morbidity for patients with UPJO.Key words: hydronephrosis, minimally invasive surgery, one trocar surgery, retroperitoneoscopy