OBJECTIVE: To investigate the feasibility and clinical results of laparoscopic ureteral spade papillary bladder reimplantation in pediatric patients. METHODS: Laparoscopic ureteral spade papillary bladder reimplantation was performed via the extravesical route to treat 11 children with congenital obstructive megaureteral disease, 4 on the left side and 7 on the right side. 1 case had ureteral outlet atresia, 9 cases had simple ureteral outlet stenosis, and 1 case had recurrent ureteral outlet stenosis after open ureteral bladder reimplantation (cohen procedure). The ultrasound and IVU examination showed severe hydronephrosis in 7 cases and moderate hydronephrosis in 4 cases. RESULTS: All 11 cases were operated successfully. The operative time ranged from 70 to 190 min, with an average of 95 min. intraoperative bleeding ranged from 10 to 40 ml, with an average of 18 ml. postoperative hospital stay ranged from 7 to 10 days, with an average of 8 days. No urinary leakage occurred. The cystoscopy or ureteroscopy showed that the vesicoureteral anastomosis had been mucosalized and the papillary constriction was effective against reflux; the average follow-up time was 6 months (3~24 months), the hydronephrosis on the operated side was reduced by B ultrasound review, and the IVU showed that the formed ureter drained well without obstruction and the symptoms basically disappeared; no vesicoureteral reflux was seen on cystography. Conclusion: After mastering the laparoscopic operation technique, laparoscopic ureteral spade papillary bladder reimplantation via extravesical route was applied to treat pediatric obstructive giant ureteropathy with good surgical results, good anti-reflux effect, and little trauma, which is a minimally innovative way to treat pediatric obstructive giant ureteropathy. From January 2003 to January 2007, we performed laparoscopic ureteral spade papillary bladder reimplantation via the extravesical route to treat 11 cases of pediatric obstructive megaureteral disease with good surgical results. I. General data Eleven cases (8 cases in Tongji Hospital and 3 cases in Wuhan Children’s Hospital), 8 males and 3 females, aged 11 months to 13 years old, average 5 years old, 4 cases on the left side and 7 cases on the right side. All children were seen for different degrees of urinary tract infections, except for one case of fever of unknown origin in a November child and three cases of abdominal pain. Ultrasound showed hydronephrosis on the affected side in all children, and high-dose IVU and magnetic resonance examination showed dilated kidneys and ureters on the affected side, with severe hydronephrosis in 7 cases and moderate hydronephrosis in 4 cases. In one case, the child was admitted to the hospital in November with fever, severe hydronephrosis and abdominal mass, and ultrasound-guided nephrostomy was performed to drain pus urine, which disappeared after 2 weeks of drainage. The procedure was performed with a gastrointestinal decompression tube and a urinary catheter. Under general anesthesia, the patient was placed in the supine position with the affected hip elevated at 30°, and a CO2 artificial pneumoperitoneum was established with an air pressure of 10-15 mm Hg (1 mm Hg = 0. 133 kPa), and three holes were poked in the abdominal wall, with hole A located above the umbilical chakra with a 5-mm trocar, hole B located at the midpoint of the line between the umbilicus and the anterior superior iliac spine on the affected side with a 10-mm or 5-mm trocar (5-mm for left-sided lesions and 10-mm for right-sided lesions), and hole C located at the midpoint of the umbilicus and the pubic symphysis. The C hole is located at the midpoint between the umbilicus and the pubic symphysis (2 transverse fingers on the healthy side if the child is less than 2 years old), and a 10 mm or 5 mm trocar is placed (depending on the operator’s left and right hand habits), with the monitor placed on the affected side; the bladder and the possible peristaltic ureter on the affected side are observed first, the pelvic peritoneum and the peritoneal reflex of the bladder are opened and the lower ureter is explored, the lower part of the ureter to the bladder wall is exposed, the bladder is disconnected at the bladder wall segment, and the stump is closed with a Hem-o The stump was clamped with Hem-o-Lock. The end of the ureter was observed microscopically and a portion was cut for biopsy, while the ureter was cut and dilated so that the proximal ureter was 2 cm in diameter and the distal ureter was 1.5 cm in diameter. A 2.5 cm lateral incision was made at the end of the ureter (2.5 cm could be left unsutured if cut), the ureteral orifice was turned and fixed with 5-0 Dexon thread; the bladder was filled with 100 ml of water through the ureter, a poke was made laparoscopically at the base of the bladder, the bladder mucosa was clamped at the poke, and the whole bladder was intermittently sutured with 5-0 absorbable thread to the proximal pulpy muscle layer of the papilla, first anastomosing the upper 3/4 part. The lower 1/4 part was sutured after the double J tube was placed under the scope. The ureter was placed in the retroperitoneal space after laparoscopic examination to see that there was no tension and torsion of the ureter, and one abdominal drain was placed. Postoperative treatment The abdominal drainage tube was left in place for 3~5 d, and was removed after 2 d without obvious drainage fluid, the catheter was kept for 6~7 