Canon Stephen J, Jayanthi Venkata R, Patel Ashay S
Section of Urology, Columbus Children's Hospital, Ohio State University, Columbus, Ohio 43205, USA.
J Urol. 2007 Jul;178(1):269-73; discussion 273. doi: 10.1016/j.juro.2007.03.059. Epub 2007 May 17.
Cross-trigonal ureteral reimplantation is a commonly performed procedure for the correction of vesicoureteral reflux. Most previously described laparoscopic techniques have used an extravesical approach. A "vesicoscopic" technique is analogous to standard open cross-trigonal repair in principle, except that 3 ports with insufflation of the bladder are used to perform the ureteral reimplantation.
A retrospective review was performed of patients treated for primary vesicoureteral reflux with either vesicoscopic or open ureteral reimplantation. For patients with vesicoscopic reimplantation a 5 mm port is placed in the dome of the bladder and 2, 3 mm ports are placed laterally. The ureters are mobilized transvesically, cross-trigonal submucosal tunnels are made and the ureters are sutured in place with intracorporeal suturing. The bladder ports are closed and a urethral catheter is left indwelling for 36 hours. Among the open reimplantation group 38 patients underwent cross-trigonal ureteral reimplantation, 2 underwent extravesical ureteral reimplantation and 2 were excluded due to insufficient records. Followup imaging for both groups included ultrasonography at 1 month and voiding cystography at 3 months postoperatively.
A total of 52 consecutive children underwent vesicoscopic ureteral reimplantation with 1 patient converted to open intravesical reimplantation, and 40 consecutive controls underwent open ureteral reimplantation. Postoperative vesicoureteral reflux resolution rates for the vesicoscopic and open groups were 91% (42 of 46 patients) and 97% (31 of 32 patients), respectively. Mean patient age and mean maximal grade of vesicoureteral reflux in the vesicoscopic and open groups were 5.7 and 4.0 years (p=0.001), and 2.8 and 3.2 (p=0.036), respectively. Mean operative times for vesicoscopic and open procedures were 199 and 92 minutes, respectively (p=0.001). While the average length of hospital stay of 2 days was similar between the groups (p=0.122), less oral and intravenous analgesia was needed postoperatively in the vesicoscopic group (p=0.001 and p=0.005, respectively). Complications of vesicoscopic ureteral reimplantation included urinary leakage in 1 child, bladder stones in 1 and bilateral ureteral obstruction in 1. There were no complications in the open group.
There is an ever increasing trend toward minimally invasive surgery. Our preliminary results indicate that vesicoscopic ureteral reimplantation is an effective procedure with minimal morbidity. Although success rates for vesicoureteral reflux resolution were slightly lower in the vesicoscopic group in this study, the favorable results of other series and the improvement in postoperative discomfort observed here suggest that this technique may be a reasonable option in the management of vesicoureteral reflux. Further refinement of the technique and critical analysis of the long-term outcomes are needed to understand fully its place in the treatment of vesicoureteral reflux.
经三角区输尿管再植术是矫正膀胱输尿管反流的常用手术。此前描述的大多数腹腔镜技术采用膀胱外入路。“膀胱镜下”技术原则上类似于标准的开放经三角区修复术，不同之处在于使用3个端口并向膀胱内充气来进行输尿管再植术。
对接受膀胱镜下或开放输尿管再植术治疗原发性膀胱输尿管反流的患者进行回顾性研究。对于膀胱镜下再植术的患者，在膀胱顶部放置一个5毫米端口，在侧面放置2个3毫米端口。经膀胱游离输尿管，制作经三角区黏膜下隧道，并用体内缝合将输尿管缝合到位。关闭膀胱端口，留置尿道导管36小时。在开放再植术组中，38例患者接受了经三角区输尿管再植术，2例接受了膀胱外输尿管再植术，2例因记录不充分被排除。两组的随访影像学检查包括术后1个月的超声检查和3个月的排尿性膀胱尿道造影。
共有52例连续儿童接受了膀胱镜下输尿管再植术，其中1例转为开放膀胱内再植术，40例连续对照患者接受了开放输尿管再植术。膀胱镜组和开放组术后膀胱输尿管反流的缓解率分别为91%（46例患者中的42例）和97%（32例患者中的31例）。膀胱镜组和开放组患者的平均年龄分别为5.7岁和4.0岁（p = 0.001），膀胱输尿管反流的平均最大分级分别为2.8级和3.2级（p = 0.036）。膀胱镜手术和开放手术的平均手术时间分别为199分钟和92分钟（p = 0.001）。虽然两组的平均住院时间均为2天相似（p = 0.122），但膀胱镜组术后所需的口服和静脉镇痛较少（分别为p = 0.001和p = 0.005）。膀胱镜下输尿管再植术的并发症包括1例儿童尿漏、1例膀胱结石和1例双侧输尿管梗阻。开放组无并发症。
微创手术的趋势日益增加。我们的初步结果表明，膀胱镜下输尿管再植术是一种有效的手术，发病率极低。尽管本研究中膀胱镜组膀胱输尿管反流的成功率略低，但其他系列的良好结果以及此处观察到的术后不适改善表明，该技术可能是治疗膀胱输尿管反流的合理选择。需要进一步完善该技术并对长期结果进行批判性分析，以充分了解其在膀胱输尿管反流治疗中的地位。
