儿童肾盂输尿管连接处梗阻手术后再梗阻的手术处理及危险因素分析  

Surgical managements and risk factors of restenosis after pyeloplasty for ureteropelvic junction obstruction in children

作　　者：王衍泽 徐宏业 吴荣德 刘伟 Wang Yanze;Xu Hongye;Wu Rongde;Liu Wei(Department of Pediatric Surgery,Affiliated Shandong Provincial Hospital,Shandong First Medical University,Jinan 250021,China;Department of Pediatric Surgery,Affiliated Women&Children's Hospital,Qingdao University,Qingdao 266034,China)

机构地区：[1]山东第一医科大学附属省立医院小儿外科,济南250021 [2]青岛大学附属妇女儿童医院小儿泌尿外科,青岛266034

出　　处：《临床小儿外科杂志》2024年第8期750-756,共7页Journal of Clinical Pediatric Surgery

基　　金：山东省立医院医疗技术创新激励项目(CXJL:ZQN—202208)。

摘　　要：目的探讨儿童肾盂输尿管连接处梗阻(ureteropelvic junction obstruction,UPJO)行离断式肾盂成形术后出现再梗阻的原因及手术处理策略,分析导致术后再梗阻的危险因素。方法回顾性分析山东第一医科大学附属省立医院小儿外科2013年1月至2023年2月收治的UPJO患儿的临床资料,收集首次手术后再梗阻患儿的临床表现、辅助检查方式、术中所见梗阻原因及再手术处理方法。根据首次手术后是否出现再梗阻,将患儿分为再梗阻组和非再梗阻组,比较两组年龄、性别、体重、肾盂前后径、是否术前行肾穿刺造瘘、UPJO病因、手术方式、术后有无泌尿系感染等,采取单因素分析及多因素Logistic回归分析发生术后再梗阻的危险因素。结果本研究纳入326例患儿(332侧肾),非再梗阻组315例(321侧肾),再梗阻组11例(11侧肾)(左侧9例、右侧2例),均经超声、CTU及逆行肾盂造影明确诊断为肾盂输尿管连接处再梗阻;再梗阻组11例(11侧肾)中10例行经腹腔镜肾盂成形术,1例行开放肾盂成形术,两次手术间隔时间为(9.68±2.71)个月。11例发生再梗阻的原因:肾盂输尿管连接处局部管腔狭窄4例(36.36%),肾盂输尿管连接处周围粘连压迫5例(45.45%),遗漏前方迷走血管压迫2例(18.18%);患儿再次手术后均获随访,随访时间(46.90±43.75)个月,肾积水均明显改善。再梗阻组与非再梗阻组术前肾穿刺造瘘以及背部小切口手术人数占比分别为3/11比22/321(χ^(2)=6.368,P=0.042)、5/11比57/321(χ^(2)=5.372,P=0.036),差异均有统计学意义。多因素Logistic回归分析显示,术前肾穿刺造瘘(OR=7.226,95%CI:1.628~32.082,P=0.009)和经背部小切口入路手术(OR=5.038,95%CI:1.376~18.440,P=0.015)是UPJO术后再梗阻的独立危险因素。结论肾盂输尿管连接处局部管腔狭窄粘连、压迫、遗漏前方迷走血管压迫是UPJO术后再梗阻的常见原因,再次经腹腔镜行肾盂成形术治疗安全有效。对�Objective To explore the causes and surgical managements of restenosis after pyeloplasty for ureteropelvic junction obstruction(UPJO)in children and examine the potential risk factors for restenosis.Methods From January 2013 to February 2023,the relevant clinical data were retrospectively reviewed for 326 UPJO children(332 sides)undergoing primary and redo pyeloplasties.The causes,diagnoses,surgical procedures and outcomes of restenosis after primary pyeloplasty were summarized.They were assigned into two groups of restenosis and non-restenosis according to follow-up results.The relevant clinical data of two groups were compared for examining the risk factors of recurrence.Results There were 11 sides in restenosis group and 321 sides in non-restenosis group.Postoperative restenosis was confirmed by ultrasonography,computed tomography(CT)and retrograde pyelography.Laparoscopic redo pyeloplasty(n=10)and open surgery(n=1)were performed.Interval between two operations was(9.68±2.71)month.The intraoperative findings included local stenosis of ureteropelvic junction(n=4,36.36%),adhesion&compression around ureteropelvic junction(n=5,45.45%)and compression of anterior crossing vessel(n=2,18.18%).During a follow-up period after redo pyeloplasty of(46.90±43.75)month,hydronephrosis improved in all cases.In the restenosis group,27.27%(3/11)cases underwent the percutoneaus nephrostomies before pyeloplasty and 45.45%(5/11)underwent miniature pyeloplasty via a dorsal paravertebral transverse incision.which were significant more than those in non-restenosis group(6.85%(22/321)and 17.76%(57/321).Multivariate Logistic regression analysis revealed that preoperative percutaneous nephrostomy(P=0.009,OR=7.226,95%CI:1.628-32.082)and dorsal mini-incision(P=0.015,OR=5.038,95%CI:1.376-18.440)were independent risk factors for recurrent UPJO.Conclusions The common causes of restenosis include local stricture of anastomosis,adhesion and compression around ureteropelvic junction and anterior crossing vessels.Laparoscopic redo pyeloplasty is

关 键 词：肾盂输尿管连接处梗阻 治疗结果 手术后并发症 输尿管梗阻 外科手术 危险因素 儿童 

分 类 号：R69[医药卫生—泌尿科学]