d, and the double J ureteral catheter was left in place for 6 weeks and then removed via cystoscopy or ureteroscopy. IV. Assessment indexes and data processing The observation indexes included operative time, estimated intraoperative bleeding, time to resume diet and bed activity after surgery, and complications. Operative time was defined as the time from skin incision to incision closure. Children were followed up by letter or telephone and outpatient review. Microsoft Excel 2000 software was used for data collection and processing. Results All 11 surgeries in this group were successful. The operation time ranged from 70 to 190 min, with an average of 95 min; intraoperative bleeding ranged from 10 to 40 ml, with an average of 18 ml; there were no intraoperative complications; all children resumed eating and bed activities 1 to 3 d after surgery; the abdominal drain was removed 1 to 3 d after surgery; the catheter was removed 1 week after surgery, and there was no urinary leakage; the postoperative hospital stay ranged from 7 to 10 days, with an average of 8 days; the double-J tube was removed 6 weeks after surgery, and the cystoscope or The cystoscopy or ureteroscopy showed that the vesicoureteral anastomosis had been mucosalized and the papillary constriction was effective against reflux; the average follow-up time was 6 months (3~24 months), and B ultrasound and IVU showed 2 cases of moderate hydronephrosis, 5 cases of mild hydronephrosis, and 4 cases of no obvious hydronephrosis; the formed ureter drained well without obstruction, and the symptoms basically disappeared; no vesicoureteral reflux was seen on cystography. The scope of giant ureter has always been a controversial topic in urology, and the origin of the debate lies in the identification of obstructive and non-obstructive causes and the indications for surgical treatment. Giant ureter currently refers to any dilated ureter in general and is considered to be a general concept and not specific to any particular disease, which is a departure from the past. However, as a means of guiding treatment, the causes of giant ureters are divided into four categories: (1) reflux; (2) obstructive; (3) both reflux and obstruction; and (4) neither reflux nor obstruction. The current disagreement lies in the treatment options for giant ureters caused by non-reflux non-obstructive factors, and there has been an increasing trend of conservative management in the last decade. Opinions on the treatment of obstructive giant ureter are basically unified, especially in pediatric patients who tend to have more rapid disease progression and more severe renal damage and should be operated as early as possible. Minimally invasive surgical techniques are now used to treat diseases of the ureter and renal pelvis. Bapat et al. reported a group of endoureterotomies for congenital primary obstructive megaureteral disease, treating five adults with six lateral ureters. The main procedure was to first observe the opening of the bladder and ureter with a cystoscope, insert a guidewire into the giant ureter, and use a cutting current to longitudinally incise the muscular layer to the fatty tissue outside the ureter at the 6 o’clock position in the obstructed segment of the ureter and, if necessary, at the 12 o’clock position, taking care to avoid damaging the bladder mucosa. After surgery, a double J tube was placed and removed after 3 weeks. Janetschek et al. reported the treatment of obstructive giant ureter by laparoscopic partial nephrectomy and ureterectomy. 12 of the 14 children were treated with upper pole nephrectomy and 2 of them were treated with open surgery to anastomose the ureter to the bladder and 2 with lower pole nephrectomy. The operative time ranged from 3.0 to 5.5 h. There were no surgical complications. Since Winfield et al. first reported laparoscopic completion of uretero-vesical anastomosis in 1991, this procedure has been rapidly performed abroad. The efficacy of laparoscopic surgery and endoureteral incision for obstructive megaureter is difficult to compare because of the small number of cases at present. Technically, endoureteral incision is simpler than laparoscopy; however, compared with the efficacy of endoluminal microscopy for UPJ stenosis, laparoscopy is better than endoureteral incision and is comparable to open surgery, especially when the degree of hydronephrosis is severe and the renal pelvis is dilated. Laparoscopic ureteral bladder reimplantation is an effective treatment for obstructive giant ureter, and the main surgical routes are transvesical extravesical ureteral transplantation (Lich-Gregoir method) [9] and transvesical intravesical ureteral transplantation (Cohen).Laksh-manan et al. reported 71 ureteral laparoscopic extravesical bladder transplants, of which 21 were unilateral and 24 were bilateral ureteral Gill et al. reported three successful ureteral transplants with cystoscopic filling of the bladder with saline and laparoscopy combined with cystoscopy, one of which had mild postoperative ureteral reflux. Yeung et al. 2002 reported that gas vesicoureteral Cohen grafting with CO2 gas dilated the bladder and improved the clarity of the visual field while avoiding spillage of fluid filling the bladder into the abdominal cavity, but this procedure has three sheaths into the bladder, which is more damaging to the bladder and requires a longer ureter, making future ureteral cannulation difficult and a higher chance of recurrence. The chance of