机器人辅助腹腔镜黏膜下隧道法输尿管再植术的临床疗效分析

目的:介绍黏膜下隧道法机器人辅助腹腔镜治疗1例医源性输尿管下段狭窄患者和1例单侧重复肾重复巨输尿管合并肾积水患者的学习经验和手术疗效.方法:回顾性分析机器人辅助腹腔镜治疗1例膀胱肿瘤电切术后左侧输尿管下段狭窄、左肾积水,患者抗反流输尿管膀胱吻合采用黏膜下隧道包埋法;1例(左侧)原发性梗阻重复肾重复巨输尿管症患者,首先分离巨输尿管前面和两侧面,保留输尿管和腹壁间系膜先不离断,测量输尿管,剪裁,放入F7双J管,缝合成形后再离断系膜,采用黏膜下隧道包埋法与膀胱再吻合.结果:2例患者手术均成功,无中转开放,手术时间分别为165.8min、176.2min,其中机器人定位时间30min;出血量分别为12.4ml、20.8ml;术后引流管拔除时间第1例5d,第2例6d,2例患者均无明显漏尿,术后尿管拔除时间为14d.术后随访6个月,复查CT和彩超显示肾积水明显减轻,未见输尿管吻合口狭窄和输尿管反流.结论:机器人辅助腹腔镜黏膜下隧道法输尿管膀胱再植术治疗复杂的输尿管下段狭窄和复杂的巨输尿管症安全有效.     

先天性巨输尿管症25例

目的：探讨先天性巨输尿管症的诊治方法。方法：报告25例先天性巨输尿管症，其中左侧13例，右侧10例，双侧2例。25例中行肾输尿管切除术6例，行输尿管膀胱吻合术12例。结果：12例输尿管膀胱吻合术均成功。结论：儿童患应尽早手术治疗，成人患可根据病变采用保守或手术治疗。治疗本症的原则是解除梗阻，尽量保留肾功能。理想的手术方式是输尿管裁剪加输尿管膀胱吻合术。     

巨输尿管症22例诊治报告并文献复习

目的探讨巨输尿管症的治疗方法。方法回顾性分析22例巨输尿管症患者的临床资料,其中男16例,女6例;左侧12例,右侧6例,双侧4例。结果 12例行输尿管整形后膀胱再植术,6例行输尿管支架管植入术,4例行患侧无功能肾切除术。随访1~6年,12例再植术后肾功能均正常,10例肾积水明显减轻,吻合口无狭窄及膀胱输尿管无返流,2例术后输尿管及肾脏积水无改善,长期观察肾积水无加重且无临床症状,未进一步治疗;6例行支架管置入术后积水可减轻,拔出支架管后5例肾积水程度无变化,1例渐加重,伴发热,给予行肾脏穿刺引流后行输尿管膀胱再植术,术后肾积水明显减轻;4例肾切除术后对侧肾脏功能正常。结论 IVU检查诊断梗阻型巨输尿管症显影率低,MRU具有较好的应用前景;巨输尿管症治疗原则是解除梗阻,保持输尿管通畅并防止返流及狭窄;最佳手术治疗方法是进行输尿管整形(裁剪或折叠)后膀胱再植术,保守治疗也可作为治疗的选择之一。     

巨输尿管症的临床特征(附21例报告)

目的：探讨巨输尿管症的临床特征。方法：对21例巨输尿管症患者均行B超和放射学检查；确诊后均行开放手术治疗，其中2例行患肾输尿管切除术，余19例行输尿管下段裁剪整形或折叠后行输尿管膀胱再吻合术。保肾手术者如有输尿管末段(或)端狭窄均于术中先行切除。结果：16例患者获1～3年随访，均行IVU复查，14例肾积水减轻，肾功能较术前有所改善，2例无明显变化。结论：B超、静脉尿路造影(IVU)、逆行尿路造影(RPG)及膀胱尿道造影是诊断巨输尿管症的主要检查手段；输尿管裁剪或折叠加输尿管膀胱吻合术是治疗巨输尿管症的理想手术方式。     

