机器人辅助腹腔镜Lich-Gregoir输尿管再植术与气膀胱Cohen输尿管再植术治疗原发性膀胱输尿管反流的疗效对比CSCD

目的初步评价机器人辅助腹腔镜Lich-Gregoir输尿管再植术与气膀胱Cohen输尿管再植术治疗儿童原发性膀胱输尿管反流(vesicoureteral reflux,VUR)的临床疗效。方法将2016年1月至2020年8月解放军总医院第七医学中心儿科医学部行手术治疗的87例VUR患儿纳入研究,按照单侧或双侧VUR将患儿分为单侧组及双侧组,单侧组和双侧组又根据手术方式进一步分为单侧机器人组(25例)、双侧机器人组(22例)、单侧气膀胱组(22例)和双侧气膀胱组(18例)。单侧机器人组和双侧机器人组统称为机器人组,实施机器人辅助腹腔镜Lich-Gregoir输尿管再植术;单侧气膀胱组和双侧气膀胱组统称为气膀胱组,实施气膀胱Cohen输尿管再植术。分别比较单侧组和双侧组中机器人组、气膀胱组的术前准备时间、腹腔内手术操作时间、术中出血量、术后留置尿管天数及术后住院天数。记录各组患儿术后随访情况。结果所有患儿均顺利完成手术,无一例中转开放手术。在单侧VUR患儿中,机器人组和气膀胱组的术前准备时间分别为(15.3±2.9)min和(28.8±4.0)min;腹腔内手术操作时间分别为(34.9±3.0)min和(46.7±8.9)min;留置尿管天数分别为4(3,4)d和4(3,5)d;术中失血量分别为(14.7±2.7)mL和(16.8±2.8)mL;术后住院天数分别为(8.8±2.1)d和(10.5±2.8)d。在双侧VUR患儿中,机器人组和气膀胱组的术前准备时间分别为(16.5±3.6)min和(20.0±2.9)min;腹腔内手术操作时间分别为(81.6±8.1)min和(95.9±7.9)min;留置尿管天数分别为4(3,5)d和4(3,5)d;术中失血量分别为(36.4±7.0)mL和(34.4±6.0)mL;术后住院天数分别为7.5(7,9)d和9(7.8,10)d。按照手术方式进行比较,机器人组与气膀胱组患儿术前准备时间[单侧机器人组比单侧气膀胱组为(15.3±2.9)min比(28.8±4.9)min;双侧机器人组比双侧气膀胱组为(16.5±3.6)min比(20.0±2.9)min]、腹腔内手术操作时间[单侧机器人组比单侧气膀胱组为(34.9±3.0)min比(46.7±8.9)min;双侧机器人组比双侧气膀胱组为(81.6±8.1)min比(95.9±7.9)min]以及术后住院天数[单侧机器人组比单侧气膀胱组为(8.8±2.1)d比(10.5±2.8)d;双侧机器人组比双侧气膀胱组为7.5(7,9)min比9(7.8,10)d]的差异均有统计学意义(P<0.05);而留置尿管天数[单侧机器人组比单侧气膀胱组为4(3,4)d比4(3,5)d;双侧机器人组比双侧气膀胱组为4(3,5)d比4(3,5)d]和术中失血量[单侧机器人组比单侧气膀胱组为(14.7±2.7)mL比(16.8±2.8)mL;双侧机器人组比双侧气膀胱组为(36.4±7.0)mL比(34.4±6.0)mL]差异无统计学意义(P>0.05)。本研究87例患儿随访1年无一例出现高级别并发症。结论两种微创输尿管再植术治疗VUR均疗效确切,机器人辅助腹腔镜Lich-Gregoir输尿管再植术手术时间更短,对膀胱的损伤更小,术后恢复更快,但需要更进一步的临床研究来证实。     

机器人辅助腹腔镜治疗肾盂输尿管连接部梗阻的临床应用及研究进展

肾盂输尿管连接部梗阻是尿路梗阻中最常见的先天性畸形, 常常导致小儿肾积水。近年来, 达芬奇机器人手术系统的运用逐步成为热点, 具有操作灵活、手术精准度高等优势, 保证了手术的安全性、准确性以及疗效, 从而在小儿泌尿外科中的应用日渐广泛。本文就运用机器人辅助腹腔镜治疗小儿肾盂输尿管连接部梗阻的临床应用及研究进展进行综述。     

