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1.
目的 建立一种输尿管战创伤动物模型.方法 使用自行研制的火器弹片伤制造模具,分别对模型建立组9条比格犬的一侧输尿管制造火器弹片伤,并于30 min后直接清创缝合.分别于术后40、80、120 d进行静脉肾盂造影、肾图检查;并分批处死比格犬,取出输尿管行组织形态观察,初步评估该模型的可行性和有效性.结果 模型建立组9条比格犬,术后损伤侧出现肾盂、输尿管积水并逐渐加重;肾脏分浓缩率比值(未损伤侧/损伤侧)逐渐增高,半排时间比值(未损伤侧/损伤侧)逐渐下降,差异有统计学意义;损伤侧输尿管吻合处瘢痕增生、狭窄.结论 该输尿管火器弹片伤比格犬模型,损伤侧术后出现肾盂、输尿管积水并逐渐加重;损伤侧较之未损伤侧,肾小管的浓聚功能下降,肾脏的半排时间延长;损伤侧输尿管吻合处狭窄、瘢痕纤维排列紊乱.证明它是一种可行、有效的输尿管战创伤动物模型.  相似文献   

2.
目的:探究自体游离输尿管移植段应用于输尿管重建在比格犬动物实验模型中的安全性及可行性。方法:6只比格犬术前随机分成两组,两组分别随访至术后12周及28周行剖腹观察及留取标本,12周组额外接受静脉肾盂造影观察肾积水及输尿管通畅情况,标本石蜡包埋后行苏木精-伊红染色并观察吻合段输尿管组织学改变。结果:5只比格犬存活至观察终点且未出现明显的术后并发症,IVU提示术侧无或仅存轻度肾积水且未出现输尿管狭窄。组织学检查提示吻合口管腔开放,血管网重建存在。结论:自体游离输尿管移植段应用于输尿管重建在解剖和技术上是可行的,但仍需大样本量和长期随访支持。  相似文献   

3.
目的长段输尿管狭窄或缺损的修复是泌尿外科棘手问题,将犬自体膀胱黏膜移植于浆肌层肠段重建输尿管,探讨其作为尿路替代材料重建输尿管的可行性。方法成年比格犬12条,体重6.5~9.3kg,雌雄不限,根据重建输尿管部位不同将其随机分成A、B、C组(n=4)。A组:自体膀胱黏膜移植于浆肌层肠段后包缝于人工输尿管支架制备人工输尿管,重建8cm长下段输尿管,将人工输尿管近端与上段输尿管断端吻合,远端与膀胱吻合。B组:同A组方法重建8cm长上段输尿管,将人工输尿管近端与肾盂吻合,远端与下段输尿管断端吻合。C组:同A组方法重建全段16cm长输尿管,将人工输尿管近端与肾盂吻合,远端与膀胱吻合。术前各组犬取血行肾功及电解质检测;术后观察犬的一般情况及支架管和造瘘管的引流、手术切口的愈合、并发症的发生等情况。术后第6周行生化指标复查及静脉尿路造影(intravenous urography,IVU)检查后,对人工输尿管行大体及组织学观察。结果B组1条犬术后2d因输尿管支架脱出,术后发生尿瘘及伤口感染,排除实验;其余犬术后均无并发症发生。术后第6周各组犬肾功和电解质检测与术前比较,差异均无统计学意义(P0.05)。IVU显示:A组1条犬术侧肾脏积水、上段输尿管扩张,B组1条犬人工输尿管与下段输尿管吻合口狭窄、同侧肾脏积水;其余各组犬术侧肾脏功能良好,人工输尿管有蠕动功能。组织病理学观察示术后第6周3组人工输尿管组织结构与正常输尿管相似,其中A、C组各1条犬出现人工输尿管炎症。结论自体膀胱黏膜移植于浆肌层肠段重建犬输尿管,可形成组织结构与正常输尿管相似的人工输尿管,且功能良好。  相似文献   