小儿腹腔镜下巨输尿管成形术

目的 探讨小儿腹腔镜下输尿管铲状乳头膀胱再植术的可行性和临床效果.方法采用经膀胱外途径行腹腔镜下输尿管铲状乳头膀胱再植术治疗先天性梗阻性巨输尿管症患儿11例.年龄11个月～13岁,平均(5.3±3.9)岁.左侧4例,右侧7例.其中输尿管出口闭锁1例、单纯性输尿管出口狭窄9例、开放输尿管膀胱再植术后(Cohen手术)输尿管出口狭窄1例.B超和IVU示重度肾积水7例、中度肾积水4例. 结果 11例手术均获成功.手术时间70～190 min,平均(103.O±35.3)min.术中出血10～40 ml,平均(18.0±9.5)ml.术后住院时间7～10 d,平均(8.0±1.4)d.无尿漏发生.术后6周拔除双J管,膀胱镜或输尿管镜下见膀胱输尿管吻合口已黏膜化,乳头收缩抗反流效果满意;11例平均随访6(3～24)个月,B超复查患侧肾积水减轻;IVU示成形输尿管排尿好,无梗阻,症状基本消失;膀胱造影未见膀胱输尿管反流. 结论 在熟练掌握腹腔镜操作技术后,应用经膀胱外途径腹腔镜下输尿管铲状乳头膀胱再植术治疗小儿梗阻性巨输尿管症创伤小、抗反流效果好,是治疗小儿梗阻性巨输尿管症的微创新途径.     

原发性巨输尿管症合并结石行体外碎石疗效

目的探讨原发性巨输尿管合并结石行体外冲击波碎石治疗的可行性，为临床治疗提供参考。 方法2013年1月至2018年6月武警陕西省总队医院试探性对原发性巨输尿管合并结石患者行体外冲击波碎石治疗，观察疗效，总结经验。12例患者中有14侧巨输尿管，其中右侧4例，左侧6例，双侧2例；输尿管全程扩张5例，中下段扩张7例；巨输尿管内经1.5～2.5 cm，平均（1.9±0.4）cm；治疗的结石中输尿管结石11例，肾结石1例；结石长径0.6～1.9 cm，平均（1.2±0.4）cm。 结果1例碎石1次后放弃体外碎石治疗选择了输尿管镜碎石取石术，11例最终将结石成功排出，碎石1次～5次，平均（2.4±1.6）次，成功率91.67%，其中碎石1次成功率33.33%。并发症发生率25%，包括肉眼血尿、排石过程中疼痛、呕吐，无严重并发症。 结论原发性巨输尿管合并的结石可采用体外冲击波碎石治疗，但1次碎石成功率较低。     

Refluxing ureteral reimplant as temporary treatment of obstructive megaureter in neonate and infant

PURPOSE: An obstructive megaureter identified in the neonatal period can be managed using a number of techniques, with the primary goal being to minimize the potential for further injury to the affected kidney. We describe our experience with refluxing ureteral reimplantation as a novel method for temporizing the obstructive megaureter. MATERIALS AND METHODS: Three patients identified prenatally with severe hydroureteronephrosis were confirmed following delivery to have an obstructive ectopic ureter. Unilateral obstruction was identified in 2 patients (1 female, 1 male). The third patient was a female with bilateral single system ectopic ureters. Treatment consisted of anastomosing the ureter proximal to the obstruction to the dome of the bladder in a freely high grade refluxing fashion. All of the patients were placed on antibiotic suppression after surgery. RESULTS: All patients demonstrated improved drainage of the affected kidney(s) following surgery. One female patient with unilateral obstruction had a poorly functioning kidney that showed no improvement of renal function 6 months following refluxing reimplantation, and laparoscopic nephrectomy was performed. The male patient with unilateral obstruction had adequate function with a significantly decreased ureteral diameter 1 year following refluxing ureteral reimplant, and a ureteral reimplantation without tapering was performed. The female patient with bilateral obstruction had 1 breakthrough urinary tract infection 6 months after surgery and now awaits second stage repair. CONCLUSIONS: Refluxing ureteral reimplantation is a safe, easy, beneficial and well tolerated means of temporizing the obstructive megaureter. This technique allows time for the child to mature, while accurately establishing renal function and preparing for a definitive surgical solution.     

The long-term outcome of bilateral Cohen ureteric reimplantation under a common submucosal tunnel

OBJECTIVE: To analyse the results of bilateral Cohen reimplantation under a common submucosal tunnel, over an 18-year period. PATIENTS AND METHODS: We retrospectively examined 102 children (35 boys and 67 girls, median age 5.5 years, range 0.5-13.5) who underwent bilateral antireflux ureteric reimplantation from 1983 to 2000 with a modified Cohen technique, re-implanting both ureters under a common submucosal tunnel in the mid-trigonal area, to treat primary vesico-ureteric reflux (VUR, 99 patients) or obstructive megaureter (three). The mean (range) follow-up was 10.6 (2-18) years. RESULTS: The operation was successful in 198 of 204 (97%) ureters. One patient had vesico-ureteric stenosis in one ureter and was re-operated successfully. In two ureters in two different patients there was transient stasis after surgery caused by oedema within the tunnel, which gradually resolved. Two ureters in two other patients had reflux after surgery, which resolved spontaneously after 12 and 24 months, respectively. A 6-month old baby had anuria after surgery because of acute compression of both ureters within a narrow tunnel; this patient was re-operated, the tunnel widened and the obstruction resolved. None of 82 patients who had reached school age by the time of their last follow-up showed signs of voiding dysfunction. CONCLUSIONS: The modified bilateral Cohen reimplantation with both ureters under a common submucosal tunnel offers very good long-term results in curing VUR or obstructive megaureter. Crossing one ureter upon the other within the tunnel does not predispose to long-term obstruction. From these results we recommend it as a reliable technique for surgically treating bilateral VUR or obstructive megaureter.     

