El-Sherbiny M T, Hafez A T, Ghoneim M A, Greenfield Saul P
Urology and Nephrology Center, Mansoura, Eygpt.
J Urol. 2002 Oct;168(4 Pt 2):1836-9; discussion 1839-40.
Ureteroneocystostomy in children with posterior urethral valves represents a surgical challenge. We reviewed our experience with this procedure to assess its indications and outcome.
Between 1996 and January 2000, 106 children with posterior urethral valves were treated of whom 20 (19%) underwent ureteroneocystostomy at a mean age plus or minus SD of 5 +/- 2.6 years. Indications for surgery were recurrent urinary infections despite adequate valve ablation in 14 patients of whom 7 had persistent reflux in 12 renal units and 7 had obstruction in 11 ureterovesical junctions. The remaining 6 patients were initially treated with high loop diversion and obstruction was confirmed in 9 ureterovesical junctions by the Whitaker test. Bladder function was assessed by videourodynamics before surgery. Transureteroureterostomy was performed in 7 ureters, and 25 ureters were tailored and reimplanted using the combined intravesical and extravesical approach, including a psoas hitch in 18 (72%).
Mean followup plus or minus SD was 2.3 +/- 1 years. Obstruction and reflux occurred in 1 (4%) and 9 (36%) ureteroneocystostomies, respectively. Obstruction was successfully managed by repeat surgery. Patients with reflux were maintained on chemoprophylaxis. No patient required repeat surgery and reflux did not resolve spontaneously in any. Reflux occurred in all ureteroneocystostomies without a psoas hitch (100%) and in 2 with a hitch (10%) (p <0.004). Dilatation of the upper tracts persisted in all patients. In 2 patients end stage renal disease developed. The remaining 18 patients had serial sterile urine cultures and with a mean serum creatinine plus or minus SD of 0.8 +/- 0.3 mg.%.
Ureteroneocystostomy is indicated for patients with persistent obstruction after high diversion or those with persistent reflux or obstruction and recurrent infections despite adequate valve ablation and a stable bladder. However, the procedure is associated with a high rate of postoperative reflux. Psoas hitch has a significant role in prevention of reflux.
后尿道瓣膜患儿的输尿管膀胱再植术是一项手术挑战。我们回顾了我们在该手术中的经验，以评估其适应证和结果。
1996年至2000年1月，106例后尿道瓣膜患儿接受了治疗，其中20例（19%）平均年龄为5±2.6岁时接受了输尿管膀胱再植术。手术适应证为：14例患儿尽管瓣膜切除充分，但仍反复发生泌尿系统感染，其中7例12个肾单位存在持续性反流，7例11个输尿管膀胱连接部存在梗阻。其余6例患儿最初接受高位造瘘治疗，经惠特克试验证实9个输尿管膀胱连接部存在梗阻。术前通过电视尿动力学评估膀胱功能。7条输尿管行输尿管输尿管吻合术，25条输尿管采用膀胱内和膀胱外联合方法进行裁剪和再植，其中18例（72%）采用腰大肌悬吊术。
平均随访时间为2.3±1年。输尿管膀胱再植术后，1例（4%）出现梗阻，9例（36%）出现反流。梗阻通过再次手术成功处理。反流患儿采用化学预防治疗。无患儿需要再次手术，且反流均未自行缓解。未行腰大肌悬吊术的输尿管膀胱再植术反流发生率为100%，行腰大肌悬吊术的2例反流发生率为10%（p<0.004）。所有患儿上尿路均持续扩张。2例患儿发展为终末期肾病。其余18例患儿连续进行无菌尿培养，平均血清肌酐为0.8±0.3mg%。
输尿管膀胱再植术适用于高位造瘘后仍存在持续性梗阻的患儿，或瓣膜切除充分且膀胱稳定但仍存在持续性反流、梗阻及反复感染的患儿。然而，该手术术后反流发生率较高。腰大肌悬吊术在预防反流方面具有重要作用。
