Shalhav A L, Giusti G, Elbahnasy A M, Hoenig D M, McDougall E M, Smith D S, Maxwell K L, Clayman R V
Division of Urology and Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA.
J Urol. 1998 Sep;160(3 Pt 1):685-9. doi: 10.1016/S0022-5347(01)62755-1.
We evaluate our experience with endopyelotomy for ureteropelvic junction obstruction by stratifying the results of an antegrade versus a retrograde approach for primary, secondary, calculi related, high insertion and impaired renal function related obstruction, individually.
We retrospectively reviewed results of 149 nonrandomized patients treated for ureteropelvic junction obstruction, of whom 83 underwent antegrade percutaneous endopyelotomy using a right angle Greenwald electrode and 66 underwent retrograde endopyelotomy using a cutting balloon device. Subjective results were based on an analog pain scale, objective results on renal scan, excretory urography or Whitaker test and cost-effectiveness analysis on total treatment cost.
In both primary and secondary ureteropelvic junction obstruction, retrograde endopyelotomy was related to a significantly shorter operating room time and hospital stay (p < 0.05). When treating noncalculous primary ureteropelvic junction obstruction (92 patients) there was a better objective, albeit not statistically significant, success rate with antegrade endopyelotomy (89 versus 71%) but retrograde endopyelotomy was 20% more cost-effective. When treating secondary ureteropelvic junction obstruction (37 patients) there was a better objective, albeit not statistically significant, success rate (83 versus 77%) with retrograde endopyelotomy, which was 37% more cost-effective. Complication rates were higher with antegrade compared to retrograde endopyelotomy for primary and secondary ureteropelvic junction obstruction (25 versus 14% and 26 versus 0%). In 20 patients with concomitant stones endopyelotomy results were better (93 to 100% success) than for any other categories of ureteropelvic junction obstruction. Of note, endopyelotomy also provided a reasonable outcome among patients with a high insertion primary ureteropelvic junction obstruction (70% success).
Antegrade endopyelotomy is the preferred approach in patients with primary ureteropelvic junction obstruction and concomitant renal calculi (13.4% of cases), and may also be preferable in patients with high insertion obstruction (6.7%). For all other primary and all secondary ureteropelvic junction obstruction, antegrade and retrograde endopyelotomy is effective therapy yet retrograde endopyelotomy results in less operating room time, shorter hospital stay, fewer complications and significantly less expense to achieve the desired outcome.
我们通过分别对原发性、继发性、结石相关性、高位输尿管肾盂连接部插入异常及肾功能受损相关性梗阻的顺行和逆行方法的结果进行分层，评估我们在输尿管肾盂连接部梗阻的肾盂内切开术方面的经验。
我们回顾性分析了149例接受输尿管肾盂连接部梗阻治疗的非随机患者的结果，其中83例使用直角格林沃尔德电极进行顺行性经皮肾盂内切开术，66例使用切割球囊装置进行逆行性肾盂内切开术。主观结果基于视觉模拟疼痛量表，客观结果基于肾扫描、排泄性尿路造影或惠特克试验，成本效益分析基于总治疗费用。
在原发性和继发性输尿管肾盂连接部梗阻中，逆行性肾盂内切开术的手术时间和住院时间明显更短（p < 0.05）。在治疗非结石性原发性输尿管肾盂连接部梗阻（92例患者）时，顺行性肾盂内切开术的客观成功率更高（89%对71%），尽管差异无统计学意义，但逆行性肾盂内切开术的成本效益高20%。在治疗继发性输尿管肾盂连接部梗阻（37例患者）时，逆行性肾盂内切开术的客观成功率更高（83%对77%），尽管差异无统计学意义，且成本效益高37%。对于原发性和继发性输尿管肾盂连接部梗阻，顺行性肾盂内切开术的并发症发生率高于逆行性肾盂内切开术（25%对14%和26%对0%）。在20例合并结石的患者中，肾盂内切开术的结果（成功率93%至100%）优于其他任何类型的输尿管肾盂连接部梗阻。值得注意的是，肾盂内切开术在高位输尿管肾盂连接部插入异常的原发性梗阻患者中也取得了合理的结果（成功率70%）。
顺行性肾盂内切开术是原发性输尿管肾盂连接部梗阻合并肾结石患者（占病例的13.4%）的首选方法，对于高位输尿管肾盂连接部插入异常的患者（占病例的6.7%）可能也是首选。对于所有其他原发性和继发性输尿管肾盂连接部梗阻，顺行性和逆行性肾盂内切开术都是有效的治疗方法，但逆行性肾盂内切开术的手术时间更短、住院时间更短、并发症更少，且实现预期结果的费用显著更低。
