背景:当指示时,重复收集系统中的输尿管囊肿和异位输尿管可以通过上或下尿路手术方法进行管理,或两者的组合。已描述了在没有下极(LP)膀胱输尿管反流(VUR)的情况下,开放式输尿管造口术(UU)可以解决这些问题。我们报告了来自全球多个中心的中期随访结果。
方法:我们的研究包括对北美机构中通过腹股沟切口进行开放远端UU的儿童的记录和成像进行回顾性回顾,以重复收集系统,而没有下极VUR,南美洲,和加勒比海。利用描述性统计和单变量分析。
结果:回顾了2009年至2022年期间接受开放式远端UU双收集系统的127例患者的记录。其中,65%为女性(n=82),手术时的平均年龄为18个月(范围3-180)。手术的主要表现包括产前肾积水(64%,n=81),其次是发热性尿路感染(28%,n=36),和尿失禁或其他(8%,n=10)。产前或偶然诊断为肾积水的患者被分为术前胎儿泌尿外科学会(SFU)3级(n=64)和4级(n=54)(96%)。被分类为SFU0-2级(4%)的患者有症状临床表现,包括高热尿路感染(UTI)(n=3),尿失禁(n=3),和一名12岁的复发性腹痛患者(n=1)。从皮肤切口到皮肤闭合的平均手术时间为86分钟(范围45-240)。平均住院时间估计为1.1天(范围0.5-4)。在我们127名患者的队列中,3(2%)发展为Clavien-DindoI级(2例输尿管支架移位,1例尿液泄漏/保守管理),6(5%)II级(3例发热和3例非发热性尿路感染用口服抗生素治疗),和2(2%)与IIIb级并发症(尿漏需要手术处理),得到了适当的治疗。没有出现IV级或V级并发症。56例患者(44%)使用了双J支架,和一个彭罗斯排水沟留在10(8%)。共有125名儿童(98%,n=125/127)显示肾积水的超声改善,或症状的解决与稳定的超声检查结果。输尿管囊肿和异位输尿管亚组的成功结局相似:49/49例输尿管囊肿患者表现出100%的改善,76/78例输尿管异位的儿童在97%的病例中表现出改善。在单变量分析中,无论是否使用输尿管支架,结果相似(p=0.11).平均随访时间为28.2个月(范围12-85)。
结论:对于无LPVUR的异位输尿管和输尿管囊肿的明确手术治疗,开放远端UU是一个很好的选择。这项多中心和中期随访研究表明,开放远端UU具有很高的成功率,低发病率,手术时间短,住院时间短,和令人满意的美学结果。此外,手术在腹膜外进行,可能不需要使用支架或引流管,取决于外科医生的偏好。正在进行进一步调查,以确定UU在与同侧LPVUR相关的双收集系统设置中的作用。
BACKGROUND: When indicated, ureteroceles and ectopic ureters in duplicated collecting systems can be managed via upper or lower urinary tract surgical approaches, or a combination of both. Open ureteroureterostomy (UU) has been described to address these conditions in the absence of lower pole (LP) vesicoureteral reflux (VUR). We report outcomes from multiple centers worldwide with mid-term follow-up.
METHODS: Our study consists of a retrospective review of records and imaging of children who underwent open distal UU via inguinal incision for duplicated collecting system without lower pole VUR in institutions from North America, South America, and the Caribbean. Descriptive statistics and univariate analysis were utilized.
RESULTS: The records of 127 patients who underwent open distal UU for double collecting system between 2009 and 2022 were reviewed. Of those, 65% were female (n = 82), with a mean age at operation of 18 months (range 3-180). Main presentation at surgery included prenatal
hydronephrosis (64%, n = 81), followed by febrile urinary tract infections (28%, n = 36), and urinary incontinence or other (8%, n = 10). The patients with antenatal or incidental diagnosis of
hydronephrosis were classified as preoperative Society for Fetal Urology (SFU) grade 3 (n = 64) and 4 (n = 54) (96%). Those who were classified with SFU grade 0-2 (4%) had symptomatic clinical presentations including febrile urinary tract infections (UTIs) (n = 3), urinary incontinence (n = 3), and a 12-year-old patient with recurrent abdominal pain (n = 1). Mean operative time from skin incision to skin closure was 86 min (range 45-240). Mean hospital stay was estimated at 1.1 days (range 0.5-4). In our cohort of 127 patients, 3 (2%) developed Clavien-Dindo grade I (2 with ureteral stent displacement and 1 with a urine leak/managed conservatively), 6 (5%) with grade II (3 febrile and 3 non-febrile UTIs managed with oral antibiotics), and 2 (2%) with grade IIIb complications (urine leaks requiring surgical management), which were appropriately treated. None presented grade IV or V complications. A double J stent was used in 56 patients (44%), and a Penrose drain was left in 10 (8%). A total of 125 children (98%, n = 125/127) showed sonographic improvement of
hydronephrosis, or resolution of symptoms with stable ultrasound findings. Successful outcome was similar for both ureterocele and ectopic ureter subgroups: 49/49 patients with ureterocele showed 100% improvement, 76/78 children with ectopic ureter showed improvement in 97% of the cases. On univariate analysis, outcomes were similar regardless of the use of ureteral stents (p = 0.11). Mean follow-up was 28.2 months (range 12-85).
CONCLUSIONS: Open distal UU is a good alternative for the definitive surgical management of ectopic ureters and ureteroceles without LP VUR. This multicentric and mid-term follow-up study demonstrates that open distal UU offers high success rates, low morbidity, short operative times and hospital stays, and satisfactory aesthetic outcomes. Additionally, the surgery is performed extra-peritoneally and may not require the use of stents or drains, depending on surgeon preference. Further investigations are being conducted to determine the role of UU in the settings of double collecting systems associated with ipsilateral LP VUR.