Ureteraugmentation der Blase bei Kindern mit „Low-compliance-Blase“

In cases of inadequate or insufficient conservative treatment of non-compliant bladders the function of the upper urinary tract is jeopardized. We present our experience with ureterocystoplasty as one possible treatment option.A total of eight children underwent ureterocystoplasty. The etiology of bladder non-compliance and the need for augmentation was neurogenic in five children, posterior urethral valves in two children, and in one child after repeated antireflux surgery. In all patients the kidney of the used ureter was functionless. Surgery was done through a transperitoneal approach. Following nephrectomy, the renal pelvis and the ureter were spatulated and sutured into the bladder incision. An additional MACE procedure was performed in three patients, antireflux surgery for the contralateral kidney in two patients, and one patient underwent stone removal in the remaining kidney. In one patient the ureter was used as a free transplant and was covered by an omental flap. In addition a simultaneous living donor kidney transplant was performed.The storage function could be improved in all patients. The function of the ureter which was used as a free transplant showed good clinical results. The longest follow-up is 8 years. Ureterocystoplasty is a useful and metabolically neutral alternative to bowel segments. In patients with only one functioning kidney and a contralateral megaureter, ureterocystoplasty is the treatment of choice in our institution.     

Laparoscopic nephroureterectomy for dysplastic kidney in children: an initial experience

BACKGROUND: Laparoscopic nephroureterectomy for dysplastic kidney is now becoming a widely accepted procedure. We report here our initial experience with laparoscopic nephroureterectomy in four girls. METHODS: Between 1993 and 1999, laparoscopic nephroureterectomy was performed in four girls (mean age 5.3 years). Three patients had an ectopic dysplastic kidney with ectopic ureter, and one patient had hydronephrosis with megaureter due to distal ureteral atresia of the upper moiety in a duplicated dysplastic kidney. The transperitoneal approach was used in all cases. RESULTS: Mean operative time was 195 min (range 150-266). Blood loss was minimal. All operations were completed successfully and there were no intraoperative or postoperative complications except for subcutaneous emphysema in one patient (case 4). Postoperative analgesia was used in three patients and administered in the form of diclofenac sodium suppositories 12.5 mg (cases 1 and 2) or acetaminophen suppositories 50 mg (case 3) for 1-2 days. One patient did not require any analgesia (case 4). Oral fluid intake was resumed on the first postoperative day and ambulation began within 1-3 days (mean 1.6, cases 1, 2 and 3) and 6 days (case 4). All children returned to normal activity within 3-6 days of surgery. Mean postoperative hospital stay was 7.3 days. All cases had uneventful courses after discharge. CONCLUSION: Laparoscopic nephroureterectomy can be performed safely, with minimal postoperative pain, excellent cosmetic results and early ambulation. We advocate the use of laparoscopy for the diagnosis and treatment of dysplastic kidney with ectopic ureter.     

Refluxing megaureter for the Mitrofanoff channel using continent extravesical detrusor tunneling procedure

PURPOSE: We present a variation on the continent procedure using the refluxing megaureter for the Mitrofanoff channel, and its results. MATERIALS AND METHODS: The Mitrofanoff procedure using the refluxing megaureter was performed in 35 patients (valve bladder syndrome 15, neurogenic bladder 10, non-neurogenic bladder 10) between 1995 and 2001. Mean patient age was 5.9 years. In 5 patients the distal segment of the megaureter was used after nephrectomy, and in 30 patients the proximal segment of the megaureter was simultaneously reimplanted unilaterally. The distal segment of the megaureter was inserted under the detrusor close to the native hiatus, pulled through the tunnel between the unresected detrusor and the mucosa, and subsequently brought to the abdominal wall. The ureterovesical junction was left intact. RESULTS: In all of our patients we obtained sufficient length and good vascularization of both ureteral segments. Satisfactory tunnel length was achieved in 29 patients. In 6 cases the tunnel was elongated by dissection of the detrusor. Median followup was 37 months. Three patients had development of stenosis at the stoma level, which resolved with minimal revision at the ureter-skin level. Minimal leakage occurred in 3 patients, all of whom were successfully treated with anticholinergics. On routine followup no patient had signs of reflux recurrence in the reimplanted ureter. CONCLUSIONS: The results of our variant procedure expand the number of patients who may benefit from use of the ureter for the Mitrofanoff channel.     

