腔内切开治疗移植肾输尿管膀胱吻合口梗阻

目的 探讨腔内切开处理移植肾输尿管膀胱吻合口梗阻的安全性与有效性. 方法 18例肾移植患者术后2～18个月出现尿量减少.实验室检查SCr 230～570/μmol/L.超声检查提示中重度肾积水.膀胱镜检查18例均无法逆行输尿管置管.经皮肾造瘘后行顺行造影显示输尿管膀胱吻合口梗阻,不完全梗阻14例、完全梗阻(闭锁)4例,梗阻长度0.5～1.3 cm.术中先经皮肾通道入镜,将斑马导丝顺行插过梗阻段达膀胱,再逆行经尿道将膀胱内导丝拉出尿道外,直视下用电刀或钬激光全层切开梗阻段;若斑马导丝无法通过梗阻段,则采用造影剂混合美蓝充盈膀胱,顺行入镜到达梗阻处,X线监视下用长针向膀胱内穿刺打通.术后留置2条双J管6～8周,定期行超声、肾图和肾功能检查. 结果 18例术中见吻合口黏膜苍白水肿,管壁僵硬、管腔狭窄、瘢痕组织增生明显,均成功将梗阻段切开,无手术并发症发生.术后夹闭肾造瘘管后排尿通畅,尿量正常.实验室复查SCr降至87～233μmol/L.超声检查提示肾血流正常,肾积水消失或仅轻度积水.随访4～90个月,平均51个月.8例1次治疗成功;5例因瘢痕组织切除不彻底经再次腔内切开(3例2次,2例3次)治疗后成功;5例拔管后梗阻复发无法逆行入镜,梗阻难以处理改开放手术治疗,其中4例治疗成功,1例仍需长期输尿管置管. 结论 肾移植术后输尿管膀胱吻合口梗阻采用腔内切开治疗安全、有效,梗阻复发者可考虑再次内切开或开放手术治疗.

Endoscopic incision in the treatment of ureterovesical anastomosis site obstruction in transplanted kidneys

Objective To report the clinical outcomes of applying endoscopic incision in the treatment of ureterovesical anastomosis site obstruction in transplanted kidneys. Methods Between February 2001 and April 2008, 13 men and 5 women with ureterovesical anastomotic site obstruction in their transplanted kidneys were treated by endoscopic incision with electrocautery or holmium: YAG laser. After the anastomosis was completely resected, two Double-J stents were placed in the ureter for 6-8 weeks. During follow-up, renal function, ultrasound examination and wash-out renal scintig-raphy were performed every month for the first 6 months, then every 3 months. Results Total 25 procedures of endoureterotomy were performed and all procedures resulted in successful incision of the obstruction. No complication was recorded during or after the procedure. At the mean follow-up of 51 months (range 4-90 months), 5 patients presented with recurred obstructive uropathy immediately after the Double-J stent removal and finally underwent open surgical correction. Conclusions Endo-scopic incision is safe and effective in the treatment of ureterovesical anastomosis site obstruction in transplanted kidney. However, open surgical reconstruction should be considered if endoscopic inci-sion procedure has failed.