医源性损伤致肾盂狭窄闭锁再手术治疗体会

目的 分析复杂性鹿角形肾结石取石术后、ESWL术后所致肾盂狭窄闭锁的原因和手术方法。方法 对9例复杂性鹿角形肾结石取石术后、1例肾盂结石行ESWL术后、1例肾结核并肾盂、肾下盏结石取石术后致肾盂狭窄闭锁患者原手术情况进行分析，寻找可能发生的原因；其中6例行肾下盏和输尿管侧侧吻合术，3例行肾下盏和输尿管端端吻合术，2例行带血管蒂腹膜加盖肾盂成形术。同时置肾造瘘管和双J管引流。结果 11例术后随访9—30个月，其中10例肾积水无加重，吻合口无狭窄，上尿路通畅；1例术后8个月再出现吻合口狭窄闭锁。结论 肾下盏与输尿管侧侧吻合术是治疗肾盂狭窄闭锁较好方法，带血管蒂腹膜加盖肾盂成形术短期疗效尚理想，长期疗效尚待观察。     

肾造瘘管与双J管一体化在mPCNL中的应用研究

目的:探讨微通道经皮肾镜取石术(minimally invasive percutaneous nephrolithotomy,mPCNL)肾造瘘管与双J管一体化在非复杂性肾盂及输尿管上段结石中的安全性及可行性。方法:收集我院2013年1月~2014年12月,超声引导行F16~18单通道mPCNL治疗肾盂及输尿管上段结石患者36例,其中脊柱严重畸形患者2例,双侧股骨头坏死患者1例。术后留置双J管与肾造瘘管绑定形成一体化,出院前将肾造瘘管及双J管同时拔出。结果:36例手术均取得成功,平均手术时间22min。一次手术取净结石率97.2%,术后4~7天同时拔出造瘘管及双J管。术后无大出血和腰痛。结论:mPCNL术中采用肾造瘘管与双J管一体化治疗非复杂性肾及输尿管上段结石安全、有效,能减少患者术后带管不适,不需要再次返院拔管,特别适用于伴有脊柱严重畸形或者股骨头坏死患者。     

复杂性肾结石取石术后肾盏肾盂闭锁的防治探讨

目的：探讨复杂性肾结石取石术后发生肾盏或肾盏闭锁的原因和防治措施。方法：回顾性地分析诊治的7命名中层得之影像学、取石的手术方法及肾引流方式等资料，以评价取石术后肾盏肾盂闭锁可能发生的原因。再手术时采用输尿管与肾下盏吻合3例，回肠代输尿管1例，扩张肾盏之间打通的旁路手术和肾盏狭窄部扩大成形术1例，肾切除2例。结果：所有患者手术后恢复良好，5例经上述手术后重建了患侧上尿跃通畅引流，治愈出院。结论：凡肾盂狭小、肾盏漏斗部狭小而肾盏显著扩张者，在取石过程中盲目钳夹造成肾盏肾盂粘膜广泛创伤而又未安置双J管内引流仅作肾造瘘者，有可能发生此类并发症。肾下盏与输尿管吻合术是治疗肾盂闭锁的较好方法，某一主盏的闭锁可行肾盏与肾盏沟通的旁路手术以重建上尿路通畅引流。     

肾结石术后并发肾盂输尿管交界处闭锁的原因及防治

目的:探讨复杂性肾结石取石术后并发肾盂输尿管交界处闭锁的原因和防治方法。方法:对7例复杂性肾结石手术取石后并发肾盂输尿管交界处闭锁的患者进行回顾性分析。6例行输尿管和肾下盏吻合术,并应用双J管作内支架引流。1例行患肾切除术。结果:7例患者均经手术治愈,术后恢复良好。随访6~24个月,6例患者行静脉尿路造影均显示重建的上尿路引流通畅,肾盂肾盏积水明显缓解。结论:肾内型肾盂、肾盂狭小而肾盏扩张者,在取石过程中盲目钳夹造成肾盂黏膜广泛损伤、撕裂,甚至完全断裂而缝合修复不良,放置双J管作内支架引流时间过短或未放置而仅作肾造瘘者,易发生本并发症。肾下盏与输尿管吻合术是治疗肾盂输尿管交界处狭窄闭锁的较好方法,而双J管内支架引流是手术成功的关键。     

