不同组织替代输尿管黏膜重建输尿管的组织病理学观察

目的观察腹膜和膀胱黏膜重建犬黏膜剥脱输尿管的组织病理学变化。方法成年杂种犬18条，随机分3组，制作输尿管黏膜剥脱模型后，重建组黏膜缺损处分别予膀胱黏膜或腹膜植入，对照组仅留置输尿管支架管，术后10周将犬处死，取重建段输尿管作病理学检查。结果对照组损伤段输尿管腔明显狭窄或闭锁，未见黏膜生长。膀胱黏膜替代组黏膜生长良好，其中1条犬重建段输尿管上段轻度扩张，重建段狭窄不明显。腹膜替代组腹膜组织消失，重建段见新生移行上皮，输尿管腔均无狭窄。结论腹膜或膀胱黏膜可作为输尿管黏膜剥脱后重建的理想修复材料。     

游离腹膜管重建黏膜剥脱输尿管的实验研究

目的探讨腹膜重建黏膜剥脱输尿管的可行性，探索治疗输尿管黏膜袖状剥脱的新方法。方法成年杂种犬12条，随机分为重建组和对照组，每组6条。首先制作输尿管黏膜剥脱模型，黏膜剥脱3—5cm。重建组采用游离腹膜管植入黏膜缺损段，并留置输尿管支架管；对照组仅留置支架管。术后10周行IVU和组织病理学检查。结果术后10周重建组IUV示术侧肾脏形态大小正常，无肾积水，输尿管均可全程显影，腹膜替代部分输尿管无明显狭窄；对照组IVU示术侧肾脏均不显影或仅显示增大模糊轮廓，输尿管均未显影。对照组犬输尿管腔均严重狭窄或闭锁。重建组犬腹膜组织被完整成熟的移行上皮替代，输尿管无明显狭窄，上皮下可见丰富的新生血管。结论输尿管黏膜剥脱〉3cm时，仅留置支架管将导致输尿管狭窄或闭锁；利用游离腹膜管替代输尿管黏膜是一种有效的治疗方法。     

Antireflux uretero-ileal implantation via a mucosal sulcus

The authors present an original antireflux uretero-ileal implantation. This procedure is based on the insertion of the ureter in a mucosal sulcus. The ileal mucosa progressively grows over the ureter. 260 ureters have been reimplanted according to this procedure. The antireflux system is effective in 85% of cases. The incidence of stenosis seems to be low: less than 2%.     

Extravesical diverticuloplasty for repair of a paraureteral diverticulum and the associated refluxing ureter

PURPOSE: Extravesical diverticuloplasty for repairing a paraureteral (Hutch) diverticulum and the related refluxing ureter is presented. MATERIALS AND METHODS: Of the 16 children in this study 10 had bilateral paraureteral diverticula with associated bilateral vesicoureteral reflux, 2 had bilateral paraureteral diverticula with a bilateral duplicated ureter, unilateral duplex refluxing ureters and contralateral lower moiety vesicoureteral reflux, and 4 had a unilateral paraureteral diverticulum with an ipsilateral refluxing ureter. The anatomical relationship of the ureteral orifice and diverticulum was identified by cystourethroscopy preoperatively and confirmed during the extravesical operation. The surgical technique differed depending on the size of the diverticulum and the position of the ureteral opening when the bladder was completely distended. The larger prolapsed diverticular mucosa served as a backing for the detrusor muscle, which was closed over the ureter, and the smaller diverticulum was repaired as a dilated ureter. Overall 30 renal units with grades II to IV vesicoureteral reflux were corrected by this method. RESULTS: All patients were followed with ultrasound and voiding cystourethrography 3 and 9 months postoperatively. The diverticula with associated refluxing ureters were successfully cured. Neither postoperative recurrence nor ureteral obstruction were noted. CONCLUSIONS: Extravesical diverticuloplasty can be performed for many sizes of paraureteral diverticula and concomitantly for the associated refluxing ureter, including refluxing duplex ureters.     