4.
后腹腔镜下肾盂输尿管切开取石术(附52例报告)   总被引:3,自引:0,他引:3  
目的探讨后腹腔镜下肾盂输尿管切开取石术治疗肾盂、输尿管结石的临床疗效。方法经腹膜后腹腔镜下行肾盂输尿管切开取石术,同时切除合并的息肉。术中均放置输尿管支架管并缝合输尿管。结果52例手术均成功,取净结石,无一例中转开放手术。手术时间50~200min,平均110min。住院时间5~14d,平均7.5d。术后8周拔出支架管。52例随访6个月:术后3个月超声检查,21例肾积水消失;术后6个月超声示共32例肾积水消失,结石无复发;ECT示8例重度积水肾脏的肾小球滤过率由术前平均16ml/min升高到平均25ml/min。结论后腹腔镜下肾盂输尿管切开取石术效果确切,创伤小,术后恢复快,是治疗肾盂及输尿管上段结石的有效术式之一。  相似文献   

5.
我院在2006年9月至2007年9月间收治了2例移植肾输尿管炎的患者,现将诊治体会总结如下. 临床资料 例1 为女性,40岁.肾移植后4个月,血清肌酐(Cr)为170μmol/L,经B型超声波检查提爪移植肾积水,经皮肾镜顺行在移植肾输尿管内留置支架管,术中见输尿管轻度狭窄,留置支架管后移植肾积水减轻,血清cr降至150μmol/L,支架管留置1个月后自行脱落,再次出现移植肾积水.血清Cr升高至180 μmol/L,磁共振尿路造影(MRU)提示移植肾肾盂与输尿管连接部狭窄.再次手术探查,术中见移植肾输尿管与膀胱的吻合口无狭窄,狭窄段位于输尿管近肾盂处,局部输尿管僵硬瘢痕化,管腔狭窄仅能通过4F输尿管导管.移植肾肾盂内尿液压力高.  相似文献   

6.
1临床资料 肾盂输尿管连接部梗阻(UPJO)是原发性肾积水的主要原因.我院自2000年1月至2002年12月采用离断性肾盂成形术治疗UPJO 40例.其中男性27例,女性13例;年龄8~34岁,平均20岁,12岁以下5例;左侧31例,右侧8例,双侧1例.病史3d~4年,有腰痛史31例,肉眼血尿8例,腹部包块6例,并发肾结石11例,高血压4例.B超提示肾积水,肾盂输尿管连接处以下输尿管不扩张.IVU提示患侧中度至重度肾积水,肾盂输尿管连接处以下输尿管不显影,对侧肾无异常.手术采用经12肋下斜形切口显露UPJO部位.术中发现梗阻原因为:管腔狭窄28例,纤维索带及异位血管压迫8例,功能性梗阻4例.对纤维索带或异位血管压迫者先行离断.切开肾盂将肾脏减压,在病变的远侧离断输尿管,近端离断肾盂.根据肾盂形态和扩张程度设计裁剪多余肾盂,输尿管断端斜形切开1.5cm,冲洗肾盂及输尿管远端,放入支架引流管,用5-0肠线作肾盂输尿管无张力漏斗状吻合.肾周脂肪覆盖吻合口并用1、2针固定,肾盂附近放置多侧孔橡皮管引流.其中6例放置肾造瘘支架管,34例放置双J管.支架管在术后4~8周内拔除.拔管前均复查B超,患侧肾积水明显减轻,肾皮质增厚,患侧肾功能改善.  相似文献   

7.
于手术显微镜下采用自行设计的肾窦内肾盂输尿管成形术,治疗小儿肾盂闭锁7例。术后随访静脉尿路造影、同位素肾图检查证实肾盂输尿管吻合口通畅,肾积水明显好转。此术式视野清楚,操作方便,肾盂与输尿管断端对合整齐,术后成功率高。文中对肾盂输尿管完全撕脱伤的预防、小儿肾盂闭锁的治疗、显微外科技术的优点及注意事项进行了讨论.  相似文献   