鹿角形肾结石取石术后尿漏原因分析

目的：探讨鹿角形肾结石取石术后尿漏原因。方法：分析150例鹿角形肾结石取石术后发生尿漏的6例患者的尿液引流方式、肾盂肾盏损伤程度、肾盂类型以及输尿管通畅情况等与发生尿漏的关系。结果：6例尿漏患者中，双J管引流不畅致尿漏3例，其中2例为肾内型肾盂伴术中肾盂肾盏损伤严重，血凝块堵塞双J管，1例为血小板减少出血致双J管堵塞。输尿管部分梗阻致尿漏2例，吻合不满意致尿漏1例。结论：双J管引流不畅和输尿管部分梗阻是导致尿漏的主要原因。建议肾内型肾盂鹿角形结石取石时，如果肾盂肾盏损伤较重，在双J管内引流同时应行肾造瘘；术前应充分了解输尿管通畅情况和凝血功能状态，必要时并作处理。     

腹腔镜下肾窦内肾盂切开取石术疗效分析

目的 报告腹腔镜下肾窦内肾盂切开取石术的初步临床经验。方法 经腹腔途径腹腔镜下施行肾窦内肾盂切开取石术治疗肾结石19例，21侧；同期处理其他上尿路疾病9例。男14例，女5例。年龄16～67岁，平均41岁。结石直径1．2～3．5cm。结石位于右侧11例，左侧6例，双侧2例。合并输尿管结石5例，其中双侧输尿管多发性结石同侧石街形成1例；肾盂息肉2例，其中致巨大肾积水1例；开放性输尿管切开取石术后狭窄伴巨大肾积水1例；妊娠期肾盂结石致巨大肾积水时放置双J管内引流术后1例。12例13侧曾行体外冲击波碎石术（ESWL）治疗失败，1例曾行微创经皮肾镜取石术（MPCNL）取石不净。结果 手术均获成功。手术时间75～240min，平均115min。术中出血量30～100m1．平均50ml。术后漏尿者1例，5d后自愈。术后住院时间5～9d，平均6d。留置双J管4～6周。随访3～36个月，KUB及IVU显示除1例肾下盏残留1枚0．7cm结石外，余无结石残留，肾盂出口输尿管无狭窄，双肾输尿管均显影。结论 腹腔镜下肾窦内肾盂切开取石术是治疗肾结石可选择的一种微创手术，且可同期处理上尿路合并症，可部分替代开放性手术。     

双J管移位的处理

我院于1994年2月～1996年11月采用双J管作内引流支架处理较复杂的上尿路手术113例，其中4例因膀胱端向上移位而改用其他方法取出，现报告如下。1病例报告例1女，34岁。因肾盂输尿管连接处狭窄伴左肾重度积水，在硬膜外麻醉下经腰部入路行狭窄处切除及肾盂格尿管成形术。术中留置双J管（此管中段长22cm）及肾盂造瘘管，术后14d行B超及造痿管造影检查均示双J管远端不在膀胱内，嘱患者带管出院。6周后拔除肾造瘘管，应用纤维胆道镜由腰部疾口插入，取出双J管。例2男，58岁。因右侧输尿管上段狭窄合并结石伴右肾中度积水，行取石术及输尿管狭…     

后腹腔镜下肾窦内肾盂切开取石术:附13例报告

目的 探讨后腹腔镜下肾窦内肾盂切开取石治疗肾鹿角状及多发性结石的疗效.方法 肾多发及鹿角状结石患者13 例,其中男8 例,女5 例.平均年龄41 岁.结石直经1.8耀2.7 cm.常规采用3 个Trocar,于腹膜后间隙建立气腹,紧贴肾盂外膜向肾窦内分离,暴露出肾盏漏斗部,切开取石,输尿管内置入双J 管,4-0 可吸收线缝合肾盂切口,冲洗、放置引流管.术后5耀6 d 拔出引流管.4 周左右拔出双J 管.结果 13 例手术均获成功,平均手术时间96 min.术后平均住院7 d.随访3耀18 个月,腹部平片(KUB)及静脉肾盂造影(IVU)示无结石残留,肾盂出口输尿管无狭窄,双肾输尿管均显影.结论 腹腔镜下肾窦内肾盂切开取石术是治疗肾结石可选择的一种微创手术,该术式能同期处理上尿路合并症,可部分替代开放性手术.     

