输尿管镜钬激光治疗输尿管纤维上皮息肉14例报告

目的：探讨输尿管镜钬激光治疗输尿管纤维上皮息肉的有效性和安全性。方法：应用输尿管镜钬激光技术治疗输尿管纤维上皮息肉患者14例，其中上段息肉10例，中、下段息肉各2例，并发输尿管结石9例。结果：术后随访3个月，12例疗效满意，肾积水明显改善．保护了肾功能；1例发生输尿管狭窄．1例残留结石。结论：输尿管镜钬激光技术是治疗输尿管纤维上皮息肉安全、有效的方法，但远期疗效尚需进一步研究。     

High incidence of and risk factors for metachronous bilateral upper tract urothelial carcinoma in Taiwan

AIM: Urothelial carcinoma (UC) can occur multifocally in the whole urothelium. A higher rate of bilateral metachronous upper tract (UT) UC was noted in Taiwan. The incidence and risk factors were largely unknown and hence were explored in the study. METHODS: From January 1977 through June 2003, 462 patients with unilateral UT-UC were studied retrospectively. The cumulative incidence of contralateral recurrence was analysed with the Kaplan-Meier analysis. Potential risk factors for contralateral recurrence including age, smoking, bladder cancer, renal function, diagnostic year etc. were evaluated with the log-rank test. Independent risk factors were identified by using the Cox regression analysis. RESULTS: The median follow-up time was 34 months (6-337). Among the 462 patients, 52 (11.3%) developed metachronous contralateral UC. The 2, 5, and 10-year contralateral disease-free survivals were 93.5%, 84.0%, and 75.7%, respectively. The median time to contralateral recurrence was 31.0 months. With the univariate analysis, only poor renal function (serum creatinine < or > OR =2.0 mg/dL, P < 0.001) and late diagnostic year (before or after 1990, P < 0.001) were risk factors for contralateral recurrence. In the multivariate analysis, poor renal function (hazard ratio: 2.98; 95% confidence interval: 1.67-5.33; P < 0.001) and late diagnostic year (hazard ratio: 4.27; 95% confidence interval: 1.71-10.65; P = 0.002) remained independent risk factors. CONCLUSIONS: The incidence of metachronous UT-UC is high in Taiwan. Patients who had either chronic renal insufficiency or a disease diagnosed after 1990 had a higher risk of contralateral recurrence.     

经尿道前列腺汽化电切术中电切深度标识的探讨

目的 探讨经尿道前列腺汽化电切术(transurethral electrovaporization of the prostate，TUVP)电切深度标识的可行性。方法 回顾性分析616例前列腺增生症临床资料，其中310例术前彩超提示合并前列腺钙化，156例合并膀胱结石，23例合并膀胱肿瘤。TUVP操作过程中，观察到合并前列腺结石和机械操作“打滑现象”，停止电切。结果 全组手术时间30～120min，平均75min。术中验证术前彩超提示合并前列腺钙化的310例前列腺钙化为结石，同时发现其余306例均存在结石。1例术中膀胱穿孔，无尿道直肠瘘和尿道电切综合征发生。325例随访3～6个月，平均4．5月，最大尿流率由6．5～8．5ml／s提高到18～22ml／s，残余尿由70～150ml降至0～10ml，国际前列腺症状评分由19～24．5分降至0～7分。138例膀胱结石和23例膀胱肿瘤无复发。结论 前列腺结石和机械操作“打滑现象”作为TUVP的电切深度标识是切实可行的。     

胆囊结石合并胆管结石微创治疗方案的选择

目的探讨胆囊结石合并继发胆道结石微创治疗的合理方案。方法108例胆囊结石合并可疑胆道继发结石均行腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC），其中腹腔镜联合胆道镜经胆囊管胆道探查取石（laparoscopic transcyctic common bile duct exploration，LTCBDE）＋LC70例，腹腔镜联合胆道镜胆总管切开胆道取石（laparoscopic common bile duct exploration，LCBDE）＋LC35例，其中放T管14例，不放T管21例，内镜乳头肌切开术（endoscopic sphincterotomy，EST）术后行胆囊切除3例。结果LCBDE＋LC术后放T管组中有1例胆漏经保守治疗治愈，4例术后胆道造影发现胆道残余结石经胆道镜取出结石治愈．其他病例无胆漏，术后3月复查B超无残余胆道结石，所有病例术后无胰腺炎发作。结论在胆囊结石继发胆道结石的治疗中合理选择多种微创手术方法能降低创伤及减少并发症的发生。     

输尿管损伤的诊断和治疗(附41例报告)

目的总结输尿管损伤的原因、诊断与治疗。方法对41例输尿管损伤的临床资料进行回顾性分析。结果41例输尿管损伤中,医源性损伤35例,外伤性损伤6例;输尿管下段损伤32例,上段9例;左侧损伤28例,右侧13例。手术治疗39例,逆行输尿管插管治疗2例;肾切除1例;肠梗阻死亡1例。结论B超检查简单易行,结合静脉尿路造影(IVU)和逆行输尿管造影(RP)多能确诊。早期发现、及时手术或腔内治疗是治愈输尿管损伤的关键。     

