Madec François-Xavier, Faraj Sébastien, Villemagne Thierry, Fourcade Laurent, Lardy Hubert, Leclair Marc-David
Paediatric Surgery and Urology Department, Children University Hospital, Nantes, France.
Paediatric Surgery and Urology Department, Children University Hospital, Nantes, France; Paediatric Surgery Department, University Hospital, Tours, France.
J Pediatr Urol. 2016 Aug;12(4):226.e1-6. doi: 10.1016/j.jpurol.2016.03.016. Epub 2016 May 13.
Laparoscopic transposition of lower-pole crossing vessels (LPCV) has been described as an effective alternative to dismembered pyeloplasty in selected indications of hydronephrosis, with purely extrinsic vascular PUJ obstruction. We hypothesized that the initial good results of laparoscopic transposition of LPCV in children presenting with pure extrinsic PUJO were sustained at puberty when these children go through statural growth, without inducing significant changes in systemic arterial blood pressure. Hence, we analysed the long-term follow-up of adolescents successfully treated with this technique during childhood, reviewed after they have reached puberty, focusing on the incidence of recurrent symptoms, renal dilatation, and systemic hypertension.
Early 2015, among a cohort of 70 patients prospectively followed-up since they had undergone laparoscopic transposition of LPCV during childhood (2005-2012), we performed systematic clinical assessment of the 33 adolescent patients (16 years; range 12-22) who had reached puberty age. Assessment focused on clinical examination, arterial blood pressure measurements, and renal ultrasonography (Table).
The median delay since surgery was 67 months (31-113 months). Arterial blood pressure adjusted for age and height was within normal range in all patients. Three patients had occasional episodes of abdominal pain: two of them had normal US (including during pain episodes), one had persistent extra-renal dilated pelvis with no calyceal dilatation. None of them showed obvious clinical characteristics linking the pain to a renal origin. Renal US showed residual SFU grade 2 pelvicalyceal dilatation in 2/33 asymptomatic patients; SFU grade 1 extra-renal pelvis dilatation in 3, and was normal in the remaining. When Doppler analysis was performed, there was no evidence of lower-pole parenchyma perfusion defect.
In adolescents successfully treated during childhood with transposition of LPCV, there seemed to be no impact of this procedure on systemic arterial blood pressure in adolescents after puberty, nor any evidence of late recurrence of symptoms or hydronephrosis. The main limitation of the present study relies in its retrospective nature, the limited sample size, and the obvious difficulty in adequate selection of candidate patients to this technique. The present experience however reinforces the hypothesis that a vast majority of children can be definitely cured with transposition of LPCV when they represent the sole aetiology of obstruction.
In the long-term follow-up, most adolescents successfully treated during childhood by laparoscopic transposition of LCPV for PUJ extrinsic obstruction remain asymptomatic, with normal arterial blood pressure, and normal renal ultrasound when they reach puberty.
对于肾盂积水特定适应证且存在单纯外在性血管肾盂输尿管连接部梗阻的情况，腹腔镜下低位交叉血管转位术（LPCV）已被描述为离断性肾盂成形术的一种有效替代方法。我们推测，对于单纯外在性肾盂输尿管连接部梗阻（PUJO）的儿童患者，在青春期经历身体生长时，LPCV腹腔镜转位术的初期良好效果能够持续，且不会引起系统性动脉血压的显著变化。因此，我们分析了童年期成功接受该技术治疗的青少年的长期随访情况，在他们进入青春期后进行复查，重点关注复发症状、肾积水及系统性高血压的发生率。
2015年初，在自2005 - 2012年童年期接受LPCV腹腔镜转位术以来进行前瞻性随访的70例患者队列中，我们对33例已达青春期年龄（16岁；范围12 - 22岁）的青少年患者进行了系统临床评估。评估重点为临床检查、动脉血压测量及肾脏超声检查（见表）。
手术至复查的中位间隔时间为67个月（31 - 113个月）。所有患者经年龄和身高校正后的动脉血压均在正常范围内。3例患者偶尔有腹痛发作：其中2例超声检查正常（包括腹痛发作时），1例有持续的肾外肾盂扩张但无肾盏扩张。他们均未表现出将疼痛与肾脏起源相关联的明显临床特征。肾脏超声检查显示，2/33例无症状患者有残余的集合系统（SFU）2级肾盂肾盏扩张；3例有SFU 1级肾外肾盂扩张，其余患者正常。进行多普勒分析时，未发现低位肾实质灌注缺损的证据。
对于童年期成功接受LPCV转位术治疗的青少年，该手术似乎对青春期后的青少年系统性动脉血压无影响，也没有症状或肾积水晚期复发的证据。本研究的主要局限性在于其回顾性性质、样本量有限以及在适当选择该技术的候选患者方面存在明显困难。然而，目前的经验强化了这样一种假设，即当LPCV转位术是梗阻的唯一病因时，绝大多数儿童可通过该手术得到根治。
在长期随访中，大多数童年期因PUJ外在性梗阻成功接受LCPV腹腔镜转位术治疗的青少年在进入青春期时仍无症状，动脉血压正常，肾脏超声检查结果正常。
