Laven Brett A, O'Connor R Corey, Gerber Glenn S, Steinberg Gary D
Department of Surgery, University of Chicago, Illinois, USA.
J Urol. 2003 Oct;170(4 Pt 1):1226-30. doi: 10.1097/01.ju.0000086701.68756.8f.
Prior studies have demonstrated that while endoureterotomy offers a reasonable initial treatment option, open anastomotic revision should remain the gold standard for managing ureteroenteric strictures. However, to our knowledge the results of contemporary endoureterotomy series have not been compared with those of open anastomotic revision, and no study has assessed the morbidity or success rate of secondary open anastomotic revision after failed endoureterotomy.
Between May 1997 and August 2002 a total of 31 renal units in 22 patients were treated for ureteroenteric strictures after radical cystectomy and urinary diversion. A total of 16 renal units were treated endoscopically, including 9 on the left and 7 on the right side, and open revision was performed in 15 renal units, including 9 on the left and 6 on the right side. Success was defined as radiological improvement and/or the ability to return to full activity in the absence of flank pain, infection, or the need for ureteral stents or nephrostomy tubes.
At a median followup of 35 months (range 17 to 62) for endoureterotomy and 34 months (range 5 to 54) for open revision the success rate of endoureterotomy and open revision was 50% (8 of 16 renal units) and 80% (12 of 15), respectively. One of the 3 patients in whom open revision failed underwent prior pelvic external beam radiation and the other 2 underwent prior endoureterotomies. Overall interventions for right strictures were more successful 85% or 11 of 13 cases than those on the left side (50% or 9 of 18) (p = 0.037). Average operative time was longer and average estimated blood loss was higher in patients treated with open repair after failed endoureterotomy (p = 0.009 and 0.016, respectively). No complications developed in patients following endoureterotomy.
Open revision remains the gold standard for the management of ureteroenteric strictures. Left strictures are considerably more resistant to management. Patients with left anastomotic strictures should be cautioned that endoureterotomy might have a lower success rate, and failure may limit the success and increase the morbidity of subsequent open anastomotic revision.
既往研究表明，虽然输尿管内切开术是一种合理的初始治疗选择，但开放性吻合口修复术仍应是治疗输尿管肠吻合口狭窄的金标准。然而，据我们所知，当代输尿管内切开术系列的结果尚未与开放性吻合口修复术的结果进行比较，且尚无研究评估输尿管内切开术失败后二次开放性吻合口修复术的发病率或成功率。
1997年5月至2002年8月，对22例患者的31个肾单位在根治性膀胱切除术后及尿流改道后出现的输尿管肠吻合口狭窄进行治疗。共16个肾单位接受了内镜治疗，其中左侧9个，右侧7个；15个肾单位进行了开放性修复，其中左侧9个，右侧6个。成功定义为影像学改善和/或在无胁腹疼痛、感染或无需输尿管支架或肾造瘘管的情况下恢复完全活动的能力。
输尿管内切开术的中位随访时间为35个月（范围17至62个月），开放性修复的中位随访时间为34个月（范围5至54个月），输尿管内切开术和开放性修复的成功率分别为50%（16个肾单位中的8个）和80%（15个肾单位中的12个）。3例开放性修复失败的患者中，1例曾接受盆腔外照射，另外2例曾接受输尿管内切开术。右侧狭窄的总体干预成功率为85%（13例中的11例），高于左侧（50%，18例中的9例）（p = 0.037）。输尿管内切开术失败后接受开放性修复的患者平均手术时间更长，平均估计失血量更高（分别为p = 0.009和0.016）。输尿管内切开术后患者未出现并发症。
开放性修复仍然是治疗输尿管肠吻合口狭窄的金标准。左侧狭窄对治疗的抵抗性明显更强。应告诫左侧吻合口狭窄患者，输尿管内切开术的成功率可能较低，且失败可能会限制后续开放性吻合口修复术的成功率并增加其发病率。
