The University of Chicago, Medicine and Biological Sciences, Comer Children's Hospital, Department of Surgery, Division of Urology, Chicago, IL 60637, USA.
J Pediatr Urol. 2013 Aug;9(4):442-7. doi: 10.1016/j.jpurol.2012.10.018. Epub 2012 Dec 4.
Urinary retention is a known complication of using an extravesical approach for ureteral reimplantation, especially in bilateral cases. The etiology may be secondary damage to pelvic nerves during ureteral dissection. Recent literature suggests that it is possible to visually identify these nerves during a robotic assisted laparoscopic approach. We performed an exploratory study to identify and document them in pediatric patients by means of electrophysiologic recordings.
Seven consecutive patients undergoing robotic assisted laparoscopic ureteral reimplantation with extravesical approach were prospectively enrolled in the study. Following dissection of the ureter below the level of vas deferens in male and the uterine artery in female, staying close to the adventitia and approaching the ureterovesical junction, the fibers as described in human cadaveric studies were identified dorsomedial to the ureter and preserved. Stimulating and recording electrodes were passed through to record post-synaptic compound muscle action potentials of the bladder.
Even though the nerve fibers were visually identified, we were unable to consistently and reproducibly record compound muscle action potentials after stimulation of putative pelvic plexus fibers at the distal ureter, despite modulation in stimulation intensity, pulse characteristics, signal recording sensitivity and stimulator probe variation.
In this pilot study, the inconsistent findings raise questions about the exact location of the neurovascular bundle, nature of bladder smooth muscle electrophysiology and the appropriate methodology of evaluation. This may provide a reason to reexamine the intraoperatively expected location of pelvic plexus nerve fibers.
在使用经膀胱外途径进行输尿管再植术时，尤其是在双侧病例中，尿潴留是一种已知的并发症。其病因可能是在输尿管解剖过程中对骨盆神经的继发性损伤。最近的文献表明，在机器人辅助腹腔镜手术中，可以通过视觉识别这些神经。我们进行了一项探索性研究，通过电生理记录来识别和记录儿科患者的这些神经。
连续 7 例接受经膀胱外途径机器人辅助腹腔镜输尿管再植术的患者前瞻性纳入研究。在男性的输精管下方和女性的子宫动脉下方进行输尿管解剖后，靠近输尿管外膜接近输尿管膀胱连接部，根据人体尸体研究描述的纤维在输尿管背内侧识别并保留。通过传递刺激和记录电极来记录膀胱的突触后复合肌肉动作电位。
尽管可以通过视觉识别神经纤维，但我们无法在刺激远端输尿管的假定骨盆丛纤维后始终如一地和可重复地记录复合肌肉动作电位，尽管刺激强度、脉冲特征、信号记录灵敏度和刺激器探头变化进行了调节。
在这项初步研究中，不一致的发现对神经血管束的确切位置、膀胱平滑肌电生理学的性质以及评估的适当方法提出了疑问。这可能是重新检查术中预期的骨盆丛神经纤维位置的原因。
