Marte Antonio, Papparella Alfonso, Pintozzi Lucia
Department Pediatric Surgery, Second University of Naples, Largo Madonna delle Grazie 1, Naples 80138, Italy.
Afr J Paediatr Surg. 2015 Oct-Dec;12(4):227-31. doi: 10.4103/0189-6725.172546.
Minimally invasive surgery is the current approach to perform heminephroureterectomy (HN) in children. This can be obtained through a transperitoneal (TP) or a retroperitoneal approach. Here, we report our experience using a TP approach.
From 2005 to 2014, 22 TP laparoscopic upper poles HN were performed at our institution. There were nine girls and 13 boys aged between 20 months and 6 years (mean age 3.9). Eight patients were diagnosed prenatally, 17 patients presented with urinary tract infection (UTI) and three with vomiting and failure to thrive. The indication for HN was reflux nephropathy and UTI in non-functioning upper pole in 19 patients and cystic dysplasia in 1 patient. The surgical technique involved the following steps: Cystoscopic recognition; positioning of 3-4 trocar (right HN); identification of the kidney (detachment of the colon); isolation and low ligation of the dilated ureter; decrossing from renal vessels; section of the parenchyma by LigaSure; haemostasis with clips and LigaSure; drain.
The mean operative time was 154 min (range: 81-220 min). All patients were discharged from the 2 nd to 4 th day. Neither major complication nor conversion was recorded. 1 patient presented leakage of urine for 7 days from the drainage which resolved spontaneously. At ultrasound follow-up, 5 patients showed a secondary perirenal cyst, 2-5 cm diameter that resolved spontaneously.
The results indicate that laparoscopic upper pole heminephrectomy is the treatment of choice in cases of non-functioning dilated lower segments of duplicated kidneys. The use of laparoscopic approach offers a good working space, a good visual control of the vessels and allows a very low isolation of the ureteral stump which counterbalance the peritoneal violation.
微创手术是目前儿童半肾输尿管切除术（HN）的手术方式。这可以通过经腹腔（TP）或腹膜后途径实现。在此，我们报告我们使用TP途径的经验。
2005年至2014年，我们机构共进行了22例TP腹腔镜上极HN手术。有9名女孩和13名男孩，年龄在20个月至6岁之间（平均年龄3.9岁）。8例患者为产前诊断，17例患者表现为尿路感染（UTI），3例患者表现为呕吐和发育不良。HN的指征为19例患者无功能上极的反流性肾病和UTI，1例患者为囊性发育不良。手术技术包括以下步骤：膀胱镜识别；放置3 - 4个套管针（右HN）；识别肾脏（游离结肠）；分离并低位结扎扩张的输尿管；从肾血管处交叉；用LigaSure切断实质；用夹子和LigaSure止血；放置引流管。
平均手术时间为154分钟（范围：81 - 220分钟）。所有患者在第2至4天出院。未记录到重大并发症或中转开腹情况。1例患者引流管出现7天的尿液漏出，自行缓解。超声随访时，5例患者出现直径2 - 5厘米的继发性肾周囊肿，自行消退。
结果表明，腹腔镜上极半肾切除术是重复肾无功能扩张下段病例的首选治疗方法。腹腔镜手术途径提供了良好的操作空间，对血管有良好的视觉控制，并允许对输尿管残端进行极低程度的分离，这抵消了对腹膜的侵犯。
