改良膀胱壁瓣输尿管成形术治疗婴幼儿供肾肾移植术后输尿管坏死的临床分析

目的探讨采用改良膀胱壁瓣输尿管成形术（改良Boari术）治疗婴幼儿供肾肾移植术后输尿管长段坏死的疗效。方法回顾性分析济南军区总医院泌尿外科2012年1月至2014年4月施行婴幼儿供肾肾移植术后发生移植肾输尿管长段坏死的3例受者临床资料。第1例为婴儿供者双肾整块移植。第2例和第3例为同一名幼儿供者双侧供肾分别移植给2例成人受者。3例受者分别于术后21，23，26d出现移植肾区肿胀、疼痛，切口渗液或阴囊水肿，以及血清肌酐升高；行移植肾彩色多普勒超声示。肾周积液增多；1例受者行CT尿路造影示造影剂大量外漏、单侧肾积水、输尿管扩张。手术探查切除坏死的输尿管后行改良Boari术，将移植肾输尿管残端插入自体膀胱管状瓣内1-2cm，不作吻合，仅行黏膜和浆肌层缝合加固。术后酌情选用抗生素控制尿路感染，定期行肾功能检测和移植肾彩色多普勒超声检查，术后6个月复查CT尿路造影。结果3例患者均成功进行改良Boari术，手术时间分别为85，90，115min，术中无明显出血，术后切口愈合良好。3例患者分别在术后12，13，16周顺利拔除双J管，血清肌酐均下降至正常范围。截至2014年3月，术后随访6-18个月，复查移植。肾彩色多普勒超声和CT尿路造影均未发现移植肾积水、肾周积液、尿漏或尿液返流等异常。结论改良膀胱壁瓣输尿管成形术是治疗婴幼儿供肾肾移植术后输尿管长段坏死的有效方法。

Clinical analysis on modified Boari bladder flap for ureteral necrosis after kidney transplantation from pediatric donor

Objective To investigate the effect of using modified Boari bladder flap in the treatment of ureteral necrosis after kidney transplantation from pediatric donor. Methods Three adult recipients complicated with long ureteral necrosis after kidney transplantation from pediatr/c donor between January 2012 and April 2014 in General Hospital of Jinan Military Command were reviewed. The first ease was en bloc kidney transplantation, the other two cases were kidney transplantation with unilateral kidney from the same pediatric donor. Ureteral necrosis occurred on postoperative days 21, 23, 26, respectively. Symptoms were graft swelling, pain, incision exudate, scrotal edema, and increased serum creatinine. Color Doppler ultrasound showed increased perirenal effusion. Resections of necrotic ureter were performed, improved Boari bladder flap were further applied to reconstruct urinary tract. The ureteral stump of transplant kidney was inserted into the Boari bladder flap for 1-2 cm, with no anastomosis and only mucous membrane and serosa were sutured. Selected antibiotics were used to control urinary tract infection. Regular renal function tests, color Doppler ultrasound examination and CT urography were performed 6 months after reconstruction. Results All three recipients hadsuccessful ureteral reconstruction. Operative time were 85 min, 90 min and 115 min, respectively. Bleeding was not be found during the operation, and the incisions healed well. The double J tube were removed at 12 weeks, 13 weeks, and 16 weeks, with the renal function improved significantly. Patients were followed up for 6 to 18 months, no transplant hydronephrosis, perirenal effusion, urine leakage, or urine reflux recurred. Conclusion Using the modified Boari bladder flap is an effective technique for lona ureteral necrosis after kidney transplantation from pediatric donor.