re-stenosis is higher. Transplantation of the ureter from outside the bladder has the advantages of light postoperative bladder spasm, short hospital stay, easy postoperative intubation, and reduced complications, and is especially suitable for larger ureters, which can avoid obstruction caused by twisting of the ureter. In the past 4 years, we have carried out laparoscopic transcystic ureteral spade papillary bladder reimplantation for 11 cases of pediatric obstructive giant ureter on the basis of proficient laparoscopic surgical operation skills, and achieved good clinical results with smooth anastomosis and good anti-reflux effect in postoperative follow-up. Through the lumpectomy anatomical study of the pelvis in this group of 11 pediatric cases, we found that: 1. The peristaltic or dilated ureter can be found more clearly under laparoscopy, and the exposure of the end of the ureter is better than that of open surgery; 2. If the ureter is difficult to be exposed, the ureter can be found near the iliac vessels at the entrance to the pelvis and freed down to the bladder, and the ureter can be freed better at the same time; 3. In male children, the lower part of the ureter has These structures are very small, and care should be taken to avoid damage when freeing the ureter; the vessels on the lateral ligament of the bladder are prone to bleeding, so care should be taken not to damage this vessel, and once bleeding has occurred, 3-0 or 4-0 absorbable sutures should be used to stop the bleeding, and the adnexa can easily affect the exposure of the surgical field. 4, after the bladder is opened, CO2 gas enters directly, so that the bladder is in a semi-filled state, which clearly exposes the bladder mucosal incision and facilitates suturing; 5, for cases with a history of open surgery, if the ureter is short, it will protrude into the abdominal cavity, and the ureter can be found by opening the peritoneum at the bulging long cord. In our group, we had a case of recurrent ureteral outlet stenosis after open cohen’s surgery, and we found the ureter quickly after opening the peritoneum at the bulging long cord. For the operation of ureteral freeing and forming surgery, we have the following experience: 1. The ureter should be separated to the lowest possible level, and the wall of the ureter with dysplastic end muscles should be fully excised; 2. The ureter should be fully free so that it can be anastomosed under no tension; 3. Care should be taken to protect the ureteral blood supply when freeing the ureter, and the blood supply of the fatty tissue and fascia on the lower pole of the kidney should be preserved when freeing to the upper part of the ureter; 4. The position of the entrance of the ureter into the bladder should be as far back as possible, the closer to the triangle the better, so as to avoid obstruction due to angular deformity of the ureter when the bladder is full; 5. If the ureteral inflammation is obvious and the adhesions with the surrounding tissues are tight, the diameter of the cut ureter is ≥2 cm; 6. If the tension is high after uretero-cystic anastomosis, the upper part of the ureter needs to be freed appropriately to reduce the tension, and if necessary, the lateral posterior wall of the bladder is freed to do the fixation of the lumbar muscle of the bladder; 7. We cut the ureter laterally at the end of the ureter at 2.5 cm and turn the ureteral opening to form a spade The purpose is to reduce the chance of anastomotic stenosis after antireflux anastomosis, to make full use of the abdominal space and the magnification of the endoscope during the anastomosis, and to reveal the distal ureteral wall and the mucosa of the cystotomy; 8, for obese children with more fat in the abdominal cavity, the head-low-foot-high position of 300 is more favorable for pelvic operation; 9, the double-J tube should be placed under the guidance of the guidewire after 3/4 of the anastomosis is completed, not before the anastomosis. To avoid obscuring the field of view and affecting the suture; 10, patients with severe hydronephrosis have dilated and thinned renal cortex, and the lower pole of the kidney has bag-like changes, ECT shows that the kidney is still functional, and the lower pole of the kidney can be folded under laparoscopy with 2-0 absorbable thread; 11, proper drainage tubes are placed next to the anastomosis to avoid postoperative urinary leakage or exudate on the abdominal cavity, and the fluid can be drained out in a timely manner; in addition, preoperative attention should be paid to the bladder function of urination In addition, preoperative examination of bladder voiding function should be emphasized, and this procedure is not recommended for those with lesions in the bladder muscle layer; urine culture should be performed a few days before surgery to ensure the sterility of the urinary tract, and if bladder inflammation is found, effective antibacterial medication should be given before surgery. In conclusion, the clinical results of this group of 11 cases showed that laparoscopic ureteral spade papillary bladder reimplantation via the extravesical route was satisfactory in the treatment of pediatric obstructive megaureteral disease, with good anti-reflux effect, low complications, simple and time-consuming operation, and can be successfully completed by mastering laparoscopic suture technique, and has the advantages of small trauma and quick recovery, which is worthy of clinical promotion and application.