Adamic B L, Lombardo A, Andolfi C, Hatcher D, Gundeti M S
Pediatric Urology Section of Urology Department of Surgery Comer Children's Hospital Pritzker School of Medicine The University of Chicago Chicago IL USA.
Pritzker School of Medicine The University of Chicago Chicago IL USA.
BJUI Compass. 2020 Nov 14;2(1):53-57. doi: 10.1002/bco2.53. eCollection 2021 Jan.
Ureterocalycostomy is a necessary option for renal salvage in cases where conventional reconstructions have failed or as a primary option in anatomic situations such as intrarenal pelvis, malrotated, or horseshoe kidney. The primary principle of this procedure is to allow for dependent drainage. Ureterocalycostomy is often difficult due to extensive scar tissue and may be complicated by bleeding in the setting of a normal functioning lower pole cortex, compared to thin renal cortex and poor renal function as seen in end-spectrum of the obstruction. Identification of a dependent calyx and hemostasis can be difficult when there is a normal cortical thickness. Though the vascular control of hilum is an option, we suggest some simple tips to avoid this step and optimize surgical results. We present our experience and salient technical tips with pediatric robotic-assisted laparoscopic ureterocalycostomy and provide a step-by-step video.
Four patients underwent robotic-assisted laparoscopic ureterocalycostomy between the years 2012 and 2016 by a single surgeon. Perioperative outcomes measured included operative time, hospital stay, pain relief, degree of hydronephrosis on postoperative ultrasound at 3 months, and renal scintigraphy as needed. We describe the operative procedure and provide tips on identifying a dependent lower pole calyx with flexible nephroscopy and needle puncture, the use of harmonic scalpel for incision of the lower pole cortex, and anastomosis by pre-placement of interrupted sutures as the urothelium of the renal calyces is thin and friable.
Patients ranged in age between 11 months and 14 years old. Three of four patients had one prior pyeloplasty, and one patient had two prior pyeloplasties. Mean operative time (incision to closure) was 208 minutes. No Clavien-Dindo 30-day complications were encountered and no patients required blood transfusion. Anatomic success was reported in all patients with a mean follow-up of 4.46 years; however, one patient ultimately required nephrectomy despite patent anastomosis, which would not drain due to a capacious pelvis.
Robotic-assisted laparoscopic ureterocalycostomy is feasible in re-operative cases with extensive scaring and in patients with normal lower pole renal cortex. We offer tips to allow for safe and proficient performance of this procedure.
在传统重建手术失败的情况下，输尿管肾盂造口术是挽救肾脏的必要选择，或者作为肾盂内型、旋转不良或马蹄肾等解剖情况下的首选术式。该手术的主要原则是实现重力引流。由于广泛的瘢痕组织，输尿管肾盂造口术通常具有挑战性，并且与梗阻终末期所见的肾皮质薄和肾功能差相比，在肾下极皮质功能正常的情况下可能并发出血。当肾皮质厚度正常时，识别重力依赖的肾盏和止血可能会很困难。尽管控制肾蒂血管是一种选择，但我们建议一些简单技巧以避免这一步骤并优化手术效果。我们介绍我们在小儿机器人辅助腹腔镜输尿管肾盂造口术方面的经验和突出的技术技巧，并提供分步视频。
2012年至2016年间，同一位外科医生为4例患者实施了机器人辅助腹腔镜输尿管肾盂造口术。围手术期观察指标包括手术时间、住院时间、疼痛缓解情况、术后3个月超声检查的肾积水程度以及必要时的肾闪烁显像。我们描述手术过程，并提供关于使用软性肾镜和穿刺针识别重力依赖的肾下极肾盏、使用超声刀切开肾下极皮质以及由于肾盏尿路上皮薄且脆弱而通过预先放置间断缝线进行吻合的技巧。
患者年龄在11个月至14岁之间。4例患者中有3例曾接受过一次肾盂成形术，1例患者曾接受过两次肾盂成形术。平均手术时间（从切开到缝合）为208分钟。未发生Clavien-Dindo 30天并发症，且无患者需要输血。所有患者均获得解剖学成功，平均随访4.46年；然而，1例患者尽管吻合口通畅，但最终因肾盂宽大无法引流而需要肾切除。
机器人辅助腹腔镜输尿管肾盂造口术在有广泛瘢痕的再次手术病例以及肾下极肾皮质正常的患者中是可行的。我们提供的技巧可使该手术安全、熟练地进行。
