Lopez Manuel, Melo Carlos, François Michel, Varlet François
Department of Paediatric Surgery, University Hospital of Saint Etienne, Saint Etienne, France.
J Laparoendosc Adv Surg Tech A. 2011 Mar;21(2):165-9. doi: 10.1089/lap.2010.0127. Epub 2010 Dec 29.
Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Nephropathy with renal scarring is still the most concerning issue in VUR. Surgical correction to eliminate VUR is an important part of its management and this need is increasing for duplicated collecting systems (DCS). Laparoscopy may have a place in the treatment of VUR. We report our initial experience in the treatment of refluxing DCS by laparoscopic extravesical transperitoneal approach (LETA) following Lich-Gregoir technique. The aim of this study was to describe the evolution and evaluate the results and benefits of this technique.
Between August 2007 and January 2010, 60 renal units in 43 children with VUR and deterioration of renal function on isotope renography were treated with LETA following the Lich-Gregoir procedure. Twelve patients had refluxing DCS in a lower polar system; three of them had bilateral VUR. Three cases of refluxing DCS were associated to obstruction. Two of them presented an ectopic ureterocele with adequate split renal function and another had an ectopic ureterocele with complete deterioration of upper polar renal function. Their mean age was 36 months (range: 15-80 months).
The mean surgical time was 90 minutes (38-140 minutes) in unilateral and 144 minutes (120-200 minutes) in bilateral VUR including cystoscopy. All procedures were successfully completed laparoscopically and the reflux was corrected in all patients. One-stage laparoscopic heminephroureterectomy with excision of ureterocele and ureteric reimplantation was done in 1 case, and ureterocele excision and ureteric reimplantation by LETA were done in 2 cases. The mean hospital stay was 27 hours. A cystogram was performed systematically in all patients at 45 days postoperatively; none of them presented recurrence of VUR. The follow-up period was 11 months (range: 2-24 months), without recurrence of VUR.
LETA following the Lich-Gregoir procedure in refluxing DCS is a safe and effective approach even in unilateral, bilateral simultaneous, and split renal function in duplicated systems. When refluxing DCS is associated with obstruction and total deterioration of upper polar function, heminephroureterectomy with excision of ureterocele and ureteric reimplantation can be safely and effectively performed in a single-stage laparoscopic procedure, which minimizes the hazards of traditional open surgical reconstruction. A shorter hospital stay, decreased postoperative discomfort, reduced recovery period, and a low morbidity to resolve VUR in DCS are the benefits of this technique, with success rates similar to the open technique.
膀胱输尿管反流（VUR）是儿童急性肾盂肾炎最重要的危险因素之一。伴有肾瘢痕形成的肾病仍是VUR最令人担忧的问题。手术矫正以消除VUR是其治疗的重要组成部分，对于重复集合系统（DCS），这种需求正在增加。腹腔镜手术可能在VUR的治疗中占有一席之地。我们报告了采用Lich-Gregoir技术通过腹腔镜膀胱外经腹途径（LETA）治疗反流性DCS的初步经验。本研究的目的是描述该技术的发展过程并评估其结果和益处。
2007年8月至2010年1月，对43例VUR且同位素肾图显示肾功能恶化的儿童的60个肾单位采用Lich-Gregoir手术方法进行LETA治疗。12例患者下极系统存在反流性DCS；其中3例为双侧VUR。3例反流性DCS合并梗阻。其中2例表现为异位输尿管囊肿且分肾功能良好，另1例表现为异位输尿管囊肿且上极肾功能完全恶化。他们的平均年龄为36个月（范围：15 - 80个月）。
包括膀胱镜检查在内，单侧VUR的平均手术时间为90分钟（38 - 140分钟），双侧VUR为144分钟（120 - 200分钟）。所有手术均通过腹腔镜成功完成，所有患者的反流均得到矫正。1例患者进行了一期腹腔镜半肾输尿管切除术并切除输尿管囊肿及输尿管再植术，2例患者通过LETA进行了输尿管囊肿切除及输尿管再植术。平均住院时间为27小时。所有患者术后45天均系统地进行了膀胱造影；无一例出现VUR复发。随访期为11个月（范围：2 - 24个月），无VUR复发。
在反流性DCS中采用Lich-Gregoir手术方法进行LETA是一种安全有效的方法，即使在单侧、双侧同时存在以及重复系统中分肾功能的情况下也是如此。当反流性DCS合并梗阻且上极功能完全恶化时，一期腹腔镜半肾输尿管切除术并切除输尿管囊肿及输尿管再植术可以安全有效地进行，这将传统开放手术重建的风险降至最低。该技术的益处包括住院时间缩短、术后不适减轻、恢复期缩短以及解决DCS中VUR的发病率低，成功率与开放技术相似。
