儿童完全性重复肾伴输尿管囊肿的手术方式选择及疗效分析

Selection and clinical effect of surgical approaches for complete duplex kidney with ureterocele in children

摘要:

目的：探讨儿童完全性重复肾伴输尿管囊肿的手术治疗方式，并分析其手术疗效。方法：回顾分析2012年1月至2018年7月行手术治疗的60例完全性重复肾伴输尿管囊肿患儿临床资料。其中，因上肾段发育不良行重复肾及输尿管切除术34例；上肾段发育良好者中，合并重度膀胱输尿管反流（vesicoureteral reflux，VUR）或非囊肿所在输尿管末端狭窄5例，行输尿管再植术，余21例行经尿道膀胱镜下输尿管囊肿开窗引流术。通过临床表现、肾积水程度、输尿管扩张程度、输尿管囊肿大小、VUR、再手术率等指标评估手术疗效。结果：术后60例患儿均获随访，随访时间1~55个月，平均11.6个月。行重复肾及输尿管切除术34例中，术后尿路感染5例；再行输尿管囊肿开窗引流2例，余32例中，B超仍可见输尿管囊肿6例，囊肿直径与术前相比有显著性差异[（13.2±4.4） mm vs. （26.3±3.9） mm，P=0.004]。行经尿道膀胱镜下输尿管囊肿开窗引流术21例中，术后尿路感染6例；再行重复肾及输尿管切除3例，再行输尿管膀胱再植术1例，余17例术后上肾段积水较术前减轻，差异有统计学意义[（9.9±8.2） mm vs. （24.9±10.8） mm，P=0.000]，其中8例仍有输尿管扩张，较术前有统计学差异[（7.0±2.5） mm vs. （10.0±3.3） mm，P=0.007]。行输尿管膀胱再植术5例中，术后尿路感染1例，无再手术者，上肾段积水较术前减轻，差异有统计学意义[（10.0±2.9） mm vs. （24.2±6.9） mm，P=0.004]。结论：膀胱镜下输尿管囊肿开窗、重复肾及输尿管切除和输尿管再植术均可作为完全性重复肾伴输尿管囊肿的治疗方式。对于上肾段发育不良者，建议行上肾段及输尿管切除术。若上肾段发育良好，且合并重度膀胱输尿管反流或其他输尿管末端畸形者，建议行输尿管再植术；而无其他合并畸形者，可选择创伤小的经尿道膀胱镜下输尿管囊肿开窗术。

Abstract:

Objective：To investigate the surgical approaches for complete duplex kidney with ureterocele in children and their clinical effect. Methods：A retrospective analysis was performed for the clinical data of 60 children with complete duplex kidney and ureterocele who underwent surgical treatment from January 2012 to July 2018. Among these children，34 underwent duplex kidney removal and ureterectomy due to dysplasia of the upper renal segment；among the 26 children without dysplasia of the upper renal segment，5 had severe vesicoureteral reflux（VUR） or stenosis at the end of the ureter without ureterocele and underwent ureteral reimplantation，and 21 underwent transurethral cystoscopic incision and drainage. Surgical outcome was evaluated by clinical manifestations，degree of hydronephrosis，degree of ureterectasia，ureterocele size，VUR，and reoperation rate. Results：All children were followed up after surgery，with a follow-up time of 1-55 months（mean 11.6 months）. Among the 34 children who underwent duplex kidney removal and ureterectomy，5 experienced postoperative urinary tract infection；2 children underwent cystoscopic incision and drainage again，and among the remaining 32 children，6 still had ureterocele on ultrasound，with a significant reduction in ureterocele diameter after surgery（13.2±4.4 mm vs. 26.3±3.9 mm，P=0.004）. Among the 21 children who underwent transurethral cystoscopic incision and drainage，6 experienced postoperative urinary tract infection；3 children underwent duplex kidney removal and ureterectomy again，1 underwent ureterovesical reimplantation，and the remaining 17 children had a significant reduction in the degree of hy－dronephrosis in the upper renal segment（9.9±8.2 mm vs. 24.9±10.8 mm，P=0.000），among whom 8 children still had ureterec－tasia，with a significant reduction in the degree of ureterectasia after surgery（7.0±2.5 mm vs. 10.0±3.3 mm，P=0.007）. Among the 5 children who underwent ureterovesical reimplantation，1 experi－enced urinary tract infection after surgery，no children underwent surgery again，and there was a significant reduction in the degree of hydronephrosis in the upper renal segment after surgery（10.0±2.9 mm vs. 24.2±6.9 mm，P=0.004）. Conclusion：Transurethral cystoscopic incision，duplex kidney removal and ureterectomy，and ureteral reimplantation can be used as an effective treatment for complete duplex kidney with ureterocele. For patients with dysplasia of the upper renal segment，resection of the upper renal segment and ureterectomy are recommended. For patients with well-developed upper renal segment，ureteral reimplantation is recommended for patients with severe VUR or deformity at the end of ureter，and transurethral cystoscopic incision with little trauma is recom－mended for those without other deformities.