Li Jiayi, Li Zonghan, He Yuzhu, Fan Songqiao, Liu Pei, Yang Zhenzhen, Wang Xinyu, Zhang Weiping
Department of Urology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
Transl Androl Urol. 2022 Dec;11(12):1680-1690. doi: 10.21037/tau-22-327.
Laparoscopic pyeloplasty (LP) has been widely accepted as an effective method to treat ureteropelvic junction obstruction (UPJO) in pediatric patients. Limited studies focused on the relationship between risk factors and negative outcomes. Our study aimed to seek independent risk factors for negative outcomes and construct a prognostic nomogram to assist clinical decision-making and improve outcomes.
A total of 535 patients with UPJO treated with primary LP between January 2016 and December 2020 were retrospectively reviewed. Negative outcomes were defined as restenosis requiring reoperation and grade III and IV complications based on the Clavien-Dindo grading system. Univariate and multivariate logistic regression analyses were used to select risk factors for negative outcomes after LP and developed the prediction model. The model was internally validated by the parametric bootstrapping method.
Among the 535 patients, 33 (6.2%) developed negative outcomes. Ten patients developed ureteropelvic junction (UPJ) restenosis and underwent secondary surgery. UPJ leakage (two cases), difficulty of urinating after the removal of the Double-J (DJ) stent (two cases), and ileus (two cases) were the most common grade IIIa complications, while distal ureteral stricture (five cases), hernia formation (three cases), and delayed wound healing around the fistula (two cases) were the most common grade IIIb complications. After univariate and multivariate logistic analyses, the patient's weight, preoperative anteroposterior pelvic diameter (APD), and difficulty of DJ stent insertion were independent risk factors for negative outcomes, and they were used to fit the prediction model. The Brier score was 0.048. The model was relatively well-calibrated. The area under the receiver operating characteristic curve was 0.831 (95% CI: 0.756-0.906). Decision curve analysis illustrated good clinical utility.
Primary LP is a safe and effective method for pediatric patients with UPJO. The patient's weight, preoperative APD, and difficulty of DJ stent insertion were independent risk factors for negative outcomes after LP. We established and validated a predictive model for negative outcomes after LP. With the help of this model, clinicians can make better decisions and improve patient outcomes.
腹腔镜肾盂成形术（LP）已被广泛认为是治疗小儿患者输尿管肾盂连接部梗阻（UPJO）的有效方法。有限的研究关注危险因素与不良结局之间的关系。我们的研究旨在寻找不良结局的独立危险因素，并构建一个预后列线图以协助临床决策并改善结局。
回顾性分析2016年1月至2020年12月期间接受初次LP治疗的535例UPJO患者。根据Clavien-Dindo分级系统，不良结局定义为需要再次手术的再狭窄以及III级和IV级并发症。采用单因素和多因素逻辑回归分析来选择LP术后不良结局的危险因素并建立预测模型。该模型通过参数自抽样法进行内部验证。
在535例患者中，33例（6.2%）出现不良结局。10例患者发生输尿管肾盂连接部（UPJ）再狭窄并接受了二次手术。UPJ漏（2例）、取出双J（DJ）支架后排尿困难（2例）和肠梗阻（2例）是最常见的IIIa级并发症，而远端输尿管狭窄（5例）、疝形成（3例）和瘘口周围伤口愈合延迟（2例）是最常见的IIIb级并发症。经过单因素和多因素逻辑分析，患者体重、术前骨盆前后径（APD）和DJ支架置入困难是不良结局的独立危险因素，并用于拟合预测模型。Brier评分为0.048。该模型校准度相对良好。受试者工作特征曲线下面积为0.831（95%CI：0.756 - 0.906）。决策曲线分析显示出良好的临床实用性。
初次LP对于小儿UPJO患者是一种安全有效的方法。患者体重、术前APD和DJ支架置入困难是LP术后不良结局的独立危险因素。我们建立并验证了LP术后不良结局的预测模型。借助该模型，临床医生可以做出更好的决策并改善患者结局。
