يورتروسيستوپلاستي خلف صفاقي در بيماراني كه كلي ههايي با عملكرد مناسب دو طرفه دارند

Retroperitoneal Ureterocyctoplasty in Bilaterally Functional Kidneys

ﺯﻣﻴﻨﻪ ﻭ ﻫﺪﻑ: ﺩﺭ ﺟﺮﺍﺣﻲ ﺳﻴﺴﺘﻮﭘﻼﺳﺘﻲ ﺗﻘﻮﻳﺖ ﻛﻨﻨﺪﻩ ﺑﻪ ﻃﻮﺭ ﻣـﺮﺳﻮﻡ ﺍﺯ ﻗﺴﻤﺖ ﻫﺎﻱ ﻣﺨﺘﻠﻒ ﺩﺳﺘﮕﺎﻩ ﮔـﻮﺍﺭﺵ ﺍﺳﺘﻔﺎﺩﻩ ﻣﻲ ﺷﻮﺩ ﻛﻪ ﻣﻲ ﺗﻮﺍﻧﺪ ﺳﺒﺐ ﺍﺧﺘﻼﻻﺕ ﻣﺘﺎﺑﻮﻟﻴﻚ ﺷﺪﻩ ﻭ ﺑﻪ ﻃﻮﺭ ﺑﺎﻟﻘﻮﻩ ﺍﺣﺘﻤﺎﻝ ﺍﻳﺠﺎﺩ ﻛﺎﻧﺴﺮ ﻣﺜﺎﻧﻪ ﺭﺍ ﺑﺎﻻ ﻣﻲ ﺑﺮﺩ. ﺩﺭ ﺍﻳﻦ ﻣﻄﺎﻟﻌﻪ ﺁﻳﻨﺪﻩ ﻧﮕﺮ ﻣﺎ ﺗﻜﻨﻴـﻚ ﺟﺮﺍﺣﻲ ﺩﻳﮕﺮﻱ ﺭﺍ ﺁﺯﻣﻮﺩﻩ ﻭ ﺍﺯ ﺑﺎﻓﺖ ﺧﻮﺩ ﺩﺳﺘﮕﺎﻩ ﺍﺩﺭﺍﺭﻱ ﺑﺮﺍﻱ ﺍﻳﻦ ﻛﺎﺭ ﺍﺳﺘﻔﺎﺩﻩ ﻧﻤـﻮﺩﻳﻢ. ﻣﻮﺍﺩ ﻭ ﺭﻭﺵ ﻫﺎ: ﺳﻪ ﺑﻴﻤﺎﺭ ﻛﻪ 2 ﻧﻔﺮ ﻣﺮﺩ ﻭ ﻳﻚ ﻧﻔﺮ ﺯﻥ ﺑﻮﺩﻧﺪ ﺑﺎ ﺗﺸﺨﻴـﺺ ﻣﺜﺎﻧﻪ ﻧﻮﺭﻭﮊﻧﻴﻚ ﻭ ﻛﻠﻴﻪ ﻫﺎﻳﻲ ﺑﺎ ﻋﻤﻠﻜـﺮﺩ ﻣﻨﺎﺳﺐ ﺍﻧﺘﺨﺎﺏ ﻧﻤﻮﺩﻳﻢ. ﻫﺮ ﺳﻪ ﺍﻳﻦ ﺑﻴﻤﺎﺭﺍﻥ ﺑﻲ ﺍﺧﺘﻴﺎﺭﻱ ﺍﺩﺭﺍﺭﻱ ﻭ ﻣﺜﺎﻧﻪ ﻫﺎﻳﻲ ﺑﺎ ﻇﺮﻓﻴﺖ ﻛﻢ ﻭ ﻏﻴـﺮﻗﺎﺑﻞ ﺍﺗﺴﺎﻉ ﻭ ﺭﻳﻔﻼﻛﺲ ﺷﺪﻳﺪ ﺩﺍﺷﺘﻨﺪ ﻛﻪ ﺑﺎ ﮔـﺮﺍﻓﻲ ﻫﺎﻱ VCUG ﺍﺛﺒﺎﺕ ﺷﺪﻩ ﺑﻮﺩ. ﺑﺮﺍﻱ ﻫﺮ ﺳﻪ ﻧﻔﺮ ﺗﺴﺖ ﻳﻮﺭﻭﺩﻳﻨﺎﻣﻴﻚ ﺍﻧﺠﺎﻡ ﺷﺪ. ﺩﻭ ﺑﻴﻤﺎﺭ ﺗﺤﺖ ﻳﻮﺭﺗﻮﺳﻴﺴﺘﻮﭘﻼﺳﺘﻲ ﺧﻠﻒ ﺻﻔﺎﻗﻲ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻫﺮ ﺩﻭ ﺣﺎﻟﺐ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻨﺪ ﻭﻟﻲ ﺩﺭ ﻳﻚ ﺑﻴﻤﺎﺭ ﺍﺯ ﻳﻚ ﺣﺎﻟﺐ ﺍﺳﺘﻔﺎﺩﻩ ﺷﺪ. ﻳﻚ ﻣﺎﻩ ﭘﺲ ﺍﺯ ﺟـﺮﺍﺣﻲ ﺑﺮﺍﻱ ﻫﺮ ﺳﻪ ﻧﻔﺮ VCUG ﺍﻧﺠﺎﻡ ﺷﺪ ﺗﺎ ﻇﺮﻓﻴﺖ ﻣﺜﺎﻧﻪ ﺁﻧﺎﻥ ﺑﺮﺭﺳﻲ ﺷﻮﺩ. ﻳﺎﻓﺘﻪ ﻫﺎ: ﻣﺘﻮﺳﻂ ﺳﻨﻲ ﺑﻴﻤﺎﺭﺍﻥ 20/3 ﺳﺎﻝ )18 -22 ﺑﻮﺩ. ﺳﻄﺢ ﻛﺮﺍﺗﻴﻨﻴﻦ ﺳﺮﻡ ﻗﺒﻞ ﺍﺯ ﻋﻤﻞ ﺁﻧﺎﻥ ﺑﻪ ﺗﺮﺗﻴﺐ 2/3 ﻭ 2/4 ﻭ 2/7 mg/dl ﻭ ﺣﺠﻢ ﻣﺜﺎﻧﻪ 100 ﻭ 77 ﻭ 50 ﺳﻲ ﺳﻲ ﺑﻮﺩ. ﻣﺪﺕ ﺯﻣﺎﻥ ﻋﻤﻞ ﺟﺮﺍﺣﻲ 3، 2/5 ﻭ 2/5 ﺳﺎﻋـﺖ ﺛﺒﺖ ﺷﺪﻩ ﺍﺳﺖ، ﺩﻭﺭﻩ ﭘﺲ ﺍﺯ ﻋﻤﻞ ﻫﺮ ﺳﻪ ﺑﻴﻤﺎﺭ ﺑﻪ ﺧﻮﺑﻲ ﻃﻲ ﺷﺪ. ﻣﺘﻮﺳﻂ ﻣﺪﺕ ﺯﻣﺎﻥ ﺑﺴﺘﺮﻱ 6/7 ﺭﻭﺯ ﺑﻮﺩ. ﻫﺮ ﺳﻪ ﺑﻴﻤﺎﺭ ﺩﺭ ﻃﻲ ﺭﻭﺯ ﺑﺎ ﺍﻧﺠـﺎﻡ CIC ﺧﺸﻚ ﺑﻮﺩﻧﺪ. ﻳﻚ ﻣﺎﻩ ﭘﺲ ﺍﺯ ﻋﻤﻞ ﺳﻄﺢ ﻛـﺮﺍﺗﻴﻨﻴﻦ ﺁﻧﺎﻥ ﺑﻪ 1/2، 1/6 mg/dl ﻭ 1/9 ﻭ ﺣﺠﻢ ﻣﺜﺎﻧﻪ ﺑﻪ 340، 360 ﻭ 290 ﺳﻲ ﺳﻲ ﺭﺳﻴﺪ. ﻧﺘﻴﺠﻪ ﮔﻴـﺮﻱ: ﻧﺘﺎﻳﺞ ﺍﻭﻟﻴﻪ ﺑﺮﺭﺳﻲ ﻫﺎ ﻧﺸﺎﻥ ﺩﻫﻨﺪﻩ ﺍﻳﻦ ﺍﺳﺖ ﻛﻪ ﻳﻮﺭﺗﺮﻭﺳﻴﺴﺘﻮﭘﻼﺳﺘﻲ ﻗﺎﺑﻞ ﻣﻘﺎﻳﺴﻪ ﺑﺎ ﺍﻧﺘﺮﻭﺳﻴﺴﺘﻮﭘﻼﺳﺘﻲ ﺑﻮﺩﻩ ﻭ ﺩﺭ ﺩﺭﺍﺯ ﻣـﺪﺕ ﻧﻴﺰ ﻋـﻮﺍﺭﺽ ﻣﺘﺎﺑﻮﻟﻴﻚ ﻭ ﻧﺌﻮﭘﻼﺳﺘﻴﻚ ﺭﺍ ﻧﺪﺍﺭﺩ. ﺟﺮﺍﺣﻲ ﺍﻓـﺰﺍﻳﺶ ﺣﺠـﻢ ﻣﺜﺎﻧﻪ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﺣﺎﻟﺐ ﺩﺍﺭﺍﻱ ﻫﻤﺎﻥ ﻣـﺰﺍﻳﺎﻱ ﺗﻜﻨﻴﻚ ﻫﺎﻱ ﺟـﺮﺍﺣﻲ ﻗﺒﻠﻲ ﺑﻮﺩﻩ ﻭﻟﻲ ﻋـﻮﺍﺭﺽ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻗﺴﻤـﺖ ﻫﺎﻱ ﻣﺨﺘﻠﻒ ﺩﺳﺘﮕﺎﻩ ﮔـﻮﺍﺭﺵ ﺭﺍ ﺑﻪ ﺩﻧﺒﺎﻝ ﻧﺪﺍﺭﺩ.

ntroduction & Objective: Traditional augmentation cystoplasty using gastrointestinal segments is known to be associated with metabolic abnormalities and alterations in the bladder causing potential carcinogenesis. In this respect alternative techniques have been searched preferably lined by urothelium. We performed retroperitoneal ureterocystoplasty in 3 patients with a diagnosis of neurogenic bladder and investigated the clinical and functional aspects. Materials & Methods: Three patients, 2 male and 1 female patients with neurogenic bladder and bilaterally functional kidneys were selected. All the patients were incontinent, had a small-capacity, noncompliant bladder, and high-grade reflux on voiding cystouretrography (VCUG). Urodynamic study was performed in all. Retroperitoneal ureterocystoplasty using distal end of both ureter in 2 patients and one ureter in other patient was performed. Postoperatively all patients were followed with voiding cystourethrography(VCUG) after one month and bladder capacity measured. Results: Median age was 20.3 years (18-22). Preoperative serum creatinine was 2.3, 2.4 and 2.7 mg/dl and preoperative bladder capacity was 100, 70 and 55ml. The operative duration for the procedure was 3, 2.5 and 2.5 hours. The postoperative course was uneventful. Mean hospital stay time was 6.7 days. All patients were dry by day with clean intermittent catheterization. Serum creatinine was 1.2, 1.6 and 1.9 mg/dl one month postoperatively. Bladder capacity was increased to 340, 360 and 290 ml. Conclusions: The early results of ureterocystoplasty compare favourably with those of enterocystoplasty without the risks of long-term metabolic and neoplastic complications. Augmentation ureterocystoplasty has the beneficial effects of enterocystoplasty without the complications that may arise from the use of bowel segments.