输尿管镜气压弹道碎石治疗输尿管结石（附32例报告）

目的 总结输尿管镜气压弹道碎石治疗输尿管结石的临床效果。方法 回顾分析32例应用输尿管镜气压弹道碎石治疗输尿管结石患者资料。男10例，女22例；平均年龄29岁。结石位于输尿管下段24例，中段6例。上段2例。其中行原位体外冲击波碎石（ESWL）治疗后结石未能排出者8例。结果 碎石成功率90．6％（29／32）。2例因输尿管异常置镜失败，转开放性手术；1例输尿管穿孔后留置双J管，择期行ESWL治疗成功。B超显示肾积水较术前减轻或消失，KUB、IVP未发现输尿管狭窄。结论 输尿管镜气压弹道碎石治疗输尿管结石创伤小、成功率高、并发症少。     

3种微创手术治疗复杂性输尿管上段结石的疗效比较

目的比较经尿道输尿管镜钬激光碎石(URSL)联合体外冲击波碎石(ESWL)、微创经皮肾镜取石(mini-PCNL)、后腹腔镜输尿管切开取石术(RLU)治疗复杂性输尿管上段结石的疗效。方法153例复杂性输尿管上段结石患者按治疗方法分为三组:URSL联合ESWL(联合组)治疗60例,mini-PCNL治疗65例,RLU治疗28例。结果联合组有5例转开放手术取石,余50例患者平均手术时间(65.45±16.39)min,术后并发症发生率为23.64%(13/55),1个月后结石清除率为90.91%(50/55)。mini-PCNL组无中转,平均手术时间(50.38±12.91)min,术后并发症发生率为9.23%(6/65),1个月后结石清除率为100%。RLU组有2例转开放取石,平均手术时间(81.73±17.89)min,术后并发症发生率为15.38%(4/26),1个月后结石清除率为100%(26/26)。mini-PCNL组的手术时间、术后住院时间均显著短于联合组和RLU组;并发症发生率明显低于联合组;1个月后结石清除率明显高于联合组。结论mini-PCNL治疗复杂性输尿管上段结石具有手术时间短、结石清除率高、术后并发症少、恢复快的优点。     

经皮肾镜下气压弹道碎石联合超声碎石术治疗复杂性肾结石疗效观察

目的：评价经皮肾镜下气压弹道碎石联合超声碎石术处理复杂性肾结石的疗效。方法：自2003年9月～2004年4月采用经皮肾镜下气压弹道碎石联合超声碎石术Ⅰ期治疗肾结石38例42侧。结果：平均手术时间85min，结石处理时间62min，结石清除率88．1％；5例多发性结石或铸形结石患者经皮通道小角度的肾盏内有直径小于1cm结石残留，辅助施行体外冲击波碎石治疗。随访1～3个月，无严重手术并发症。结论：经皮肾镜下气压弹道碎石联合超声碎石术处理大的复杂性肾结石具有高效、安全的特点，结石清除率高，值得临床推广应用。     

Angiotensin II and renal prostaglandin release in the dog. Interactions in controlling renal blood flow and glomerular filtration rate

The relationship between angiotensin II and renal prostaglandins, and their interactions in controlling renal blood flow (RBF) and glomerular filtration rate (GFR) were investigated in 18 anaesthetized dogs with acutely denervated kidneys. Intrarenal angiotensin II infusion increased renal PGE₂ release (veno-arterial concentration difference times renal plasma flow) from 1.7 ± 0.9 to 9.1 ±0.4 and 6-keto-PGFja release from 0.1 ±0.1 to 5.3 ± 2.1 pmol min^-1. An angiotensin II induced reduction in RBF of 20% did not measurably change GFR whereas a 30% reduction reduced GFR by 18 ± 8%. Blockade of prostaglandin synthesis approximately doubled the vasocon-strictory action of angiotensin II, and all reductions in RBF were accompanied by parallel reductions in GFR. When prostaglandin release was stimulated by infusion of arachidonic acid (46.8± 13.3 and 15.9± 5.4 pmol min^-1 for PGE₂, and 6-keto-PGFja, respectively), angiotensin II did not change prostaglandin release, but had similar effects on the relationship between RBF and GFR as during control. In an ureteral occlusion model with stopped glomerular filtration measurements of ureteral pressure and intrarenal venous pressure permitted calculations of afferent and efferent vascular resistances. Until RBF was reduced by 25–30% angiotensin II increased both afferent and efferent resistances almost equally, keeping the ureteral pressure constant. At greater reductions in RBF, afferent resistance increased more than the efferent leading to reductions in ureteral pressure. This pattern was not changed by blockade of prostaglandin synthesis indicating no influence of prostaglandins on the distribution of afferent and efferent vascular resistances during angiotensin II infusion. In this ureteral occlusion model glomerular effects of angiotensin II will not be detected, and it might well be that the shift from an effect predominantly on RBF to a combined effect on both RBF and GFR induced by inhibition of prostaglandin synthesis is located to the glomerulus. We therefore postulate that renal prostaglandins attenuate the effects of angiotensin II on glomerular surface area and the filtration barrier, and not on the afferent arterioles as previously suggested.     

妇产科手术泌尿系损伤防治方法的探讨

目的 探讨妇产科手术泌尿系损伤的特点及防治方法，为临床妇产科手术中防止泌尿系损伤提供参考。方法 对我院妇产科手术中发生的泌尿系损伤的10例临床资料进行回顾性分析。结果 10例患者中输尿管损伤3例，均为术中发现，术中行输尿管端端吻合；膀胱损伤7例，其中5例于术中发现，2例术后形成膀胱阴道瘘，行膀胱修补术，所有病例均痊愈出院。妇产科损伤泌尿系的主要原因有输尿管解剖移位，盆腔粘连严重等。结论 绝大多数妇产科手术中的泌尿生殖系损伤是可以防范的，一旦发生，应及时发现，尽早修补预后良好。