2014年复旦大学小儿泌尿外科及腔镜技术研讨会暨小儿泌尿腔镜国家级继续教育学习班通知（第一轮）

复旦大学附属儿科医院小儿泌尿外科腔镜技术国家级继续教育项目今年继续开展。现拟定于2014年11月7日至11月11日在上海市举行小儿泌尿外科及小儿腔镜技术研讨会（11月8日）,同时开展国家级继续教育项目。复旦大学附属儿科医院在国内较早开展小儿泌尿腔镜治疗,在肾脏输尿管积水、重复肾、神经源性膀胱、泌尿系统结石等疾病的腔镜、内镜治疗中积累了大量经验,接受大量医师前来进修学习,历年举办腹腔镜技术学习班,受到广大同行的欢迎。     

输尿管镜在小儿泌尿系结石中的应用

近年来,随着腔内泌尿外科设备和技术的发展,输尿管镜在小儿泌尿系疾病中的应用越来越广泛.其中运用输尿管镜腔内碎石已成为治疗小儿泌尿系结石的一种重要微创手段.     

微创在小儿泌尿外科中的应用

小儿泌尿外科开展微创技术非常早和普及,成人泌尿外科的膀胱镜、尿道镜、显微镜、输尿管镜、经皮肾镜等技术几乎同步用于小儿泌尿外科疾病的诊断和治疗.代表当前微创应用趋势的是腹腔镜技术.随着腹腔镜技术在小儿外科各专业的广泛运用,加上成人泌尿外科腹腔镜的迅速普及,促使小儿泌尿外科的腹腔镜技术水平不断提高.Cortesi于1976年最早用膀胱镜观察腹腔,辅助诊断不能触及的睾丸位置.此后,随着设备改良,尤其是广大外科医生对微创认识的加深,腹腔镜手术开展范围逐渐增宽.腹腔镜手术实现了最初设计的优势:伤口美观、大视野、恢复快.后来达芬奇机械臂辅助腹腔镜系统出现,更是具有三维视野、操作方便、学习曲线短等优势.小儿泌尿外科手术以先天性畸形重建居多,比其它专业难度和精度要求更高.且传统小儿泌尿外科开放手术已非常成熟,要求腹腔镜手术必须在保证相同的治疗效果基础上,达到微创效果.     

输尿管软镜在小儿多发性肾结石治疗中的应用

目的 探讨输尿管软镜在小儿多发性肾结石经肾盂切开取石术治疗中的应用价值。方法 将输尿管软镜用于小儿肾多发性结石经肾盂切开取石术，术中经输尿管软镜配合气压弹道碎石，以及钳夹冲洗等方法取出结石。结果 全部一次性取尽结石。输尿管软镜对肾盂肾盏内其他病变也能起到检查及治疗作用，具有对肾脏损伤小，恢复快，并发症少等优点。结论 小儿多发性肾结石经肾盂切开并配合输尿管软镜治疗是一种安全有效的方法。     

湖南省儿童医院泌尿二科

湖南省儿童医院泌尿二科定编床位40张。全科医务人员20名，科室在积极开展泌尿生殖系统常见先天性畸形矫治手术的同时，着重发展微创泌尿外科和儿童性发育异常的监测和诊治。先天性尿道下裂、肾积水治愈率高，科室先后引进膀胱尿道镜、尿道电切镜、输尿管肾镜、经皮肾镜，率先将腹腔镜技术、钬激光技术对泌尿系畸形（肾积水、输尿管囊肿、重复肾输尿管畸形等）、生殖器疾病（腹腔型隐睾、精索静脉曲张、性腺异常等）、小儿泌尿系结石等进行微创手术治疗；儿童性发育监测和诊疗中心开展男童肥胖性性发育异常、儿童性分化异常、小儿女性泌尿外科疾病的诊治已多年，疗效良好。     

输尿管镜在小儿外科的应用

随着的微创外科迅速发展，腔镜技术的应用日益广泛，输尿管镜（ureteroscopy，URS）在小儿输尿管疾病的诊断与治疗方面已显示出较为重要的作用。但由于小儿解剖结构小及输尿管镜在小儿适应范同等问题，较多小儿科医师对小儿输尿管镜技术的开展，仍心存疑虑。笔者自2001年12月至2004年2月，应用输尿管镜技术处理小儿输尿管相关疾病患儿12例，报告如下。     

我国小儿泌尿外科的发展要追求更高的目标

小儿泌尿外科近年来在国内取得了相当大的进步.如全国小儿泌尿外科的学术会议每年进行一次,并逐步增加影像报告和手术演示的比例,促进了同行的交流、技术推广;尿道下裂尿道成形术在主要大城市大型医院小儿泌尿外科都能达到比较高的成功率;一些单位相继开展了小儿泌尿系疾病的腹腔镜治疗如肾盂成形和膀胱输尿管再植等.     

