Gerber G S, Lyon E S
Department of Surgery, University of Chicago Pritzker School of Medicine, Illinois.
Urology. 1994 Jan;43(1):2-10. doi: 10.1016/s0090-4295(94)80253-x.
The popularity of minimally invasive surgical techniques, such as endopyelotomy, has increased markedly among urologists in recent years. While it was initially thought that this procedure was best utilized in patients with secondary UPJ obstruction, recent evidence suggests that endopyelotomy should be considered in the majority of cases. The primary contraindication to endoscopic incision of the UPJ is a long stricture, although a large redundant renal pelvis and the presence of crossing lower pole vessels are considered by some to be relative contraindications as well. Although the majority of surgeons have used a percutaneous, antegrade approach to endopyelotomy, successful results also have been reported with a ureteroscopic, retrograde technique. With the development of modified ureterotomes and balloon-cutting devices, the retrograde approach eventually may become the preferred method since no skin incision or external drainage are needed. The role of endopyelotomy in children remains undefined. While successful results have been reported in infants, the relative morbidity and long-term success of open pyeloplasty in this age group are excellent, thus limiting the relative advantage of an endoscopic approach. However, there may be a role for endopyelotomy in older children and in those patients with secondary obstruction who have failed open surgery. From a technical standpoint, there are several minor variations in surgical technique and postoperative management that are important. The success rate of endopyelotomy using a cold knife or small electrocautery probe appears to be comparable, and the use of cautery may allow for precise control of minor bleeding thus decreasing the risk of complications. However, larger electrodes may induce greater tissue reaction leading to fibrosis and should be avoided. Postoperatively, most authors prefer a tapered double-pigtail stent which allows for adequate internal drainage while avoiding excessive pressure within the distal ureter. While successful results have been reported with stenting intervals of only four days, it is generally recommended that the stent be left in place for a minimum of six weeks following endoscopic incision of the UPJ. Overall, endopyelotomy is associated with shortened hospitalization, more rapid return to normal activity levels, and decreased morbidity compared with open pyeloplasty. The success rates reported with endopyelotomy approach those achieved with open surgery, and it is likely that an endoscopic approach to UPJ obstruction will assume an increasingly greater role in the future.
近年来，诸如肾盂内切开术等微创外科技术在泌尿外科医生中越来越受欢迎。虽然最初认为该手术最适合用于继发性肾盂输尿管连接处（UPJ）梗阻的患者，但最近的证据表明，在大多数情况下都应考虑进行肾盂内切开术。UPJ内镜切开术的主要禁忌症是长段狭窄，不过一些人认为巨大的肾盂积水和下极血管交叉的存在也是相对禁忌症。虽然大多数外科医生采用经皮顺行途径进行肾盂内切开术，但输尿管镜逆行技术也报告了成功的结果。随着改良输尿管切开刀和球囊切割装置的发展，逆行途径最终可能成为首选方法，因为无需皮肤切口或外部引流。肾盂内切开术在儿童中的作用仍不明确。虽然婴儿中已报告有成功的结果，但该年龄组开放肾盂成形术的相对发病率和长期成功率都很高，因此限制了内镜手术的相对优势。然而，肾盂内切开术在大龄儿童和开放手术失败的继发性梗阻患者中可能有一定作用。从技术角度来看，手术技术和术后管理有几个小的差异很重要。使用冷刀或小型电灼探头进行肾盂内切开术的成功率似乎相当，使用电灼可能有助于精确控制轻微出血，从而降低并发症风险。然而，较大的电极可能会引起更大的组织反应，导致纤维化，应避免使用。术后，大多数作者更喜欢使用锥形双猪尾支架，它能提供足够的内引流，同时避免远端输尿管内压力过大。虽然仅留置四天的支架也报告了成功的结果，但一般建议在UPJ内镜切开术后至少六周留置支架。总体而言，与开放肾盂成形术相比，肾盂内切开术可缩短住院时间，更快恢复正常活动水平，并降低发病率。肾盂内切开术报告的成功率接近开放手术，未来内镜治疗UPJ梗阻可能会发挥越来越大的作用。
