儿童肾盂输尿管成形术后不同引流方式的比较研究

目的探讨腹腔镜下肾盂输尿管成形术后的最佳引流方式。方法以2016年1月至2019年12月重庆医科大学附属儿童医院收治的165例接受经腹入路腹腔镜下Anderson-Hynes肾盂成形术治疗的肾积水患者为研究对象,根据不同引流方式分为双J管组和支架管组,双J管组采用常规术中输尿管,置入双J管引流肾盂内尿液至膀胱(n=108);支架管组采用F4输尿管支架管经肾盂至尿道外口,引流肾盂内尿液至体外(n=57)。通过术后并发症、有无非计划再手术、拔管后自觉症状、术后住院时间以及住院费用等指标,评价两种不同引流方式在儿童肾盂输尿管成形术中的疗效。结果所有患者从术后随访至2019年12月,随访时间为2个月至4年。支架管组中4例发生术后感染,3例术后出现尿外渗,4例出现术后血尿;双J管组中7例发生术后感染,2例术后出现尿外渗,2例出现术后血尿,上述指标差异均无统计学意义(P>0.05)。但在总体并发症发生率上,双J管组低于支架管组。支架管组中4例因拔管后出现输尿管引流不畅,再次行输尿管支架管置入术;2例因肾积水复发,再次行肾盂输尿管成形术。双J管组中有4例术后感染,1例双J管堵塞,均行双J管拔除+输尿管支架管置入术,1例因肾积水复发再次行肾盂输尿管成形术。支架管组总体非计划再手术率为10%,双J管组为5%,差异无统计学意义(P>0.05)。双J管组中,1例管腔堵塞,2例支架管上移,1例双J管脱出体外,支架管组无一例管腔堵塞、移位及脱落情况发生,差异无统计学意义(P>0.05)。支架管组中拔管后,1例出现腹胀合并高血压,8例出现腹胀伴纳差,2例出现腹痛,双J管组拔管后有2例出现腹痛,1例出现腹胀。支架管组拔管后总体不良反应发生率为19.2%,双J管组为2.7%,差异有统计学意义(P<0.05)。双J管组平均住院时间为(5.8±1.9)d,支架管组为(8.8±2.3)d,差异有统计学意义(P<0.05)。结论双J管和支架管两种引流方式在术后并发症发生率及非计划再手术率上并无差异,两者均为有效的引流方式。但在缩短住院时间、减轻患者家属经济成本及降低拔管后不良反应发生率方面,双J管引流均优于支架管引流。支架管引流在带管期间无堵塞、移位、脱落的情况发生,并且可避免二次入院,对于交通不便的患者可考虑选择。

Comparison of different drainage methods after ureteroplasty in children

Objective To explore the optimal drainage method after laparoscopic pelvic ureteroplasty.Methods From January 2016 to December 2019,a total of 165 hydronephrotic children undergoing Anderson-Hynes pyeloplasty under laparoscopic peritoneal approach were divided into two groups.Group A:conventional intraoperative ureter was employed and a double J tube inserted for draining urine from renal pelvis to bladder(double J tube group,n=108);group B:a F4 ureteral stent tube was deposited through renal pelvis to outer urethra to drain urine from renal pelvis to body(stent tube group,n=57).With the indicators of postoperative complications,unplanned reoperation,post-extubation symptoms,postoperative hospital stay and hospitalization costs,the efficacy was evaluated for two different drainage methods after pyeureteroplasty.Results The postoperative follow-up period was until December 2019.The longest follow-up time was 48 months and the shortest 2 months.In stent tube group,there were postoperative infection(n=4),urinary extravasation(n=3)and postoperative hematuria(n=4);in double J tube group,postoperative infection(n=7),urinary extravasation(n=2)and postoperative hematuria(n=2).No significant difference existed in the above indicators(P>0.05).However,the overall complication rate was lower in double J tube group than stent tube group.In stent group,4 cases underwent ureteral stenting for poor ureteral drainage after extubation;ureteroplasty was performed for 2 cases due to recurrent hydronephrosis.In double J tube group,there were postoperative infection(n=4)and double J tube blockage(n=1).All underwent double J tube removal plus ureteral stenting and one case of recurrent hydronephrosis underwent pyeloplasty.The overall unplanned reoperative rate was 10% in stent tube group and 5% in double J tube group and the difference was not statistically significant(P>0.05).In double J tube group,there were lumen blockage(n=1),upward movement of stent tube(n=2)and prolapse of double J tube(n=1).There was no lumen blockage,displacement or shedding in stent tube group and the difference was not statistically significant(P>0.05).In stent tube group,there were abdominal distension&hypertension post-extubation(n=1),abdominal distension(n=8)and anorexia&abdominal pain(n=2).In double J tube group,abdominal pain post-extubation(n=2)and abdominal distension(n=1).The overall adverse reaction rate post-extubation was 19.2%in stent tube group and 2.7%in double J tube group.And the difference was statistically significant(P<0.05).The average hospital stay was(5.8±1.9)days in double J tube group and(8.8±2.3)days in stent tube group.And the difference was statistically significant(P<0.05).Conclusion No inter-group difference existed in the incidence of postoperative complications or the rate of unplanned reoperation.Both drainage methods are effective.However,double J tube is better than stent tube in terms of shorter hospital stay,lower economic costs of children's family members and a lower incidence of adverse reactions post-extubation.The stent tube group has no blockage,displacement or falling off during tube period and avoids secondary hospitalization.It is recommended for for families with children with inconvenient transportation.