8.
目的 探讨后腹腔镜手术治疗双支肾静脉间输尿管所致UPJ狭窄的可行性及效果.方法 患者为男性,28岁.左腰部酸痛6个月,于外院诊断为左侧UPJ狭窄、左肾积水,留置左输尿管支架管3个月后拔除.B超检查示左肾积水、左侧UPJ狭窄,CT示左侧UPJ狭窄,狭窄处与左肾静脉关系密切,且走行于双支肾静脉之间.肾图示双肾功能受损,左肾GFR 35 ml/min,右肾GFR34 ml/min,左肾积水,左侧上尿路机械性梗阻.全麻下行后腹腔镜下左肾盂离断成形术. 结果 手术顺利,术中发现左肾静脉为双支,左肾盂输尿管在肾静脉间穿行,位于腹侧的一支肾静脉主干压迫左UPJ,同时存在肾迷走动脉与输尿管伴行入肾.术中切除狭窄段约0.5 cm后将输尿管绕行至腹侧肾静脉分支前方,将肾盂成形后与输尿管吻合,同时留置输尿管支架管.手术时间240 min,出血量50 ml,术后住院4d,无发热、术后大出血等并发症.术后随访4个月,复查B超示肾积水明显减轻.结论 双支肾静脉间输尿管所致UPJ狭窄临床罕见,可行后腹腔镜下肾盂离断成形术,创伤小,短期随访效果满意.  相似文献   

9.
肾盂输尿管成形术及其辅助治疗   总被引:26,自引:0,他引:26  
目的:探讨肾盂输尿管连接部(UPJ)梗阻的最佳治疗方法。方法报告63例(70例)UPJ梗阻的治疗情况,48侧行Anderson-Hynes肾盂成形术,其中8例巨大及重度肾积水者加作肾内翻折叠及肾固定术,6例行肾盂瓣输尿管成形术,5侧行Y-V成形术,11例行肾切除术,全部病例均放置输尿管支架引流,其中11例患儿应改良式双J管内引流。结果。48侧行Anderson-Hytes肾盂成形术者术后复查IVU显示肾盂明显缩小,肾功能改善,UPJ处蠕动良好,1例吻合口处狭窄,扩张后再次放置双J管8周后治愈。6侧行肾盂瓣成形术及5侧行Y-V成形术者术后复查肾积水有改善,但肾盂缩小不明显,UPJ处蠕动幅度、频率改善不明显。11侧应用改良双J管的患儿术后4周门诊拔管,均获治愈。停顿上以往外引流的18-20d缩短至6-7d.51例随访6个月5-年,1例吻合口处狭窄者扩张置管后治愈,余无复发。结论Anderson-Hynes肾盂成形术为最佳术式。巨大肾积水者行Anderson-Hynes肾盂成形术加肾内翻折叠及肾固定术不仅改善外观,更利于引流及功能恢复,改良式双J管可用于儿童患者内引流。  相似文献   

10.
目的:探讨后腹腔镜离断式肾盂成形术治疗肾内型肾盂输尿管连接部梗阻(ureteropelvic junction obstruction,UPJO)的手术技巧与临床效果。方法:2008年3月至2014年10月为6例肾内型UPJO患者行后腹腔镜离断式肾盂成形术。患者先取截石位,患侧输尿管逆行置入6Fr输尿管支架,经后腹膜腹腔镜下于肾下极腰大肌前缘间隙找到输尿管,沿输尿管向近端分离至肾门,紧贴肾盂表面钝性剥离肾窦,显露肾内型肾盂与输尿管连接部,行腹腔镜离断式肾盂成形术。结果:6例手术均顺利完成,无中转开放手术。手术时间145~260 min,平均(185.0±48.3)min;术中出血量30~100 ml,平均(52.0±21.5)ml;住院9~21 d,平均(13.0±3.6)d。6例术后随访6~24个月,平均(18.0±4.6)个月,肾盂输尿管连接部吻合口无狭窄,肾积水得到改善。结论:后腹腔镜离断式肾盂成形术是治疗肾内型UPJO有效、安全的手术方式,近期随访临床效果满意。  相似文献   

11.
Li G  Wang ZX  Fu WJ  Hong BF  Wang XX  Cao L  Xu FQ  Song Q  Cui FZ  Zhang X 《BJU international》2011,108(6):901-906
Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

? To study the operability and effectiveness of a biodegradable ureteral stent for clinical treatment of ureteral war injury using a canine model.

MATERIALS AND METHODS

? A device was designed and employed to generate firearm fragment wounds in unilateral ureters (on randomly chosen sides) of nine beagles (Group A). The wounded ureters were then debrided and sutured. ? Intravenous pyelography (IVP) and radioactive renography were performed 40, 80 and 120 days postoperatively. In Group B, firearm fragment wounds were made to the bilateral ureters in nine beagles. A polylactic acid stent was placed unilaterally (on a randomly chosen side) whereas the ureter on the other side was debrided and sutured without stenting. ? Both IVP and radioactive renography were performed 40, 80 and 120 days postoperatively. The operability and effectiveness of the biodegradable ureteral stent were studied thereafter.

