| Background:Ureteral terminal malformations refer to a group of lesions,predominantly consisting of primary obstructive megaureter(POM)and vesicoureteral reflux,which can present with various clinical manifestations.These malformations including hydroureter,dilated and tortuous ureters,and recurrent urinary tract infections,which can progress to impaired kidney function on the affected side.Vesicoureteral reimplantation is the preferred treatment for ureteral terminal malformations.This procedure comprises several different surgeries,such as Cohen,Politano-Leadbetter,Glenn-Anderson,and Lich-Gregoir.Among these surgeries,Cohen ureteral reimplantation is performed in the trigonal area of the bladder and involves creating a submucosal tunnel.When performed under laparoscope pneumovesic,it offers an esthetic appearance and requires a shorter incision compared to conventional open surgical treatments.As a result,Cohen ureteral reimplantation under laparoscope pneumovesic has become a crucial surgical procedure for treating ureteral terminal malformations.The department of pediatric surgery at Shandong Provincial Hospital has successfully implemented laparoscope pneumovesic over the last decade.It is now essential to evaluate the effectiveness of Cohen ureteral reimplantation under laparoscope pneumovesic compared to traditional open surgery.Our team has identified a gap in the assessment of ureter morphology during postoperative follow-ups of POM patients,and few studies have explored specific changes in this area after ureteral reimplantation.Additionally,we have observed significant differences in the recovery of ureteral dilation among POM children undergoing vesicoureteral reimplantation.Given that ureteral dilation is one of the chief symptoms of POM,parents of affected children are understandably concerned about the restoration of their child’s ureter morphology following surgery.Therefore,it is crucial to thoroughly evaluate laparoscope pneumovesic procedures and follow-up on the recovery of POM patients’ureter morphology to ensure optimal postoperative care.Based on our observations,POM patients tend to experience more pronounced ureteral dilation in the retrovesical and distal portions.By studying the dynamic change law of the retrovesical ureteric diameter(RUD),we can gain deeper insights into the postoperative recovery of ureter morphology.These changes in RUD offer an indirect reflection of the relief of obstructive processes in the upper urinary tract and the restoration of kidney function.Therefore,it is crucial to study the RUD changes in postoperative follow-ups of patients with POM.By doing so,we can better understand the effectiveness of treatments and gauge the degree of recovery in kidney function and upper urinary tract health.Object:The primary objective of this study is to evaluate the effectiveness of Cohen ureteral reimplantation under laparoscope pneumovesic as a treatment for children with ureteral terminal malformations.Our secondary goal is to observe the postoperative recovery of retrovesical ureteric diameter(RUD)in POM patients who have undergone ureteral implantation and identify risk factors that may impact RUD resolution.Methods:This study retrospectively analyzed clinical data of children who had undergone Cohen ureteral reimplantation for POM or vesicoureteral reflux at our institution between May 2011 and January 2021.Patients were divided into two groups based on surgical approach:open group and laparoscope pneumovesic group.The recovery during hospitalization and postoperative follow-up for each group was recorded.Multiple metrics,including operative time,incision length,postoperative hematuria,length of postoperative stay,hydronephrosis and hydroureter recovery,postoperative complications,reoperation rate,and other indicators were compared between the two groups.Children who underwent vesicoureteral reimplantation for POM(Cohen procedure)were included in a study analyzing postoperative recovery of RUD according to additional inclusion and exclusion criteria.B-scan ultrasonography was employed to record morphological changes in dilated ureters during postoperative follow-up.The ureter was set as the statistical unit to analyze the recovery pattern of RUD after ureteral reimplantation.Survival analysis was utilized to identify clinical factors that may impact RUD recovery.A RUD of<7 mm was defined as a normal shape and outcome.Survival times were calculated from surgery to resolution of RUD or until the last follow-up.Univariate survival analyses were conducted first;then,a multivariate survival analysis was performed for significant factors from the univariate survival analyses.Kaplan-Meier survival curves were plotted for significant factors in the multivariate survival analysis.Results:After applying the inclusion and exclusion criteria,118 patients were enrolled in the study,including 48 in the open group and 70 in the laparoscope pneumovesic group.The baseline parameters,such as age,weight,disease types,and severity of hydronephrosis and hydroureter were similar between the two groups.The laparoscope pneumovesic group showed a lower number of patients who required blood products(P=0.007),shorter incision length(P<0.001),and a larger submucosal tunnel and ureter terminal diameter ratio(P=0.001)than the open group.Meanwhile,the laparoscope pneumovesic group experienced shorter postoperative hematuria(P=0.005),catheter retention(P=0.023),and postoperative stay(P<0.001),but had a longer operation time(P<0.001).Both groups exhibited a clear improvement in hydronephrosis and hydroureter,with the laparoscope pneumovesic group showing a more significant degree of hydronephrosis recovery(P=0.035).There were no significant inequalities between the two groups in terms of pain medication use,urinary system infection during postoperative stay,postoperative vesicoureteral reflux,postoperative ureter obstruction,postoperative voiding abnormalities,and reoperation rate.In the analysis of postoperative recovery of RUD,49 patients with 54 ureters were included.The median survival time was 6 months,and all 54 ureters showed significant recovery.Additionally,47 megaureters(87.04%)had resolution,with 29(61.7%)occurring within 6 months after surgery.Univariate analysis found that bilateral ureterovesical reimplantation(P=0.015),ureteral terminal tapering(P=0.019),weight(P=0.036),and age(P=0.015)were all related to the recovery time of RUD.Further analysis using multivariate Cox regression revealed a delayed recovery of RUD in bilateral reimplantation(HR=0.336,P=0.017).Conclusions:1.Laparoscope pneumovesic procedure offers numerous benefits,such as an aesthetically pleasing abdominal incision,reduced surgical trauma,and shorter postoperative recovery time compared to traditional open surgery.Given its safety and effectiveness,laparoscope pneumovesic should be widely used in clinical practice.2.Postoperative recovery of retrovesical ureteric diameter in primary obstructive megaureter patients who underwent Cohen vesicoureteral reimplantation is mostly completed within six months.Moreover,bilateral ureterovesical reimplantation is a risk factor for delayed postoperative recovery of retrovesical ureteric diameter in primary obstructive megaureter. |
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