歷經12年追蹤後遲發性復發之腎盂輸尿管交界處阻塞：腹腔鏡二次 Y-V 腎盂成形術之病例報告

林杰民¹、蔡逸文²

高雄長庚紀念醫院 外科部 泌尿科¹, 小兒外科²

Laparoscopic Re-do Y-V Pyeloplasty for Late Recurrence of Ureteropelvic Junction Obstruction After a 12-Year Follow-up: A Case Report

Chieh-Ming Lin¹, Yi-Wen Tsai²

Division of Urology¹; Division of Pediatric Surgery², Department of Surgery, Chang Gung Memorial Hospital, Kaohsiung, Taiwan

Purpose: Primary pyeloplasty for pediatric ureteropelvic junction obstruction (UPJO) generally yields excellent long-term outcomes; late recurrence over a decade later is exceedingly rare. We present a challenging case of late-onset UPJO recurrence during the pubertal growth spurt, successfully managed with a laparoscopic re-do Y-V flap pyeloplasty.

Case presentation: A completely asymptomatic 12-year-old boy was noted to have dramatic disease progression during routine ultrasound surveillance. His medical history was significant for congenital right ureteropelvic junction obstruction (UPJO), for which he underwent a right transumbilical laparoscopic-assisted dismembered pyeloplasty at 6 months of age. The initial histopathology revealed prominent circular muscle hyperplasia. Following a period of early postoperative stabilization, serial ultrasonography and Tc-99m DTPA renography confirmed stable split renal function for over a decade.

Recent imaging, including intravenous pyelography (IVP) and magnetic resonance urography (MRU), demonstrated a markedly dilated right hydronephrotic sac with a non-visualized proximal ureter, while serum creatinine remained normal (0.56 mg/dL). A laparoscopic re-do right pyeloplasty was indicated. Intraoperatively, the right ureter was severely kinked by a dense fibrotic band tethered to the lower pole of the renal pelvis. After dividing the fibrotic band, a Y-V flap pyeloplasty was meticulously performed over the stenotic region, followed by double-J stenting. The re-do pathology showed focal congestion and hemorrhage, consistent with chronic mechanical obstruction. The postoperative course was uneventful.

Conclusions: Congenital UPJO patients may experience insidious, silent deterioration during their pubertal growth spurt, driven by the mechanical tethering of preexisting fibrotic bands. This case compellingly advocates for the extension of morphological and functional surveillance in UPJO patients well into adolescence. Furthermore, the laparoscopic Y-V flap pyeloplasty serves as a highly effective, minimally invasive salvage technique to overcome the anatomical challenges inherent in complex re-do reconstructive surgeries.