RESULTS

? In Group A, hydronephrosis and hydroureter occurred and worsened postoperatively on the wounded sides in all nine beagles. The ratio of the renal partial concentration indices (RPCI) between the kidneys (unwounded side : wounded side) increased. ? The ratio of the kidney washout half‐time between the kidneys (unwounded side : wounded side) decreased. In Group B, neither hydronephrosis nor hydroureter was found postoperatively in the stented ureters but both occurred in the unstented ureters in all nine beagles. ? The ratio of RPCI between kidneys (stented side : unstented side) increased whereas the kidney washout half‐time ratio between the stented and unstented sides decreased. Differences were significant.

CONCLUSION

? In Group A, the new canine model for firearm fragment wounds was tested and proved to be operable and effective. In Group B, hydronephrosis and hydroureter were effectively prevented in ureters by biodegradable stent placement compared with the non‐stented ureters where hydronephrosis and hydroureter occurred. The renal concentration capacity was effectively protected and the half‐time of kidney washout was shortened.  相似文献   

12.
OBJECTIVE: To evaluate the suitability of a new biodegradable double-helical spiral self-reinforced poly-L,D-lactide copolymer (SR-PLA 96; L/D ratio 96/4) stent as a device for ureteral stenting in respect to changes in kidney function during the biodegradation process. MATERIALS AND METHODS: Sixteen dogs were used as experimental animals and were subdivided into two groups of eight. In Group A, both ureters were cut transversally, sutured, and stented. The right ureter was stented using an SR-PLA 96 stent, whereas a double-J C-Flex stent was used on the left side. Cystotomy was performed at 6 weeks to remove the double-J stents. In Group B, the right ureter of each dog was cut and stented in similar manner using an SR-PLA 96 stent, whereas the left ureters served as untreated controls, and cystotomy was not performed. Serum creatinine and nitrogen values were measured, urine was analyzed for signs of infection, and renal function was evaluated by urography and renography examinations preoperatively and at 6, 12, and 24 weeks postoperatively, at which time points, the dogs were euthanized and the ureters dissected to find persistent SR-PLA 96 particles and macroscopic local changes. There were no urinary tract infections found during the study. RESULTS: In the SR-PLA 96-stented ureters, obstructive hydronephrosis and stricture formation were observed in two cases (11%), with distal displacement of the SR-PLA 96 stent in another case (5.5%). In two additional renal units, a temporary prolongation in the kidney washout time was observed at 6-week renogram examinations. In the C-Flex-stented ureters, temporary changes in renography studies were observed in three cases (37.5%) at 6 weeks. Kidney washout times were protracted at 6 weeks in the pigtail-stented ureters in Group A as a sign of a pressure rise in the renal pelvis secondary to the direct connection between the renal pelvis and bladder, whereas pressure remained normal in SR-PLA 96-stented ureters. In Group B, renal function remained normal after ureteral repair in SR-PLA 96-stented ureters compared with the controls. CONCLUSIONS: The double-helical apical stent design offers some advantages over a double-J design. The risk of pressure-induced kidney damage is lowered, because there is no direct connection between the bladder and renal pelvis, and the risk of upper urinary tract infections is reduced. The biodegradation of the device necessitates the removal of the stent. These preliminary results suggest that a biodegradable SR-PLA 96 stent with more effective expansion capacity can be used for stenting after a ureteral repair.  相似文献   

13.
目的 设计漏斗形生物降解材料输尿管内支架,探讨该支架在上段输尿管梗阻治疗中应用的可行性。方法 制备己内酯丙交酯乙交酯三元共聚材料(PCLGA20:60:20),并加工成漏斗形支架管。雄性家犬4只,体重12~15kg,通过手术方法建立输尿管上段不完全梗阻动物模型;在此基础上行输尿管狭窄段切除吻合术,术中留置漏斗形PCLGA支架管支撑引流;术后定期行IVU检查,并于术后12周行术侧输尿管组织病理学分析。结果 4只犬成功建立输尿管上段梗阻动物模型。漏斗形PCLGA支架管内引流效果良好,肾盂及输尿管扩张积水逐渐缓解;6~8周支架管密度减低,陆续发生断裂,断裂的支架管并未造成输尿管梗阻;术后12周支架管完全降解并排出体外,吻合段输尿管无狭窄,造影剂通过顺畅,局部组织病理学改变轻微,仅见移行上皮细胞增生和固有层增厚。结论 漏斗形PCLGA支架管生物相容性良好,降解时间适宜,在上段输尿管手术中具有良好的内引流效果。  相似文献   

