Locke Rachel A, Kwenda Elizabeth P, Archer Jeremy, Bergamo Jeremy, Domino Maria Paula, DeMarco Romano T, Bayne Christopher E
Department of Urology, University of Florida College of Medicine, Gainesville, Florida, USA.
J Endourol Case Rep. 2020 Dec 29;6(4):264-267. doi: 10.1089/cren.2020.0043. eCollection 2020.
Pediatric urolithiasis may coexist with congenital urinary tract abnormalities, complicating conventional methods of stone treatment. Here, we present an effective case of robot-assisted laparoscopy and simultaneous ureteropyeloscopy for the definitive management of pediatric urolithiasis complicated by a congenital ureteral stricture. A 3-year-old girl presented to clinic with an outside noncontrast CT scan showing two 6-7 mm nonobstructing calculi in a mildly distended upper pole moiety of a duplex left kidney. Ureteral duplication status was unclear. The patient had suffered multiple febrile urinary tract infections throughout her life. Retrograde ureteropyelogram showed a stenotic waist in the upper pole ureter just proximal to the duplex ureteral convergence, and flexible ureteroscopy confirmed a congenital ureteral stricture. Simultaneous robot-assisted laparoscopic and ureteroscopic ureterolithotomy and ureteroplasty were offered and performed using a 3-armed robotic approach. The precise location of the stricture was identified robotically with simultaneous left ureteroscopy. A medial 1.5 cm longitudinal ureterotomy was made through the ureteral stricture to facilitate upper moiety ureterorenoscopy. The calculi were visualized in the upper moiety and retrieved in whole using a stone basket. The calculi were passed via the ureterotomy to the robotic instruments intraperitoneally. The longitudinal ureterotomy was closed transversely. A ureteral stent was placed, and indocyanine green was administered intravenously to confirm good perfusion of the ureteroplasty segment via fluorescence imaging. The stent was removed at 4 weeks. Retrograde ureterography and flexible ureteroscopy revealed complete patency of the anastomosis. At 11 months, the upper pole moiety remained decompressed on ultrasonography. The patient has remained off antibiotic prophylaxis without further infection. Robot-assisted approaches can be primary or adjunct tools in the definitive treatment of pediatric urolithiasis with concomitant urinary tract abnormalities.
小儿尿路结石可能与先天性尿路异常并存，使传统的结石治疗方法变得复杂。在此，我们报告一例机器人辅助腹腔镜手术联合输尿管肾盂镜检查治疗小儿尿路结石合并先天性输尿管狭窄的有效病例。一名3岁女孩因外院非增强CT扫描显示左肾重复肾轻度扩张的上极部分有两颗6-7毫米的无梗阻结石而就诊。输尿管重复情况不明。该患者一生中曾多次发生发热性尿路感染。逆行输尿管肾盂造影显示在重复输尿管汇合处近端的上极输尿管有一个狭窄段，软性输尿管镜检查证实为先天性输尿管狭窄。采用三臂机器人手术方式，同时进行机器人辅助腹腔镜输尿管切开取石术和输尿管成形术。通过同时进行的左侧输尿管镜检查，机器人精确确定了狭窄的位置。在输尿管狭窄处做一个1.5厘米的内侧纵向输尿管切口，以便于对上极部分进行输尿管肾镜检查。在上极部分看到结石，并用结石篮完整取出。结石通过输尿管切口经腹膜内传递给机器人器械。纵向输尿管切口横向缝合。放置输尿管支架，并静脉注射吲哚菁绿，通过荧光成像确认输尿管成形段血运良好。4周后取出支架。逆行输尿管造影和软性输尿管镜检查显示吻合口完全通畅。11个月时，超声检查显示上极部分仍无梗阻。患者不再使用抗生素预防感染，也未再发生感染。机器人辅助手术可作为小儿尿路结石合并尿路异常确定性治疗的主要或辅助工具。