机器人辅助腹腔镜下Lich-Greqoir手术治疗儿童原发性膀胱输尿管反流

目的探讨机器人辅助腹腔镜下Lich-Greqoir手术治疗儿童原发性膀胱输尿管反流的可行性、安全性和手术技巧。方法回顾性分析2014年5月至2019年2月上海市儿童医院收治的11例原发性膀胱输尿管反流患儿临床资料,其中男童10例,女童1例,均应用达芬奇系统辅助腹腔镜行Lich-Greqoir输尿管再植手术。患儿平均年龄9.4岁(3.2~18岁)。其中双侧4例,单侧7例。反流程度Ⅱ~Ⅳ级(Ⅱ级2侧,Ⅲ级3侧,Ⅳ级10侧)。结果患儿均采用Lich-Gregoir术式,术中患侧输尿管平均直径9 mm(5~15 mm),平均黏膜下隧道长度4.4 cm(3~6 cm)。术中无中转开放手术,单侧输尿管手术平均时间152 min(132~175 min),双侧输尿管手术平均时间257 min(249~264 min),术后平均住院时间4.5 d(3~6 d),1例双侧VUR患儿术后出现短期尿潴留,延长留置导尿管2周后痊愈。患儿平均随访时间2.5年(6个月至5.3年),所有病例均无发热性尿路感染,B超均未见患侧输尿管肾盂积水加重。术后完成VCUG 9例(其中双侧4例,单侧5例),其中1例双侧病例术后发现左侧反流Ⅰ级。结论机器人辅助腹腔镜下Lich-Greqoir手术治疗儿童原发性膀胱输尿管反流安全、有效,可以应用于3岁以上儿童的治疗。     

机器人辅助腹腔镜与传统腹腔镜在儿童肾盂成形术的应用价值

目的:评价机器人辅助腹腔镜在儿童肾盂成形术中的应用价值。方法:收集2018年1月至2019年12月在郑州大学第一附属医院小儿外科接受肾盂成形术的170例患儿的相关资料。将接受腹腔镜肾盂成形术(laparoscopic pyeloplasty,LP)的102例患儿作为LP组,其中男56例,女46例;患侧为左侧79例,右侧...     

机器人辅助腹腔镜与传统腹腔镜治疗儿童肾盂输尿管连接部梗阻的疗效对比

目的对比机器人辅助腹腔镜与传统腹腔镜治疗儿童肾盂输尿管连接部梗阻(ureteropelvic junction obstruction, UPJO)的疗效。方法本研究为回顾性研究, 以2021年1月至2022年5月在宁夏医科大学总医院小儿外科接受UPJO治疗的63例患儿为研究对象, 其中31例接受机器人辅助下腹腔镜肾盂成形术(robot-assisted laparoscopic pyeloplasty, RALP), 为RALP组;32例接受传统腹腔镜下肾盂成形术(laparoscopic pyeloplasty, LP), 为LP组。对比分析两组患儿年龄、性别、体重、手术时间、术中估计出血量、术后引流时间、术后住院时间和住院费用、肾盂前后径(anteroposterior diameter, APD)、肾盂与肾实质厚度比值(pelvis/cortex ratio, PCR)、分肾功能(differential renal function, DRF)等临床资料。结果两组均无一例中转开放手术。RALP组手术时间(119.87±15.64)min, LP组手术时间(128.53±36....     

腹腔镜下膀胱外输尿管膀胱再植术治疗儿童输尿管膀胱连接部异常21例报告

目的 探讨腹腔镜下膀胱外输尿管膀胱再植术治疗儿童输尿管膀胱连接部异常的临床疗效.方法 回顾性分析我院2014年10月至2016年1月用腹腔镜膀胱外输尿管膀胱再植术治疗21例输尿管膀胱连接部异常患儿的临床资料.其中输尿管膀胱连接部狭窄14例,输尿管膀胱连接部反流3例,输尿管异位开口4例.术前检查包括泌尿系统超声检查、泌尿系统CT三维重建成像检查、排泄性膀胱尿道造影和肾图检查.所有患儿术前检查均提示输尿管全程扩张,有反复尿路感染史14例,伴发肾积水9例,输尿管全程扩张达20 mm以上者6例,术前肾图结果提示异常者10例.结果 21例均经腹腔镜完成手术,无中转开放.手术时间120～170 min.术后4例出现轻度肉眼血尿,1d后消失.术后平均住院时间为8d,所有患儿术后无尿潴留发生,无吻合口漏发生.术后随访3～12个月,有2例发生尿路感染(9.5％),1例予口服抗生素及多饮水后缓解,1例抗感染治疗无效后,膀胱镜下取出双J管后缓解.术前肾图11例正常,10例患侧异常,术后3个月异常者有8例复查肾图,较术前有改善,失访2例.术后3～6个月超声复查输尿管直径均小于6mm.结论 腹腔镜下膀胱外输尿管膀胱再植术治疗儿童输尿管膀胱连接部异常疾病安全有效,术中用时合理、出血少,膀胱创伤小,肾功能有明显改善,临床疗效确切,且具有微创优势.     