14.
目的 探讨对于良性输尿管狭窄的患者,放置单根双J管无效后,改用同侧输尿管腔内放置两根双J管引流的安全性和有效性.方法 对本院2012年1月至2016年4月收治11例良性输尿管狭窄的患者,留置单根双J管无效后,输尿管腔内置入两根4.7F双J管引流,3个月后拔除,拔管后1个月B超或CT测定患者的肾积水的变化.结果 11例患者随访3~12个月,平均6个月.患者都能耐受两根双J管,无明显的腰腹胀痛、发热、肉眼血尿等症状.术后3个月拔管前查腹部平片示双J管无移位,拔管后1个月B超或CT示患者肾积水不同程度减轻或消失.结论 对于良性输尿管狭窄的患者,放置单根双J管无效后,改用同侧输尿管腔内留置两根双J管引流安全有效,但远期效果和机制需要大样本进一步研究验证.  相似文献   

15.
PURPOSE: The present study was done to evaluate the biocompatibility of a new biodegradable double helical spiral self-reinforced poly-L, D-lactide copolymer (L/D ratio 96/4, SR-PLA96) ureteric stent. MATERIALS AND METHODS: In sixteen dogs, the right ureter was cut transversally, sutured and stented with a 50 mm. long SR-PLA 96 stent. In eight dogs, left ureter was similarly operated and stented with a double-J pigtail stent (C-Flex, Cook Urological Inc.), while eight remaining ureters served as plain controls. Urine was analyzed for signs of infection. The dogs were terminated at 6, 12 and 24 weeks postoperatively and the ureters dissected to find persistent SR-PLA 96 particles or local ureteric changes. Histologic samples were taken at three levels of dissected ureters in contact with the stent. RESULTS: C-Flex and SR-PLA 96 materials were well tolerated. Both of these induced only minimal ureteral wall edema, epithelial hyperplasia, epithelial destruction and inflammatory cell reaction. In SR-PLA 96 stented ureters the tissue reaction subsided after the degradation of the device. CONCLUSIONS: SR-PLA 96 spiral stent is regarded highly compatible and SR-PLA 96 might be a suitable material for a partial ureteric stent. Biodegradation of a SR-PLA 96 stent makes stent removal unnecessary.  相似文献   

16.
PURPOSE: We evaluated the use of a poly-L-lactide-co-glycolide (PLGA) bioabsorbable ureteral stent after Acucise balloon incision (Applied Medical Resources, Rancho Santa Magarita, California) endopyelotomy in a porcine model. MATERIALS AND METHODS: After unilateral Acucise endopyelotomy in 9 female Yucatan minipigs a self-reinforced PLGA stent was placed in 5 (group 1) and a 7Fr double pigtail Percuflex stent (Boston Scientific, Natick, Massachusetts) was placed in 4 (group 2). Preoperatively, and 6 and 12 weeks postoperatively plain x-ray of the kidneys, ureters and bladder, cystography, side specific creatinine clearance and retrograde ureterography were done. The contralateral ureters served as untreated controls. The 7Fr stents were removed at 6 weeks. All animals were sacrificed at 12 weeks after bilateral flow studies. Histological specimens from 4 sites along the urinary tract were graded on a healing score of 0-normal, to 3-severe changes. RESULTS: Side specific creatinine clearance was similar to preoperative values at 6 and 12 weeks. At the 2 time points plain x-ray of the kidneys, ureters and bladder in group 1 showed retroperitoneal stent fragments in 3 of the 5 animals, which was confirmed at autopsy. Retrograde ureterography in group 1 showed mild hydronephrosis in all 5 ureters and saccular diverticula in 4, which was similar in 2 and 3 animals, respectively, in group 2. Cystography demonstrated grades 1 to 2 reflux in 2 animals at 6 weeks but none at 12 weeks in group 1 and no reflux at either time point in group 2. Flow rates and healing scores were statistically similar in the 2 groups but the latter trended toward less favorable healing of ureteral musculature with application of the absorbable stent. CONCLUSIONS: In this pilot study the use of self-reinforced PLGA biodegradable ureteral stents was feasible after Acucise endopyelotomy in a porcine model with radiographic and fluid flow results that were relatively similar to those of standard 7Fr stents but with less favorable biocompatibility.  相似文献   