微创手术治疗婴儿双侧上尿路多发结石并肾衰竭一例报告

患儿,男,11个月.因虚弱、哭闹、拒食8 d,无尿3 d于2007年7月25日入院.外院血生化测定及B超、KUB、CT等检查诊断为双肾重度积水,双肾、双输尿管阴性结石,肾衰竭.复查SCr 1100 μmol/L,血K+5.7 mmol/L.急诊B超引导下行双侧经皮肾穿刺造瘘引流术,留置7 F单J管引流.双侧造瘘管每日引流尿液1500～2000 ml,患儿肾功能恢复正常,1周后自尿道排尿,2～3次/d,并排出3枚绿豆大小结石.B超及经肾造瘘管造影示双肾中重度积水,双肾结石,左输尿管下段结石.全麻下行双侧微创经皮肾镜取石术(MPCNL).筋膜扩张器扩张通道至16 F,置入8.0～8.9 F输尿管镜至肾盂,见右肾盂内结石2枚、左肾盂内2枚、左输尿管上下段各1枚,最大径0.6 cm.     

自制器械在腹腔镜上尿路结石手术中的应用体会

目的:总结自制器械用于腹腔镜肾盂输尿管上段结石手术的价值。方法:回顾分析为50例尿路结石患者行腹腔镜肾盂输尿管切开取石术的临床资料。取出肾盂输尿管结石后利用自制器械冲洗,并放置双J管。结果:48例一次性置入双J管2,例因输尿管末端狭窄,更换较细双J管后置管成功。手术时间40～100 min,平均60 min;术中出血量10～30 ml,平均20 ml。20例合并肾盏泥沙样结石,术后复查,效果满意。结论:腹腔镜肾盂输尿管切开取石术中利用自制器械置入双J管简单、易行,用时短,冲洗肾盂肾盏满意,不增加医院及患者经济负担,值得推广应用。     

Nephrostomy tube drainage with pyeloplasty: is it necessarily a bad choice?

PURPOSE: Despite continued controversy regarding the optimal method of urinary diversion after dismembered pyeloplasty in children, we have treated the majority of our patients with postoperative nephrostomy tubes and no stents. We report our experience. MATERIALS AND METHODS: The records of all patients who underwent surgery for ureteropelvic junction obstruction from August 1985 to October 1998 and were treated only with a nephrostomy tube after pyeloplasty were reviewed for hospital course, complications and postoperative followup. All patients had a perinephric Penrose drain as well as a Foley catheter placed for bladder drainage. RESULTS: A total of 137 pyeloplasties were performed in 132 patients, including 5 with bilateral ureteropelvic junction obstruction, using only nephrostomy tube drainage with an average followup of 2.1 years. Initial nephrostograms demonstrated good drainage across the repair with no extravasation in 91% of patients. Subsequent nephrostograms revealed a widely patent anastomosis in the remaining cases. No patient had postoperative obstruction, or required secondary pyeloplasty or nephrectomy. Urinary tract infection developed in 2 patients (1.5%). Mean hospitalization was 4.4 days. There was a significant difference in length of stay in the last 5 years compared to that in previous years (3.4 versus 5.8 days, p <0.05) and hospital stay continues to decrease. CONCLUSIONS: Use of only a nephrostomy tube after pyeloplasty resulted in few complications and an open anastomosis in 100% of cases. Nephrostomy drainage not only serves as a protective mechanism, but also allows easy access for radiographic studies before removal of the tube. In addition, nephrostomy tube drainage does not prolong hospitalization and the tube may be easily removed on an outpatient basis without further anesthesia.     