达芬奇机器人辅助手术治疗儿童双侧肾盂输尿管连接部狭窄

目的 初步总结达芬奇机器人辅助手术治疗儿童双侧肾盂输尿管交界部狭窄的经验,探讨达芬奇机器人手术同时治疗双侧肾盂输尿管交界部的安全性和有效性.方法 回顾性分析中山大学附属第一医院小儿外科2016年1月至2019年11月采用达芬奇机器人辅助手术治疗的7例双侧肾盂输尿管交界部狭窄患者临床资料.7例均为男性,年龄4岁6个月至1...     

达芬奇机器人与传统腹腔镜在治疗小儿先天性胆总管囊肿的对比研究

目的对比达芬奇机器人与传统腹腔镜在治疗小儿先天性胆总管囊肿的优劣势。方法回顾性收集2018年3月至2019年9月郑州大学第一附属医院诊断为胆总管囊肿的103例患儿的临床资料,其中行达芬奇机器人手术的21例患儿作为机器人组,行传统腹腔镜治疗的82例患儿为腹腔镜组,所有手术均由同一团队完成。其中,机器人组患儿的年龄为(3.85±0.79)岁,范围为1~11岁;Todani分型为胆总管囊性扩张型(Ⅰ型)17例,其他分型4例;囊肿最大径为(36.76±10.13)mm,范围为16~79 mm。腹腔镜组患儿的年龄为(3.71±0.67)岁,范围为3个月至12岁;Todani分型为Ⅰ型70例,其他分型12例;囊肿最大径为(35.98±8.25)mm,范围为10~82 mm。分析两组在一般资料及术前情况、术中及术后等方面的差异。结果①机器人组与腹腔镜组患儿在年龄、性别、体重、临床表现、Todani分型、囊肿最大径、术前C反应蛋白(C-reactive protein,CRP)值、术后并发症发生率、术后疼痛评分方面差异无统计学意义(P>0.05);②机器人组的术中失血量、术后第一天及第三天腹腔引流液量、术后CRP值、术后禁食时间、术后出院时间均小于腹腔镜组,差异具有统计学意义(P<0.05)。结论达芬奇机器人在治疗小儿先天性胆总管囊肿方面较传统腹腔镜具有术中出血量少、组织损伤小、恢复快、愈合好等优点,具有可行性、安全性、有效性等优点。不足之处为手术总时间较长、费用较高。随着技术的进步及手术医生经验的积累,机器人治疗小儿先天性胆总管囊肿将会发挥更大的优势。     

Cohen再植术后反流影响因素的研究

目的 通过回顾性研究Cohen术围手术期各变量值,分析影响Cohen术后反流因素.方法 回顾性研究及追踪随访2008年1月至2013年12月我院收治的原发性膀胱输尿管反流(VUR)及原发性膀胱输尿管交界处梗阻(POM)患儿,排除继发反流及梗阻患儿,设置围手术期各个变量,对各变量进行统计学分析,找寻影响Cohen术后反流因素.结果 共随访218例原发VUR及POM,排除2例术中输尿管折叠再植术,1例术后出现对侧反流,1例术侧产生梗阻并发症.共纳入研究214例,其中VUR 74例,POM 140例.平均年龄3.7岁(7个月至17岁),平均手术时间72.3 min(60～95 min),平均出血5.5ml,随访时间6～53个月.19例患儿术后产生反流的并发症,其中11例通过保守治疗好转,8例通过再次Cohen术治愈,术后无反流率91.1％,最终手术成功率96.3％.经统计学检验发现在手术年龄7个月至17岁、输尿管黏膜下埋植长度与直径比2.5～7情况下,手术成功率与性别、年龄、病种、单双侧、反流度数、裁剪、埋植长度、埋植直径、埋植长度与直径比、支架管留置时间,导尿管留置时间、术前输尿管直径、术前泌尿系感染(UTI)无关(P＞0.05);输尿管黏膜下长度与直径比以≥5与＜5分成两组,两组手术成功率也无差异(P＞0.05).结论 在7个月至17岁、输尿管黏膜下埋植长度与直径比2.5～7情况下,Cohen术后反流与围手术期各个因素无关,即在此年龄段输尿管黏膜下埋植长度与直径比≥2.5即可起到抗反流作用.     

Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery

ObjectiveOur aim was to assess the outcomes of infant robot-assisted laparoscopic (RAL) upper urinary tract reconstruction.Materials and methodsThe medical records of all infants who underwent RAL upper urinary tract reconstruction were reviewed. Patients less than 1 year of age at surgery were included. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed.ResultsTen infants met the study criteria. There were five right and five left-sided procedures. Eight pyeloplasties (4 right, 4 left) and two ureteroureterostomies (1 right single system, 1 left duplex system) were performed. The median age was 8 months (range 3–12 months). Median weight was 7.7 kg (range 5.8–10.9 kg). Median operative time was 128 min (range 95–205 min). There was no significant blood loss or intraoperative complications. One (10%) patient received a regional block. Eight (80%) patients did not receive postoperative narcotics. Median hospital stay was 1 day (range 1–2). Median follow-up was 10 months (range 3–18 months). Complications included one urinary leak, one ileus, and one urinary tract infection. Hydronephrosis improved in all patients.ConclusionsInfant RAL upper urinary tract reconstruction is technically feasible, safe, and effective. It can be applied for duplication anomalies and single system obstructions in infants.     

Robot-assisted laparoscopic ureteral reimplantation with excisional tailoring for refluxing megaureter

ObjectiveTo demonstrate a novel technique for robot-assisted laparoscopic excisional tailoring and reimplantation of a refluxing megaureter.MethodsA 9-year-old boy with dysfunctional elimination was found to have a refluxing megaureter and diminished ipsilateral renal function. Robotic ureteral reimplantation with excisional tailoring was performed using a three-port approach. Stay sutures were placed in the anterior aspect of the distal ureter and sequentially lifted to allow freehand excision of redundant ureter. The ureterovesical junction was left intact, and the ureter was repaired over a 6 Fr double-J stent. Detrusorotomy to create flaps for ureteral tunneling was performed with a carbon dioxide (CO₂) laser.ResultsThe patient's vesicoureteral reflux was successfully corrected, and he is now asymptomatic.ConclusionSpecific technical modifications can facilitate robotic megaureter repair with intracorporeal excisional tailoring. The CO₂ laser is advantageous for detrusorotomy.     

Management of primary non-refluxing upper urinary tract dilation: an analysis of 219 pediatric patients

Antenatal ultrasound (US) examinations have changed the diagnostic approach to and management of malformative uropathies. Primary non-refluxing upper urinary tract (UUT) dilation is one of the urinary malformations that has undergone significant evolution in recent years. From January 1972 to June 1991, 219 children with primary non-refluxing megaureter (caliber more than 10 mm on radiologic examination) were admitted to our pediatric surgical department; 37 (16.8%) had bilateral UUT dilatation, an overall 256 renal units. The patients were divided into two groups: from January 1972 to June 1985 and from July 1985 to June 1991. In the latter period there was a considerable and progressive increase in admissions of infants in whom a prenatal US diagnosis of UUT dilation was made. A total of 186 renal units in 166 patients were operated upon; the success rate was 92%. A total of 70 megaureters (17 bilateral) in 53 patients were managed conservatively. The percentage of conservatively managed cases has increased in recent years; in almost all these patients the diagnosis was made antenatally. Our criteria for conservative management have been absence of obstruction and normal renal function as assessed by dynamic diuretic DTPA renography. These patients were carefully followed by serial US examinations and diuretic DTPA renograms. The follow-up of these 53 patients ranged from 6 months to 16 years with an average of 3 years 6 months; 47 have had a minimum follow-up of 18 months. In all these patients there has been progressive, spontaneous reduction or normalization of the dilation and no deterioration of renal function. In the authors opinion less than 50% of infants with grossly dilated non-refluxing megaureter diagnosed prenatally should be considered candidates for surgery, while the majority can be successfully managed without surgery. Correspondence to: G. Belloli