先天性巨输尿管症的超声显像诊断

报道资料完整和经手术与病理证实的１３例１５侧先天性巨输尿管症的超声显像诊断结果，符合率为９２．３％（１２／１３）。巨输尿管症主要声像图表现管腔扩张内径为１．８～４．２ｃｍ，平均３．１ｃｍ，患侧肾多伴有轻度或中度积水。输尿管中下段局部显著扩张者７例，全程呈柱状扩张者６例。扩张输尿管可有迂曲，巨输尿管近狭窄段可呈杵指状、梭形或鼠尾状扩张。实时观察可见输尿管蠕动频率低，蠕动波幅增大，蠕动波向下传递间断或波幅逐渐减小等声像图表现。超声显像诊断本病时，主要应与输尿管机械性梗阻鉴别。     

成人先天性巨输尿管症30例报告

目的 :探讨成人先天性巨输尿管症的诊治方法。方法 :报告 30例成人先天性巨输尿管症 ,其中左侧 18例 ,右侧 7例 ,双侧 5例。 30例中行肾输尿管切除术 2例 ;行输尿管膀胱吻合术 2 8例 ,其中先行肾造瘘术 ,二期行输尿管膀胱吻合术 5例。结果 :2 8例输尿管膀胱吻合术中 ,成功 2 6例 ,成功率 92 .9%。结论 :对静脉肾盂造影不显影的患肾应行同位素肾动态显像 ,以决定手术方案。治疗本症的原则是解除梗阻 ,尽量保留肾功能。理想的手术方式是输尿管裁剪加输尿管膀胱吻合术     

先天性巨输尿管症的诊治体会（附9例报告）

目的：探讨先天性巨输尿管症的诊治特点。方法：9例先天性巨输尿管症,其中左侧4例,右侧2例,双侧3例。主诉症状不典型,最终经B超、KUB＋IVP、膀胱镜逆行插管造影、CT、MRU等检查确诊。采用输尿管中、下段裁剪、坑逆流输尿管膀胱再植术5例。1例先行肾盂穿刺造瘘术,3个月后行输尿管膀胱再植术。因肾重度积水,功能严重受损而行。肾、输尿管切除术1例。1例行输尿管末端切开术。1例行保守治疗,定期更换双J管。结果：输尿管膀胱再植术6例（包括先行肾盂穿刺造瘘术,3个月后再行输尿管膀胱再植术的患者）,均于6-12周后拔除支架管或双J管（幼儿患者约6周拔除支架管导尿管,成人患者约2-3个月拔除双J管）。术后随访经B超及静脉肾盂造影检查,显示患侧输尿管扩张度和肾积水均明显减轻。1例行输尿管末端内切开术的患者在术后3个月拔除并更换双J管1次,复查B超亦提示恢复良好。保守治疗的1例患者到目前为止,病情尚无恶化征象。结论：B超和KUB＋IVP检查是诊断先天性巨输尿管症的首选检查方法,但MRU近年体现出更多的诊断优势。治疗本症的原则是解除梗阻,尽量保留肾功能。手术方式以输尿管剪裁或折叠加输尿管膀胱吻合术为主,但腹腔镜和内镜手术也逐渐受到重视。肾功能尚好者也可行扩张或放置内支架等保守治疗。     

先天性巨大输尿管积水的诊断与治疗(附六例报告)

目的　提高先天性巨大输尿管积水的诊治水平。　方法　对 6例病例资料进行回顾性总结并从胚胎学、诊断及治疗方法方面进行探讨。　结果　 6例病人均有输尿管极度迂曲、扩张 ,并伴有肾发育不全 ,采用患侧肾、输尿管全切除术取得良好效果。　结论　结合病史、查体及B超、CT及IVU检查可确定诊断 ,手术切除发育不全的小肾脏及扩张的输尿管是主要治疗方法     

先天性巨输尿管症(附10例报告)

目的：探讨手术治疗先天性巨输尿管症的时机和有效性。方法：总结本病１０例,其中男６例,女４例,儿童４例,成人６例,左侧４例,右侧２例,双侧４例。保守治疗１例;手术治疗９例,包括输尿管剪裁整形再植术５例,肾输尿管全切术４例。结果：９例获随访３个月－６年。４例患儿发育正常,健肾代偿性增大。     

