Tsuji Yoshikazu, Fujita Takashi, Kimura Toru, Hirano Atsushi, Hatsuse Katsuro, Furukawa Toru, Tanaka Kuniaki, Kinukawa Tsuneo, Nojiri Yoshikatsu, Okamura Kikuo, Ono Yoshinari, Ohshima Shinichi
Department of Urology, Chukyo Hospital.
Nihon Hinyokika Gakkai Zasshi. 2006 Mar;97(3):583-90. doi: 10.5980/jpnjurol1989.97.583.
We report a technique and outcome of endoscopic trigonoplasty II (ET II), anti-reflux surgery via a transvesicostomy transurethral approach and discuss its usefulness.
Fifteen female patients, aged 5 to 64, with 23 refluxing ureters (grade I : 5, II : 2, III : 14, IV : 2) underwent the ET II. The principle of this surgery is tightening the muscular backing and elongating the intramural ureter. The operation consists of three steps: 1) two 5 mm locking trocars are placed into the bladder, 2) irrigating with 3% D-sorbitol solution, the bladder wall is incised upward along each side of the ureter using a resectoscope, to make a 2 to 3 cm U-shaped bladder flap including the ureter, 3) under a pneumobladder, the incised wall is sutured to make a muscular bed with a needle-holder via the urethra and forceps via the abdominal trocar. The U-shaped flap is fixed with two distal anchor sutures and four additional mucosal sutures. Urethral catheter is indwelled and the operation is finished. In recent four cases, we closed the tracts endoscopically.
The average operative time was 144 minutes per ureter. In one patient with unilateral reflux, we switched to open surgery because of bleeding. Of 22 refluxing ureters, the reflux disappeared in 18 ureters (82%) and improved grade III to I in 1 ureter (5%) after 3 months and disappeared in 19 ureters (86%) after 12 months postoperatively. Ureteral injury was occurred in 3 patients during the transurethral incision of the bladder. Though we repaired it by placing a double-J stent in the 2 patients, reflux recurred in 12 months postoperatively in one of them. In the other patient cystoscopy revealed a vesicoureteral fistula in the injured portion. She subsequently underwent successful open Politano-Leadbetter ureteroneocystostomy. The average duration of indwelling catheter was shortened from 4.3 to 3.0 days by closing the tracts endoscopically.
The overall cessation rate of the ET II was inferior to those of open anti-reflux surgeries or laparoscopic extravesical ureteral reimplantation. We do not recommend ET II for vesicoureteral reflux.
我们报告内镜下三角形成形术II（ET II）、经膀胱造口经尿道抗反流手术的技术及结果，并讨论其效用。
15例年龄5至64岁的女性患者，共23条反流输尿管（I级：5条，II级：2条，III级：14条，IV级：2条）接受了ET II手术。该手术的原则是收紧肌层并延长壁内段输尿管。手术包括三个步骤：1）将两根5毫米锁定套管针置入膀胱；2）用3% D -山梨醇溶液冲洗，使用电切镜沿输尿管两侧向上切开膀胱壁，形成一个包括输尿管的2至3厘米U形膀胱瓣；3）在膀胱充盈状态下，经尿道用持针器和经腹部套管针用钳子将切开的壁缝合形成肌床。U形瓣用两根远端锚定缝线和另外四根黏膜缝线固定。留置尿道导管，手术完成。在最近4例中，我们通过内镜封闭通道。
每条输尿管平均手术时间为144分钟。1例单侧反流患者因出血转为开放手术。22条反流输尿管中，3个月后18条输尿管（82%）反流消失，1条输尿管（5%）反流程度从III级改善为I级，术后12个月19条输尿管（86%）反流消失。3例患者在经尿道切开膀胱时发生输尿管损伤。虽然我们对其中2例患者通过置入双J支架进行了修复，但其中1例在术后12个月反流复发。另一例患者膀胱镜检查显示损伤部位存在膀胱输尿管瘘。她随后成功接受了开放的Politano - Leadbetter输尿管膀胱再植术。通过内镜封闭通道，平均导管留置时间从4.3天缩短至3.0天。
ET II的总体反流停止率低于开放抗反流手术或腹腔镜膀胱外输尿管再植术。我们不推荐ET II用于膀胱输尿管反流。
