Lakshmanan Y, Mathews R I, Cadeddu J A, Chen R N, Slaughenhoupt B L, Moore R G, Docimo S G
Division of Pediatric Urology, James Buchanan Brady Urological Institute, The Johns Hopkins Hospital, Baltimore, Maryland 21287-2101, USA.
J Endourol. 1999 Feb;13(1):41-5. doi: 10.1089/end.1999.13.41.
The aim of minimally invasive approaches to vesicoureteral reflux, such as endoscopic trigonoplasty, is to lower the morbidity of open procedures without compromising the results. Initial successes have not been sustained, mainly because of trigonal splitting, which results in the ureteral orifices returning to their preoperative positions. This study was designed to address trigonal splitting by mobilizing the ureters before repositioning them and to evaluate the feasibility of accomplishing this intravesically with 2- to 3-mm endoscopic mini-instruments.
Bilateral vesicoureteral reflux was surgically created in 10 minipigs. After radiologic confirmation of success 4 weeks later, modified trigonoplasty was performed by endoscopic intravesical mobilization of both ureters and incision of the trigonal mucosa using 2-mm instruments. The ureteral orifices were then advanced toward the midline and sutured in place. The initial surgical techniques were modified to permit the entire procedure to be performed endoscopically in the last four minipigs. Cystograms and intravenous urograms were obtained 4 weeks later.
Two minipigs died postoperatively. Six of the remaining eight had persistent reflux, including three of the four in the group treated completely by endoscopic means. None of the dissected ureters showed evidence of stricture or necrosis.
Although the procedure was not successful in correcting reflux in this model, this study demonstrates the feasibility of endoscopic ureteral mobilization. With current instrumentation, there is no significant technical obstacle to complete intravesical endoscopic surgery, including ureteral reimplantation.
诸如内镜下膀胱三角成形术等治疗膀胱输尿管反流的微创方法旨在降低开放手术的发病率，同时不影响治疗效果。最初的成功并未持续，主要是因为膀胱三角区裂开，导致输尿管口回到术前位置。本研究旨在通过在重新定位输尿管之前游离输尿管来解决膀胱三角区裂开问题，并评估使用2至3毫米的内镜微型器械在膀胱内完成该操作的可行性。
在10只小型猪身上手术制造双侧膀胱输尿管反流。4周后经放射学确认成功后，使用2毫米器械通过内镜在膀胱内游离双侧输尿管并切开膀胱三角区黏膜，进行改良膀胱三角成形术。然后将输尿管口向中线推进并缝合到位。对最初的手术技术进行了改进，以便在最后4只小型猪中完全通过内镜进行整个手术。4周后获得膀胱造影和静脉肾盂造影。
2只小型猪术后死亡。其余8只中有6只仍有持续性反流，包括完全通过内镜治疗的4只中的3只。所有游离的输尿管均未显示出狭窄或坏死的迹象。
尽管该手术在本模型中未能成功纠正反流，但本研究证明了内镜下输尿管游离的可行性。使用目前的器械，完全在膀胱内进行内镜手术，包括输尿管再植术，没有重大技术障碍。