Ureterocystoplasty: a novel approach to augment small capacity urinary bladder in adults

Ureterocystoplasty is a novel operation well suited for patients having small capacity urinary bladder with unilateral poorly functioning kidney and megaureter. The megaureter is detubularized and used for urinary bladder augmentation. The ureter lining has advantage of being non-secretory and free from the metabolic complications of enterocystoplasty. This operation is mainly done in children. This is one of the very few from the Asian subcontinent which describes the short term results of ureterocystoplasty in an adult patient. We report a case wherein ureterocystoplasty was performed in an 18-year male presented with a small capacity neurogenic bladder with a grossly dilated and tortuous left ureter and a non-functioning left kidney. Left ureter was detubularized and used for augmentation after left nephrectomy. Blood supply to the left ureter was preserved during the dissection. After the operation, the bladder capacity increased adequately and he is doing well at a followup of 1 year. Ureterocystoplasty works well in the adult patients also and the bladder capacity increases adequately following this procedure.     

成人先天性巨输尿管症37例诊疗分析

目的：探讨成人先天性巨输尿管症（CM）的诊治方法.方法：回顾性分析37例成人CM的临床资料：男18例,女19例.左侧18例,右侧10例,双侧9例.超声检查、静脉尿路造影（IVU）检查提示输尿管全段扩张伴肾盂积水22例,输尿管下段扩张9例.IVU不显影或显影不清13例;同位素肾动态显像检查提示患肾不同程度损害.手术治疗34例,其中行肾输尿管切除术2例,输尿管膀胱再植术32例.间断性双J管置入1例,保守观察2例.结果：随访32例,随访时间4个月～20年.患侧肾输尿管积水减轻29例,无明显变化3例.结论：成人CM的诊断主要依据影像学检查.治疗原则为解除梗阻、尽量保留息肾功能,应根据输尿管扩张程度选择输尿管折叠或裁剪加输尿管膀胱再植术,吻合方法推荐Lich-Gregoir术式;肾功能良好、无明显症状者可保守治疗.     

Reparación totalmente laparoscópica de megauréter obstructivo primario con pieloplastia,preparación escisional completa y reimplante ureteral sin reflujo

ObjectiveTo describe a new surgical technique of the first case of totally laparoscopic repair of primary obstructive congenital megaureter with pyeloplasty, intracorporeal excisional tailoring of the ureter and nonrefluxing ureteroneocystostomy.MethodsA 15-year-old male presented with obstructive megaureter. The standard three-port transperitoneal pyeloplasty technique and an additional 5-mm port for dynamic traction were used. Pelvic and ureteral dissection, pyeloplasty, intracorporeal excisional ureteral tailoring and nonrefluxing ureteroneocystostomy were all completed laparoscopically. A double-J stent was used to calibrate the ureter.ResultsOperative time was 240 min. No intra and postoperative complications were observed, and there was discharge on postoperative day 2. The patient was pain-free and without urinary tract infection during the 4-month period after surgery. Follow up revealed complete resolution of the ureteral obstruction and adequate pelvic and ureteral caliber.ConclusionLaparoscopic pyeloplasty, intracorporeal excisional tailoring, and non-refluxing reimplantation are safe and effective for the treatment of obstructive congenital megaureter. The totally laparoscopic approach is reproducible and provides low morbidity with inherent cosmetic advantages.     

后腹腔镜及经腹膜外径路腹腔镜技术在泌尿外科器官保留、功能重建手术中的应用

目的：探讨后腹腔镜及经腹膜外径路腹腔镜技术在泌尿外科器官保留、功能重建手术中的应用方法,并评价其治疗效果。方法：2000年7月～2005年8月完成后腹腔镜及经腹膜外径路泌尿外科器官保留、功能重建手术71例,包括重复肾切除术4例,肾部分切除术8例,肾盂成形术13例,肾盂输尿管切开取石术30例,腔静脉后输尿管成形术2例,先天性巨输尿管成形术1例,膀胱部分切除术4例,前列腺癌根治术9例。结果：71例均一次成功,手术时间30～270min,平均85min,术中出血少。术后腹膜后及腹膜外引流量少,3～5天拔出引流管,多无明显并发症。术后5天～2周出院（平均8．6K）。结论：经腹膜外径路腹腔镜手术具有创伤小、安全、术后恢复快、住院时间短、并发症少等优点,在泌尿外科器官保留及功能重建手术中具有明显优势。