小儿泌尿外科一些基本和热点问题

小儿泌尿外科的快速发展是最近十年间的事情，其重要的标志是北京、上海、武汉等地的尿道下裂尿道成形术的成功率达到了国际先进水平，在先天性肾盂输尿管连接部狭窄致肾积水、巨输尿管、膀胱输尿管返流、尿路重复畸形等畸形的纠治方面效果更为优异。本期小儿泌尿外科专栏，重点选择了各地具有特色的文章，也是发展成就的一个展示。     

经输尿管软镜钬激光碎石术治疗儿童肾结石和输尿管上段结石

目的 探讨经输尿管软镜钬激光技术治疗儿童肾结石和输尿管上段结石的疗效.方法 回顾性分析47例（52侧）采用经输尿管软镜钬激光技术治疗的上尿路结石患儿临床资料.结果 47例52侧上尿路结石,单用输尿管软镜碎石取石术35例、硬镜＋软镜12例.其中2侧一次入鞘置镜碎石成功;其余采用双J管扩张输尿管后,45侧置入软镜导引鞘成功.45侧置入导引鞘者,39侧一次碎石成功;另外3侧进行了第二次碎石手术;其他3侧未寻及结石,2侧改由MPCNL,1侧观察.5侧导引鞘置入不成功者,其中2侧在斑马导丝引导下置入软镜到肾盂进行碎石成功;另外2例改由微创经皮肾穿刺碎石取石术（MPCNL）,1例失访.共49侧入镜成功并碎石.术后1个月复查B超或CT,46侧结石全部排尽,清石率88.5%（46/52）,3例残留下盏结石,术后2～4周再行软镜碎石取石术,术后1个月复查,结石全部排尽.术后2个月总清石率92.3%（49/52）.本组平均手术时间为 45 min（25~115 min）.术后平均住院时间3 d（2~5 d）,术后出血少,发生输尿管口撕裂1例,无输尿管反流和狭窄.3例出现术后发热.43例术后随访2～24个月,未见输尿管狭窄,1例术后1年结石复发.结论 选择合适的输尿管软镜,熟炼掌握操作技术,采用经输尿管软镜钬激光碎石术,是治疗儿童肾和输尿管上段结石安全有效的方法.     

小儿膀胱镜输尿管插管逆行造影检查术在肾输尿管先天畸形诊断中的价值

目的 评价小儿膀胱镜输尿管捕管逆行造影检查术在肾输尿管先天畸形诊断中的价值.方法 总结分析2806年8月-2008年11月本院收治的经小儿膀胱镜输尿管插管逆行造影检查术诊断为肾输尿管先天畸形的患儿病例资料.71例患儿中肾盂输尿管连接部梗阻(UPJO)43例(60.56%),其中狭窄35例,息肉5例,高位输尿管2例,下腔静脉后输尿管1例,并肾结石9例;输尿管末端狭窄17例(23.94%),并输尿管末端结石5例;输尿管中段狭窄6例(8.45%);肾发育不良3例(4.23%);重复肾重复输尿管畸形2例(2.82%).所有病例依据小儿膀胱镜逆行造影检查的术前诊断进行相应手术,术后随访49例,其中11例行逆行造影检查.结果 71例肾输尿管畸形术前均行小儿膀胱镜输尿管插管逆行造影检查术,术前诊断在术中均得到证实,符合率为100%.其中43例UPJO者均行Anderson-Hynes肾盂输尿管成形术,并肾结石9例,同期取净结石;3例肾发育不良和2例重复肾重复输尿管畸形行发育不良肾、重复肾及输尿管切除术;6例输尿管中段狭窄者行狭窄段输尿管切除、输尿管斜形吻合术;17例输尿管末端狭窄者行输尿管膀胱吻合术,并结石者同期取出.出院时疗效均满意.术后随访期间11例再次经小儿膀胱镜输尿管插管逆行造影检查,输尿管均通畅,全程显影,未见狭窄及扩张.结论 随着小儿膀胱镜输尿管插管逆行造影检查术的开展,使得肾输尿管先天畸形的术前正确诊断得到明显的提高,有利于手术方法 的正确选择,从而防止了术中的盲目探查;同时还可进行术后的有效随访.     

Urolithiasis in children: surgical approach

Over the past 3 decades, minimally invasive stone surgery has completely overtaken open surgical approaches to upper tract pediatric urolithiasis. Progressing from least to most minimally invasive, extracorporeal shock wave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy are the surgical methods of today for kidney and ureteral stones. The choice of treatment modality is individualized in children, considering patient age, stone size, number, location, and anatomic and clinical contributing factors. The purpose of this article is to review these techniques for pediatric upper urinary tract stones and summarize outcomes and complications.     

