Godbole P, Mushtaq I, Wilcox D T, Duffy P G
Department of Pediatric Urology, Great Ormond Street Hospital for Children, London, UK.
J Pediatr Urol. 2006 Aug;2(4):285-9. doi: 10.1016/j.jpurol.2005.11.017. Epub 2006 Apr 18.
Dismembered pyeloplasty is the traditional technique in the management of ureterovascular pelvi-ureteric junction obstruction (PUJO) in children. Controversy remains regarding the role of lower pole vessels as the sole aetiology for PUJO. Endopyelotomy and concomitant laparoscopic transposition of lower pole vessels for PUJO has been described in adults. We describe our technique of laparoscopic transposition of lower pole vessels in children with PUJO, leaving the PUJ intact.
Thirteen patients (seven boys and six girls) with a mean age of 10.2 years (range 7-16 years) underwent laparoscopic transposition of lower pole vessels. Surgery was indicated on the basis of intermittent pain and ultrasound/MAG3 appearance of obstruction with or without reduced function. The technique involved laparoscopic transperitoneal mobilization of the lower pole vessels from the region of the PUJ thereby freeing the junction and transposing them superiorly onto the anterior wall of the pelvis. The main outcome measures were relief of pain and improvement in ultrasound appearance or drainage parameters on a postoperative MAG3 renogram performed within 4-6 weeks of surgery.
Median operating time was 92 min. All patients were discharged within 36 h of surgery. All patients remain pain free at a median of 6 months (range 3-18 months). Twelve patients showed good drainage on the postoperative MAG3 renogram and improvement in ultrasound appearance. One patient had recurrent symptoms requiring insertion of a JJ stent. She has undergone further laparoscopic exploration. The vessels were in their transposed position and there was a kink at the PUJ which was released. She had a vertical pyelotomy and transverse closure over the JJ stent with good results.
This technique is simple and requires less operating time. No anastomosis or temporary JJ stent is required. Our early results are very encouraging with no serious complications.
离断性肾盂成形术是治疗儿童输尿管血管性肾盂输尿管连接部梗阻（PUJO）的传统技术。关于下极血管作为PUJO唯一病因的作用仍存在争议。成人中已描述了内镜下肾盂切开术及同时进行的下极血管腹腔镜移位术治疗PUJO。我们描述了在儿童PUJO患者中保留PUJ完整的下极血管腹腔镜移位术。
13例患者（7例男孩和6例女孩），平均年龄10.2岁（范围7 - 16岁），接受了下极血管腹腔镜移位术。手术指征基于间歇性疼痛以及超声/MAG3显示有梗阻表现，伴或不伴有功能降低。该技术包括通过腹腔镜经腹将下极血管从PUJ区域游离，从而松解连接部，并将其向上移位至肾盂前壁。主要观察指标为疼痛缓解情况，以及术后4 - 6周进行的MAG3肾图检查中超声表现或引流参数的改善情况。
中位手术时间为92分钟。所有患者均在术后36小时内出院。所有患者在中位时间6个月（范围3 - 18个月）时均无疼痛。12例患者术后MAG3肾图显示引流良好，超声表现改善。1例患者出现复发性症状，需要置入双J支架。她接受了进一步的腹腔镜探查。血管处于移位位置，PUJ处有一个扭结，已被松解。她接受了垂直肾盂切开术，并在双J支架上进行横向缝合，效果良好。
该技术简单，所需手术时间较少。无需吻合或置入临时双J支架。我们的早期结果非常令人鼓舞，无严重并发症。