Open dismembered tubularized flap pyeloplasty: an effective and simple operation for treatment of ureteropelvic junction obstruction

OBJECTIVE: To evaluate the success rate of dismembered tubularized flap pyeloplasty (DTFP) in the treatment of ureteropelvic junction obstruction (UPJO). PATIENTS AND METHODS: In a prospective study from August 2002 to September 2004, 15 patients with a mean age of 21 years (range 2-47) in whom UPJO had been diagnosed by sonography, excretory urography or diuretic renography and who had a large extrarenal pelvis, underwent operation via flank intercostal incision. The proximal ureter and renal pelvis were dissected and mobilized retroperitoneally, the site of UPJO was excised and the site of insertion of the ureter on the renal pelvis was closed with a stitch. A wide based renal pelvic flap was created and tubularized to bridge the upper ureteral defect. After insertion of a nephrostomy tube, a double-J tube was inserted as an internal ureteral stent and anastomosis of the tubularized flap to the spatulated upper ureter was done and the renal pelvis window was closed. Patients were followed 3, 6 and 12 months postoperatively. RESULTS: Mean operation time was 1 h and mean hospital stay was 3 days. The ureteral stent was removed 4 weeks after operation and at the same time a nephrostogram was done that showed a widely patent ureteropelvic junction with good renal pelvis drainage in 12 ( approximately 80%) of the cases, but in 3 cases (approximately 20%) passage of contrast materials was not seen. In these patients, methylene blue was injected via a nephrostomy tube and in 2 patients (14%) urine color turned blue 20 min later, but in 1 patient (7%) this test was also negative. The latter patient underwent percutaneous endopyelotomy later. Mean patient follow-up was 14 months. Follow-up excretory urography confirmed patent and unobstructed ureteropelvic junction in all patients. The overall success rate of DTFP was 93%. CONCLUSION: DTFP is a simple and effective procedure for patients with UPJO who have long or multiple upper ureteral strictures and a large extrarenal pelvis.     

Usefulness of short-term retrievable ureteral stent in pediatric laparoscopic pyeloplasty

PURPOSE: Methods of stenting after laparoscopic pyeloplasty have included indwelling Double-J stents and percutaneous nephrostomy tubes. The disadvantages of these methods are that they necessitate a second surgery for stent removal or require an external drainage bag. To circumvent these issues, the tolerance, safety and outcomes of using a Double-J ureteral stent with a dangler, permitting early office removal, was investigated in a series of pediatric laparoscopic pyeloplasties. MATERIALS AND METHODS: Medical records from a consecutive series of pediatric patients undergoing transperitoneal laparoscopic pyeloplasties were reviewed. Indications for surgery included ipsilateral flank pain with severe hydronephrosis (12 patients), recurrent pyelonephritis with severe hydronephrosis (2), and hematuria and flank pain (6). All patients were discharged home within 24 to 48 hours of the procedure with prophylactic oral antibiotics. The stent was removed by postoperative day 18 during a followup office visit. Patient tolerance of the indwelling stent, outpatient removal and success of pyeloplasty were assessed. RESULTS: A total of 20 patients underwent transperitoneal laparoscopic pyeloplasty by 1 surgeon (LAB) between 2001 and 2005. All patients underwent cystoscopy and retrograde Double-J ureteral stent placement before pyeloplasty under the same anesthesia. Mean patient age at operation was 11.3 years (median 11.3, range 4.6 to 17.2). Stents were left indwelling for a mean of 10.3 days (median 10, range 7 to 18). All patients tolerated the Double-J stent well, with 2 requiring anticholinergic therapy for mild urgency symptoms and 1 demonstrating urinary tract infection. All patients tolerated outpatient stent removal via the dangler at the office without discomfort. One patient was lost to followup. At a mean followup of 1.04 years (range 0.1 to 2.88) 17 of 19 patients (89%) had resolution of flank pain/urinary tract infections, with sonographic improvement in hydronephrosis with or without endoscopic intervention. Six patients (30%) had flank pain with or without continuous hydronephrosis and required re-stenting, and 3 also required balloon dilation. Of these 6 patients 2 (10%) had recurrent ureteropelvic junction obstruction and required open pyeloplasty. All patients are now clinically and radiologically unobstructed and asymptomatic. CONCLUSIONS: Pediatric transperitoneal laparoscopic pyeloplasty with indwelling Double-J ureteral stent with a dangler is successful and the stent is well tolerated. Whether the duration of ureteral stenting affects the surgical success will require further controlled long-term studies.     

