Lapointe S P, Charbit M, Jan D, Lortat-Jacob S, Michel J L, Beurton D, Gagnadoux M F, Niaudet P, Broyer M, Révillon Y
CHUL-Centre Hopitalier Universitaire de Québec, Ste-Foy, Quebec, Canada.
J Urol. 2001 Sep;166(3):1046-8.
Ureterovesical reimplantation is most often performed for renal transplantation in children. We reviewed our experience to evaluate the safety and efficacy of ureteroureteral reimplantation in pediatric renal transplantation.
We retrospectively evaluated the charts of 92 boys and 72 girls who underwent a total of 166 ureteroureteral anastomoses for renal transplantation from January 1990 to December 1999. Spatulated end-to-end anastomosis was performed between recipient and graft ureters without stenting and with a bladder catheter for at least 10 days.
Mean patient age at transplantation was 11.2 years (range 1 to 21.5). There were 22 living related donor and 144 cadaveric grafts. Urological anomalies and nephropathy were the cause of end stage renal disease in 146 and 20 patients, respectively. Urological complications were noted in 14 of the 166 transplantations (8.4%) in 10 boys and 4 girls, including 12 initial and 2 repeat grafts from 2 living related and 12 cadaveric donors. Five of these patients had undergone previous urological surgery. The 2 children (1.2%) with acute ureteral obstruction underwent repeat intervention after stent failure. Anastomotic leakage in 7 cases (4.2%) was treated conservatively in 1 and with a Double-J stent (Medical Engineering Corp., New York, New York) only required in 3. Reoperation was required in 3 cases. One patient (0.6%) with late ureteral stenosis underwent repeat anastomosis, 1 (0.6%) required reimplantation for recurrent pyelonephritis due to vesicoureteral reflux in the graft, 1 (0.6%) with a valve bladder required bladder augmentation and ureteral reimplantation, and 1 (0.6%) with lymphocele and 1 (0.6%) with lithiasis were successfully treated conservatively. Complications were associated with acute rejection in 6 cases. Mean followup without graft loss in patients who presented with versus without complications was 58.3 months (range 1 to 112) versus 75 (range 1 to 118). In the former patients with a mean age of 16 years 9 months versus those without urological complications mean serum creatinine was 116 and 108 mol./l., respectively. Two grafts were lost in patients with urological complications, including 1 who died of pulmonary embolism and 1 with refractory chronic rejection. Seven patients were lost to followup after 54 months (range 12 to 113) of adequate graft function.
Ureteroureteral anastomosis is a safe and effective technique for pediatric renal transplantation with a low complication rate, which may be due to better vascularization of the shorter ureteral end of the graft. Our results should encourage the use of this technique in pediatric renal transplantation. Efforts to preserve the recipient ureters should be made at nephrectomy.
输尿管膀胱再植术最常用于儿童肾移植。我们回顾了我们的经验，以评估输尿管输尿管再植术在小儿肾移植中的安全性和有效性。
我们回顾性评估了1990年1月至1999年12月期间接受了166次输尿管输尿管吻合术进行肾移植的92名男孩和72名女孩的病历。在受体和移植输尿管之间进行了铲形端端吻合，不放置支架，并留置膀胱导管至少10天。
移植时患者的平均年龄为11.2岁（范围1至21.5岁）。有22例活体亲属供体和144例尸体供体移植。泌尿系统异常和肾病分别是146例和20例终末期肾病的病因。166例移植中有14例（8.4%）出现泌尿系统并发症，其中10名男孩和4名女孩，包括来自2名活体亲属和12名尸体供体的12例初次移植和2例再次移植。这些患者中有5例曾接受过泌尿外科手术。2名（1.2%）发生急性输尿管梗阻的儿童在支架置入失败后接受了再次干预。7例（4.2%）吻合口漏，1例保守治疗，3例仅需置入双J支架（纽约医学工程公司）。3例需要再次手术。1例（0.6%）晚期输尿管狭窄患者接受了再次吻合，1例（0.6%）因移植肾膀胱输尿管反流反复肾盂肾炎需要再植，1例（0.6%）瓣膜膀胱患者需要膀胱扩大和输尿管再植，1例（0.6%）淋巴囊肿和1例（0.6%）结石患者保守治疗成功。6例并发症与急性排斥反应有关。出现并发症与未出现并发症的患者无移植肾丢失的平均随访时间分别为58.3个月（范围1至112个月）和75个月（范围1至118个月）。前一组患者平均年龄为16岁9个月，与无泌尿系统并发症的患者相比，血清肌酐分别为116和108μmol/L。2例泌尿系统并发症患者移植肾丢失，包括1例死于肺栓塞和1例难治性慢性排斥反应。7例患者在移植肾功能良好54个月（范围12至113个月）后失访。
输尿管输尿管吻合术是小儿肾移植的一种安全有效的技术，并发症发生率低，这可能是由于移植肾较短输尿管端的血运较好。我们的结果应鼓励在小儿肾移植中使用该技术。肾切除术时应努力保留受体输尿管。