儿童泌尿系统梗阻畸形合并上尿路结石的术中内镜治疗

目的 探讨儿童泌尿系统梗阻畸形外科手术中联合内镜治疗儿童泌尿系统梗阻畸形合并上尿路结石的安全性和有效性.方法 回顾分析我院小儿外科2010年1月1日至2013年8月31日收治的17例儿童泌尿系统梗阻畸形合并上尿路结石的患儿临床资料.男13例,女4例,年龄3～12岁,平均年龄5.9岁,左侧14例,右侧3例.肾积水、UPJO合并肾脏结石11例,输尿管膀胱连接处狭窄合并肾盂内结石3例,输尿管膀胱连接处狭窄合并输尿管末端结石者2例,输尿管膀胱连接处狭窄合并肾输尿管多处结石1例,结石直径4～12 mm.结果 11例肾积水、UPJO(肾盂输尿管连接处狭窄)患儿均顺利行离断式肾盂输尿管成形术,术中均行经肾盂输尿管镜或膀胱镜检查肾盂内各盏,10例患儿成功取出结石,1例术中未见找到结石,术后辅助行体外震波碎石治疗(ESWL).6例输尿管膀胱连接处狭窄(UVJO)患儿均顺利行膀胱外输尿管膀胱再植术,术中4例顺利行输尿管硬镜检查术,2例顺利行输尿管软镜检查术,结石顺利取出4例,2例术中检查未能发现结石.结论 对于儿童泌尿系统梗阻畸形合并上尿路结石,在梗阻畸形外科手术治疗的同时联合内镜治疗上尿路结石是理想、安全、有效的.     

Magnetic resonance urography and laparoscopy in paediatric urology: a case series

Paediatric urology often presents challenging scenarios. Magnetic resonance urography (MRU) and laparoscopy are increasingly used. We retrospectively studied children affected by a disease of the upper urinary tract who after MRU were elected for laparoscopic treatment. This pictorial essay draws on our experience; it illustrates some specific MRU findings and highlights the usefulness of MRU for the diagnosis of upper urinary tract pathology in children. It also offers some examples of the potential additional diagnostic information provided by laparoscopy as well as its therapeutic role.     

Robotics and future technical developments in pediatric urology

Minimally invasive surgery (MIS) has represented the main innovation in the field of pediatric surgery and urology over the last 30 years. Pediatric MIS is a wide field, ranging from the standard laparoscopic surgery using 3-mm ports to robotics mainly adopted for pediatric urology indications. The aim of this paper was to summarize the current status of robotic surgery in pediatric urology and to evaluate possible future technical developments for this technique. In pediatric urology, many procedures are challenged by the narrow working space available in smaller children, the difficulty to perform complex and long suture lines to repair complex urinary malformations, and the challenge to remove renal or adrenal tumors. The main characteristic of robotic surgery is that the robotic instruments inserted into the abdominal cavity are remotely controlled by the surgeon, who is sitting at a console next to the patient or even far away, avoiding human tremor during complex suturing. Due to the magnification of the operative field view and the six degrees of freedom of the robotic instruments compared to conventional laparoscopic instruments, providing enhanced 3D vision and improved surgeon ergonomics, robot-assisted surgery appears to be beneficial over conventional MIS, especially in complex reconstructive procedures. Currently, there are two robotic systems available on the market and certified for robotic surgery in children: the DaVinci (Intuitive Surgical, since 2001) and Senhance (Transenterix, since 2020). However, almost the totality of papers published in the international literature are focused on robotic procedures using the DaVinci platform. Analyzing the current literature, there is no evidence about the indications where robotics are preferable to conventional MIS approaches. Currently, the main indications of robotic surgery in pediatric urology are: pyeloplasty for ureteropelvic junction obstruction (UPJO), ureteral reimplantation according to Lich Gregoire technique, Mitrofanoff procedure, nephrectomy or partial nephrectomy for oncological indications, removal of renal cysts, bladder neck reconstruction or removal of urinary tract stones. The future developments in this field are certainly represented by intraoperative use of indocyanine green (ICG) fluorescence imaging that permits to have a better vision of vascular anatomy or clearly identify nodes in case of tumors, and by development of 5G technology. The main limitation of robotic surgery today remains the excessive cost of the machine itself and the limited lifespan of robotic instruments. We believe that robotic surgery will surely represent the new field of development in pediatric surgery, but its widespread application will depend on the introduction of new robotic platforms in the market, that will certainly low the costs, and also to the development of smaller size instruments more suitable for pediatric use.     

