Kumar Santosh, Panigrahy Benu
Department of Urology, PGIMER, Chandigarh, India.
J Laparoendosc Adv Surg Tech A. 2009 Aug;19(4):521-8. doi: 10.1089/lap.2008.0397.
Ureteropelvic junction (UPJ) obstruction is associated with complex anatomic problems, such as pelvic kidneys, giant hydronephrosis, crossed fused ectopia with L-shaped kidneys, and poses a real challenge in management. In this paper, we describe simple laparoscopic techniques for the management of these cases of atypical and complex UPJ obstruction.
From 2004 to 2008, 9 cases of UPJ obstruction with atypical anatomic problems were operated on laparoscopically at PGIMER (Chandigarh, India). The different surgical procedures performed lap-aroscopically were pyelovesicostomy (5 cases), ureterocalicostomy (1 case), calicovesicostomy (1 case), heminephrectomy (1 case), and ureteropyelostomy (1 case) as per the merits of each case. The four-port technique was followed for pyelovesicostomy, calicovesicostomy, and ureterocalicostomy (two 10-mm ports, one each at the umbilicus and lateral border of the ipsilateral rectus, and two 5-mm ports, one each at the lateral border of the contralateral rectus and midway between the umbilicus and symphysis pubis). Pyelovesicostomy and calicovesicostomy were stented with a suprapubically placed Foley catheter. Mean operating time was 140 minutes, with an average intraoperative blood loss of 50 mL.
There were no intraoperative complications. The patients recovered well from the surgery. Postoperative nephrostograms confirmed anastomotic patency and good drainage. On follow-up, patients are asymptomatic with normal renal functions. Patients with calicovesicostomy and pyelovesicostomy were advised double voiding, and they need to be on long-term, perhaps lifelong, follow-up.
In pelvic kidneys with UPJ obstruction and in select cases of giant hydronephrotic kidneys, anastomosis of the bladder with the most dependent part of the pelvicalyceal system ensures adequate drainage. Ureterocalicostomy is the choice of treatment in cases of UPJ obstruction with an intrarenal pelvis where calicovesicostomy is not feasible. Laparoscopic performance of these procedures is feasible and simple.
肾盂输尿管连接部（UPJ）梗阻与复杂的解剖问题相关，如盆腔肾、巨大肾积水、交叉融合异位肾伴L形肾，给治疗带来了实际挑战。在本文中，我们描述了用于处理这些非典型和复杂UPJ梗阻病例的简单腹腔镜技术。
2004年至2008年，印度昌迪加尔的PGIMER对9例伴有非典型解剖问题的UPJ梗阻患者进行了腹腔镜手术。根据每个病例的具体情况，腹腔镜下进行的不同手术操作包括肾盂膀胱吻合术（5例）、输尿管肾盂吻合术（1例）、肾盂膀胱吻合术（1例）、肾部分切除术（1例）和输尿管肾盂吻合术（1例）。肾盂膀胱吻合术、肾盂膀胱吻合术和输尿管肾盂吻合术采用四孔技术（两个10毫米端口，分别位于脐部和同侧腹直肌外侧缘；两个5毫米端口，分别位于对侧腹直肌外侧缘以及脐部与耻骨联合中点）。肾盂膀胱吻合术和肾盂膀胱吻合术通过耻骨上放置的Foley导管进行支架置入。平均手术时间为140分钟，术中平均失血量为50毫升。
无术中并发症。患者术后恢复良好。术后肾造影片证实吻合口通畅且引流良好。随访时，患者无症状且肾功能正常。肾盂膀胱吻合术和肾盂膀胱吻合术的患者被建议进行二次排尿，并且需要长期随访，可能是终身随访。
对于伴有UPJ梗阻的盆腔肾以及部分巨大肾积水病例，将膀胱与肾盂肾盏系统最依赖部位进行吻合可确保充分引流。对于肾盂内肾盂输尿管连接部梗阻且无法进行肾盂膀胱吻合术的病例，输尿管肾盂吻合术是治疗的选择。这些手术的腹腔镜操作是可行且简单的。