17.
Laparoscopic ureterolysis and reconstruction of a retrocaval ureter   总被引:2,自引:0,他引:2  
A 32-year-old man was investigated for repeated episodes of right-sided flank pain. Ultrasonography showed a dilated right pelvicalyceal system and upper ureter as well as multiple gallstones; subsequent intravenous urogram demonstrated a retrocaval ureter. At surgery, a right-sided double-J ureteric stent was placed under fluoroscopic guidance. Initially, three laparoscopic ports were used. The dilated pelvis and upper ureter were mobilized, followed by the lower ureter. The pelvis was transected and transposed anterior to the inferior vena cava. Reconstruction was carried out with an intracorporeally sutured anastomosis over the double-J stent. A fourth port was added for completion of cholecystectomy. The patient had an uneventful recovery and was discharged on the third day. Fourteen months later he remains well, with a recent intravenous urogram showing regression of hydronephrosis. We review the previously reported cases of laparoscopic and retroperitoneoscopic reconstruction of retrocaval ureter to compare and contrast these minimal access approaches.  相似文献   

18.
This paper is the 13th report in a series of studies on the application of microexplosion to medicine and biology. The recovery process of injured ureters was investigated in the day. The 60 ureters of 42 mongrel dogs were used. The ureter was injured with a nail, punch or surgical knife. The "pierced injury" was passed through the ureter with a nail of 1 mm or 2 mm in diameter, the "punch injury" was punched out in the ureter by a puncher of 1 mm or 2 mm in diameter and the "cut injury" was cut in the ureter 5 mm or 10 mm in size with a surgical knife. The recovery process of the injured ureter was observed in each of the two ureters 3 days, 1 week, 3 weeks, 6 weeks and 12 weeks after the injury by means of IVP, for macroscopic and microscopic findings. The results were as follows: 1) In IVP, it was observed that the 1 mm pierced injury resulted in no urine leakage after 3 days, that the 2 mm pierced injury and 1 mm punch injury in no urine leakage after almost 1 week and that the 2 mm punch injury and 5 mm cut injury and 10 mm cut injury in no urine leakage after almost 3 weeks. Hydroureter due to tissue edema was observed only in one ureter with a 10 mm cut injury after 1 week. No ureteral stricture, hydronephrosis or hydroureter was observed in the other ureters.(ABSTRACT TRUNCATED AT 250 WORDS)  相似文献   

19.
BACKGROUND AND PURPOSE: Implanted foreign bodies are associated with a higher risk of infection. Little has been published on infectious complications associated with ureteral double-J stents. The aim of this study was to define risk factors and characterize the febrile complications of the insertion of double-J stents. PATIENTS AND METHODS: One hundred consecutive cases of retrograde stent insertion (55 men and 45 women) were evaluated retrospectively. Eighty-one patients had an obstructing stone, either in the ureter or at the ureteropelvic junction; 10 had an obstructing tumor; and 9 had hydronephrosis and pain without calculi. Risk assessment was calculated for two major categories: urgent (N = 47) and elective (N = 53) insertion. Potentially confounding factors such as age, sex, accompanying medical problems, and types of prophylaxis were assessed. All but six patients received prophylactic antibiotics prior to stent insertion. RESULTS: All thirteen patients who had fever at the initial evaluation underwent urgent stent insertion. Of the 87 afebrile patients (53 elective and 34 urgent insertions), 22 (25%) developed fever (> or = 38 degrees C) after the procedure. Fever developed in 19 (56%) of the 34 urgent-insertion group who were not originally febrile as opposed to 3 (6%) of the elective-insertion group (P < 0.001). Six of these 22 patients (27%) had a positive urine culture after insertion. None had a positive blood culture, including the 13 patients who underwent the procedure while febrile. CONCLUSIONS: Urgent insertion of a double-J stent is associated with a high risk of fever but a favorable outcome.  相似文献   

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