Recent management of urinary stone disease in a pediatric population

The incidence of stone disease has been increasing and the risk of recurrent stone formation is high in a pediatric population. It is crucial to use the most effective method with the primary goal of complete stone removal to prevent recurrence from residual fragments. While extracorporeal shock wave lithotripsy (ESWL) is still considered first line therapy in many clinics for urinary tract stones in children, endoscopic techniques are widely preferred due to miniaturization of instruments and evolution of surgical techniques. The standard procedures to treat urinary stone disease in children are the same as those used in an adult population. These include ESWL, ureterorenoscopy, percutaneous nephrolithotomy (standard PCNL or mini-perc), laparoscopic and open surgery. ESWL is currently the procedure of choice for treating most upper urinary tract calculi in a pediatric population. In recent years, endourological management of pediatric urinary stone disease is preferred in many centers with increasing experience in endourological techniques and decreasing sizes of surgical equipment. The management of pediatric stone disease has evolved with improvements in the technique and a decrease in the size of surgical instruments. Recently, endoscopic methods have been safely and effectively used in children with minor complications. In this review, we aim to summarize the recent management of urolithiasis in children.     

Percutaneous ultrasonic lithotripsy of symptomatic renal calculi in children

Percutaneous ultrasonic lithotripsy of upper urinary tract lithiasis is a well-established procedure in adults. We successfully applied this technique to completely remove symptomatic renal calculi in two children with idiopathic hypercalciuria. The procedure was well tolerated and no complications occurred. Both patients were discharged within 4 days of the lithotripsy. This method is an alternative to surgery for the removal of large or impacted calculi from the upper urinary tracts of pediatric patients.     

组织工程技术在儿童下尿路重建修复中的若干问题

组织工程的发展日新月异,并且在儿童下尿路重建修复的临床前研究中取得了不错的成效。但临床前研究在向临床转化时效果都不太理想。临床转化失败的原因很多,其中最重要的一点是临床前研究常使用的是健康动物模型,从而不能准确模拟病态组织的结构和功能。针对当前组织工程向临床转化的困境,很多新的研究方案也应运而生,包括使用多种来源的干细胞,改善移植物血供,应用可控释放生长因子的新型支架,探究深层次的信号通路以及细胞间相互作用等,但单用其中一种方法很难在临床应用中获得成功。本文阐述组织工程技术在儿童下尿路重建修复中已取得的研究进展及当前面临的主要问题。     

Percutaneous retrieval of coiled double-J stent from renal pelvis after Anderson-Hynes pyeloplasty: report of two cases

Double-J (DJ) ureteral stents are routinely placed for internal urinary diversion post renal pyeloplasty. Malfunction of the stent may occur due to migration, necessitating removal. Upward migration of a DJ stent is rarely encountered in urologic practice when a ureteroscope is used to retrieve the stent. However, retrieval of upwardly migrated stents through ureteroscopy may be challenging in the pediatric population, especially in postoperative cases. We report two pediatric cases of post Anderson-Hynes pyeloplasty in whom the DJ stents were found coiled up in the renal pelvis and were retrieved successfully through percutaneous nephrostomy using semirigid bronchoscopic forceps.     

In vitro motility investigations and electron microscopic observations on children's upper urinary tract muscle wall.

This study was performed as a part of a longer research programme on urinary tract smooth muscle layer in children. All the children whose samples were investigated underwent surgery for urinary tract malformations. Specimens were taken from different segments of upper urinary tract during surgical intervention. Specimens were investigated by either in vitro motility tests or electron microscopy or both of them. Basic patterns of tissue strips were recorded after incubation of varying duration and then tested by administering neurotransmitter agents like noradrenaline and acetylcholine-bromide. Microstructure of samples were examined electron microscopically. Investigations were performed in order to find correlation between microarchitecture and motility patterns of urinary muscle wall. Factors influencing urinary muscle motility, characteristic features of impaired musculature and its possible regeneration are discussed too. Microhistological deteriorations inhibit spontaneous smooth muscle motility but muscle contractility proved by administering noradrenaline and acetylcholine-bromide remained in some extent. Taking into consideration that smooth muscle is able to regenerate and rebuild close contacts pediatric surgeon and urologist should spare kidney parenchyma as far as it is possible.     

Office laboratory procedures, office economics, parenting and parent education, and urinary tract infection

Four areas of pediatric office practice are again reviewed: office laboratory procedures, office economics, parenting and parent education, and urinary tract infection. Screening for celiac disease and the use of rapid antigen testing for extrapharyngeal group A Streptococcus infections are included in office laboratory procedures. Utilization of health care among patients with public insurance, electronic medical records, billing among pediatric residents, and satisfaction surveys are reviewed in office economics. Challenges related to breastfeeding, obesity management and timely immunizations are covered within parenting and parent education. Finally, the use of an augmented urinalysis and a discussion of imaging for first febrile urinary tract infections are included in the area of urinary tract infection.