二期手术处理33例输尿管上段结石合并肾积脓

目的探讨二期经皮肾镜取石术处理输尿管上段结石合并同侧。肾积脓的围手术期处理要点。方法回顾分析我院收治的33例输尿管上段结石合并肾积脓患者的临床资料,所有患者均采用一期经皮。肾穿刺造瘘配合抗感染治疗,待引流液变清、炎症症状消失及实验室指标好转后3～5d行二期经瘘道输尿管镜下钬激光碎石取石术,术中常规留置输尿管内支架引流及肾造瘘管,观察手术的效果及并发症。结果所有手术均取得成功,无大出血、水中毒、菌血症等并发症发生;33例术后复查无明显结石残留;随访3～12个月,1例肾功能无法恢复,行患肾切除术,其余患。肾功能得到不同程度恢复。结论早期诊断上段结石合并肾积脓是治疗成功的关键,积极有效的。肾造瘘引流并适时行二期碎石取石可减少手术并发症的发生,同时可有效的保护患肾功能。     

Nephrovesical subcutaneous stent: an alternative to permanent nephrostomy

PURPOSE: We studied whether a subcutaneous ureteral bypass may be an alternative to a permanent nephrostomy tube in patients with ureteral obstruction caused by pelvic malignancy. MATERIALS AND METHODS: Using local anesthesia we inserted an especially designed nephrovesical stent into subcutaneous tissue. The stent consists of 2 J stents that are joined by a connector after insertion into the renal pelvis and bladder. RESULTS: In 8 patients 10 subcutaneous stents were inserted instead of a permanent nephrostomy tube. Nephrostomy was required because of obstructed ureters caused by metastatic prostate or invasive bladder cancer. Attempted Double-J stent insertion into the obstructed ureter had previously failed. The bypass has functioned well in all cases during 6 weeks to 18 months of followup (mean 5.5 months). CONCLUSIONS: The high complication rate of a permanent nephrostomy tube and frequent rehospitalization render the subcutaneous stent an important alternative to nephrostomy. The subcutaneous stent eliminates external devices for urine drainage and improves patient quality of life.     

后腹腔镜离断式肾盂成形术的改良及应用效果

目的：探讨后腹腔镜离断式肾盂成形术中输尿管吻合及双J管置人方法的改良及应用效果。方法：2010年6月～2013年1月,对32例肾盂输尿管连接部梗阻（ureteropelvicjunctionobstruction,UPJO）患者实施后腹腔镜离断式肾盂成形术,吻合方法采取两针固定连续缝合法,双J管放置采取Trocar外推置法。观察手术时间、吻合时间、置双J管时间、住院时间、并发症发生率、引流管放置时间等,总结手术技巧,并与前期18例采用间断缝合和双J管经Trocar内放置的后腹腔镜离断式肾盂成形术进行比较。结果：两组手术均获成功。改良手术组和对照组平均手术时间分别为（78．2±16．3）min、（114．7±17．5）min（P〈0．05）,输尿管吻合时间分别为（24．2±4．9）min、（49．4±7．5）min（P〈0．05）,双J管置入时间分别为（3．6±1．0）min、（9．1±2．2）min（P〈0．05）,两组引流管放置时间、住院时间和并发症发生率比较差异无统计学意义（P〉O．05）。改良手术组随访3～30个月,平均9．2个月,B超提示肾积水消失11例,肾积水不同程度减轻21例。结论：后腹腔镜离断式肾盂成形术中采取两针固定连续缝合法吻合,可以降低输尿管吻合难度,缩短手术时间;经Trocar外推置法放入双J管,简便快速。     

Tubeless percutaneous nephrolithotomy: what about replacing the Double-J stent with a ureteral catheter?

