McGarry Laura, Sahadev Ravindra, Hogan Grace, Long Chrisopher, Otero Hansel, Srinivasan Arun K, Shukla Aseem R
Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Children's Hospital of Philadelphia, Philadelphia, PA, USA.
J Pediatr Urol. 2020 Apr;16(2):221.e1-221.e6. doi: 10.1016/j.jpurol.2020.01.014. Epub 2020 Feb 8.
Calyceal diverticula (CD) are abnormally dilated calyces caused by a narrowed infundibulum. Although rare, with incidence rates previously reported between 0.21% and 0.45%, CD pose diagnostic dilemmas in children as they mimic other cystic lesions of the kidney with different etiologies. Calyceal diverticula can become symptomatic if they become a locus for infections and stone formation, and the optimal treatment strategy is currently undefined.
The aim of the study is to present a large series of consecutive cases of pediatric CD and investigate the authors' hypothesis that CDs are more common than previously reported, size of the lesion drives intervention, and laparoscopic ablation is the most effective intervention.
The authors conducted an observational case-control survey by reviewing all cases of pediatric CD through a prospectively maintained database of renal cystic lesions at their institution between 2012 and 2018. They analyzed the clinical and radiological presentation and description of symptoms with particular emphasis on the outcomes of ureteroscopic or laparoscopic surgical interventions.
Of 757 renal cysts evaluated in the pediatric urology clinics at the authors' institution, there were 43 (5%) cases of CD confirmed by cross-sectional imaging or retrograde pyelogram. The median age was 12 years. There was a female preponderance (67%), and 14% were bilateral. Twenty-five of 43 children underwent surgery (58%). On multivariate analysis, the size/complexity of the cyst (odds ratio = 2.13, 1.02 to 4.4, P = 0.04) and the presence of pain (5.931, 1.36 to 25.87, P = 0.018) were found to correlate with the need for intervention. Ureteroscopic intervention (i.e., balloon dilatation, laser incision, or diathermy incision) was the most used index procedure (17/25), followed by laparoscopic ablation (6/25), with success rates of 40% and 100%, respectively (P = 0.01). Complications in either of the approaches were usually mild and similar (P = 0.63). The majority of ureteroscopic interventions required multiple sessions (11/17, 65%, median = 2 major procedures) to achieve resolution, whereas none in the laparoscopic group required a second procedure. There were a total of 30 ureteroscopic and 8 laparoscopic approaches.
The authors demonstrate that CD comprise at least 5% of cystic lesions and that CD size and pain at presentation predict intervention in 60% of children diagnosed at their institution. Laparoscopic ablation is the optimal treatment and has significantly higher success rates than the ureteroscopic approach.
肾盏憩室（CD）是由漏斗部狭窄导致的肾盏异常扩张。尽管罕见，既往报道的发病率在0.21%至0.45%之间，但CD在儿童中会造成诊断难题，因为它们可模仿其他病因不同的肾囊性病变。如果肾盏憩室成为感染和结石形成的病灶，就可能出现症状，而目前最佳的治疗策略尚不明确。
本研究旨在呈现一系列连续的小儿CD病例，并调查作者的假设，即CD比之前报道的更为常见，病变大小决定干预方式，而腹腔镜消融是最有效的干预手段。
作者通过回顾2012年至2018年期间其机构前瞻性维护的肾囊性病变数据库中的所有小儿CD病例，进行了一项观察性病例对照研究。他们分析了临床和影像学表现以及症状描述，尤其着重于输尿管镜或腹腔镜手术干预的结果。
在作者机构的小儿泌尿外科诊所评估的757个肾囊肿中，有43例（5%）经横断面成像或逆行肾盂造影确诊为CD。中位年龄为12岁。女性占多数（67%），14%为双侧病变。43名儿童中有25名接受了手术（58%）。多因素分析发现，囊肿的大小/复杂性（比值比=2.13，1.02至4.4，P=0.04）和疼痛的存在（5.931，1.36至25.87，P=0.018）与干预需求相关。输尿管镜干预（即球囊扩张、激光切开或透热切开）是最常用的主要手术方式（17/25），其次是腹腔镜消融（6/25），成功率分别为40%和100%（P=0.01）。两种手术方式的并发症通常都很轻微且相似（P=0.63）。大多数输尿管镜干预需要多次手术（11/17，65%，中位=2次主要手术）才能解决问题，而腹腔镜组无一例需要二次手术。总共进行了30次输尿管镜手术和8次腹腔镜手术。
作者表明，CD至少占囊性病变的5%，且CD大小和出现疼痛可预测在其机构诊断的60%儿童是否需要干预。腹腔镜消融是最佳治疗方法，其成功率显著高于输尿管镜手术。