PURPOSE: To evaluate the feasibility and safety of replacing the Double-J stent with a ureteral catheter in tubeless percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: From August 1998 to February 2007, 33 patients underwent tubeless PCNL for renal calculi by the same surgeon. A retrograde 7F ureteral catheter was placed at the beginning of the surgery in all patients. A nephrostomy tube was not used in any patient. At the end of the procedure, the working tract was electrocauterized using a 26F resectoscope with a rollerball electrode; no hemostatic sealant was used. The ureteral catheter was the sole means of drainage left in place. The incidence and type of complications, the operative time, the length of hospitalization, the rate of transfusion, and the degree of pain were obtained by chart review. RESULTS: In this group of patients, the mean stone burden was 17.25 mm. The mean operative time was 71.5 min. The mean length of hospitalization was 1.9 day (range 1 to 7 days). The mean hemoglobin decrease was 0.8 g/dL. No blood transfusions were needed. The mean visual analog pain intensity scale was 1.87. Complications developed in five (15%) patients, of whom one needed a Double-J stent placement. The complications were pyelonephritis, urinary extravasation, sustained hematuria, and renal colic. The ureteral catheter was removed by postoperative day 1 in 91% of patients. CONCLUSIONS: Replacing the Double-J stent with a ureteral catheter in tubeless PCNL is an effective procedure and can be performed in patients with a moderate stone burden. The electrocauterization of the bleeding points at the end of percutaneous renal surgery with a rollerball resectoscope is safe.     

Pediatric robot assisted retroperitoneoscopic pyeloplasty: a 5-year experience

PURPOSE: We report our 5-year experience with retroperitoneoscopic robot assisted pyeloplasty for the treatment of ureteropelvic junction obstruction in children using the da Vinci Surgical System. MATERIALS AND METHODS: A total of 65 children (median age 7.9 years, range 1.7 to 17.1) underwent 67 robot assisted retroperitoneoscopic pyeloplasties with the da Vinci Surgical System between 2002 and 2006. Operative data were sampled prospectively, while outcome data were collected from chart review. Retroperitoneal access was modified from standard retroperitoneoscopic access due to the limits of the camera arm movement. RESULTS: Median operative time was 143 minutes (range 93 to 300). Complications occurred in 12 of the 67 procedures (17.9%), with urinary tract infection observed in 2 cases, transient hematuria in 2, displaced Double-J catheter in 3 and postoperative temporary nephrostomy in 4. One case was converted to open surgery due to lack of space and limits in the movement of the camera arm. Four patients (6%) underwent repeat surgery due to a kinking ureter (2 patients), an overlooked aberrant vessel (1) and decreasing differential function on renography necessitating balloon dilation (1). In all other cases followup was uneventful. CONCLUSIONS: Robot assisted retroperitoneoscopic pyeloplasty gives more direct access to the ureteropelvic junction, allowing shorter operative times with results and complication rates comparable to transperitoneal robot assisted pyeloplasty, and laparoscopic and open procedures in children.     

Percutaneous endopyeloplasty: description of new technique

PURPOSE: We present a novel technique of percutaneous endopyeloplasty, in which the conventional longitudinal endopyelotomy incision is precisely sutured in a horizontal Heineke-Mikulicz fashion through the solitary percutaneous tract, thus, achieving Fenger-plasty type of repair of the ureteropelvic junction. MATERIALS AND METHODS: Percutaneous endopyeloplasty was performed in 9 patients with primary ureteropelvic junction obstruction. Essential steps of our novel technique include retrograde placement of a ureteral catheter over a guide wire into the renal pelvis, establishing conventional percutaneous renal access, creating a conventional longitudinal endopyelotomy incision and performing full-thickness horizontal suturing of the endopyelotomy incision in Heineke-Mikulicz fashion. Suturing was done using the novel 5 mm. Sew Right 5 SR laparoscopic suturing device (LSI Solutions, Rochester, New York) passed through the nephroscope. RESULTS: Percutaneous endopyeloplasty was technically successful in all 9 patients. Mean total operative time was 100.8 minutes (range 62 to 140.), including an endopyeloplasty suturing time of 26.6 minutes (range 14 to 54.). We placed 1 to 4 endopyeloplasty sutures per case. Blood loss was minimal, mean hospital stay was 2.2 days (range 2 to 3) and the ureteral Double-J stent (Medical Engineering Corp., New York, New York) was removed in 2 weeks. At a mean followup of 4 months all operated kidneys showed relief of obstruction, as confirmed by clinical improvement in symptoms and improved renal drainage on excretory urography and diuretic renography. CONCLUSIONS: Percutaneous endopyeloplasty is technically feasible, safe and effective. Potential advantages over conventional endopyelotomy include wider caliber reconstruction of the ureteropelvic junction, full-thickness healing with primary intent, minimal urinary extravasation and shorter stenting duration. To our knowledge the initial clinical experience is presented.