Ureteral action potential and histological changes in the upper urinary tract receiving the formalin

The present study investigates the ureteral action potential and histological changes of pelvi-ureteral system after injection of the formalin into the obstracted ureters or the renal pelvis. In the first experiment, formalin was injected into the obstructed ureters of 18 dogs for 30 minutes. In the second, formalin was injected into the obstracted renal pelvis of 13 dogs for 30 minutes using ureteral balloon catheters, and then renal pelvis were released from obstraction and catheters were removed. In these experiments, ureteral electromyogram were recorded and histological changes of pelvi-ureteral system were also observed microscopically. Results 1. After injection of formalin into the ureters, ureteral action potential disappeared and had not restored. Histologically, damage was observed in the ureteral smooth muscle as well as in the mucosa. 2. After injection of formalin into the renal pelvis, ureteral action potential disappeared in 46% of the ureters. In 54% of the ureters, action potential had not disappeared, however discharge interval became irregular. Histological changes of the renal pelvis was not related to the presence or absence of ureteral action potential. The results of the present study show that ureteral smooth muscle play part in the conduction of the ureteral excitation, and have an irregular autonomic discharge.     

Survivin expression in the ureteral wall of high degree vesicoureteral reflux in children

Introduction Survivin is a member of inhibitor of apoptosis protein family which suppresses apoptosis and regulates cell division. Survivin was not found to be expressed in normal differentiated tissues. CD95 is a cell surface receptor, and it is believed to induce cell death in a variety of cells. The goal of this study is to evaluate the survivin and CD95 expression in bladder and uerters of children operated for vecsicoureteral reflux (VUR). Materials and methods Sixteen paraffine embeded ureteral units of 11 children with vescico ureterl reflux were treated immunohistochemicaly with survivin and CD95. At operation the distal margins of the ureters were send to histologic exam and a full thickness biopsy from the anterior bladder wall including muscle and mucosa were performed. The control was taken from a urologically normal 9 days old baby who died from myocarditis. The sections were stained with the antibody in the regular method and the degree of staining was graded from 0 to 3, by a single uropathologist. Results Immunohistochemistry staining with survivin was positive in all ureters. We had 13 high grade (grade 3–5) and 3 low grade (grade 1–2) vesicoureteral reflux. The average survivin degree of staining in the low grade reflux was 1.33 compared to 2.3 (P = 0.019) in the high grade refluxing ureters. The staining of the control sample was graded 1. The average degree of staining was 1.2 in the bladder wall compared to 2.125 in the ureters. CD95 stained mast cells in ureters and bladders. Conclusions Possitive staining of survivin was found in both ureters and urinary bladders of children that underwent surgical repair of vesicoureteral reflux. The degree of survivin staining was significantly higher in the high grade refluxing ureters compared to low grade reflux and to the bladder wall in the same patients.     

Tuberculous stricture of ureter

Tuberculous stricture of the ureter is not uncommon in centers which treat large numbers of patients with urinary tuberculosis. Ninety-seven such strictures were seen in 92 patients over a twenty-five-year period. All patients were treated with appropriate antituberculous chemotherapy. Transurethral dilatation of the ureteral stricture was done on 80 ureters. Dilatation was successful in 51 ureters (64%) and failed to relieve the strictures in 29. Technical difficulties prevented dilatation of 17 ureters. We believe that transurethral dilatation should be attempted on all tuberculous ureteral strictures and that other procedures should be employed only if dilatation fails.     

Endoscopic and fluoroscopic pyeloureterotomy for ureteropelvic junction obstruction and ureteral stricture

Endoscopic or fluoroscopic pyeloureterotomy was performed in a total of 32 patients (34 ureters) with ureteropelvic junction obstruction (UPJO) or ureteral stricture from March 1985. Cold incision was performed, using a flexible knife over a guidewire, endoscopically on 23 ureters and fluoroscopically on 11 ureters. The mean operation time was 98.9 +/- 48.3 minutes. Twenty-five (74%) of the 34 ureters showed relief of subjective symptoms, normalized urinalysis and radiographical improvement of hydronephrosis with a mean follow-up period of 11.7 +/- 10.0 months (range: 3-43). The clinical results by etiology were as follows: primary UPJO, 13/16 (81%); secondary UPJO, 4/4 (100%); ureteral stricture, 6/7 (85%); obliteration of ureteral implantation, 2/7 (29%). No major complication was noted with this endourological technique. This endourological technique might be clinically useful for the treatment of UPJO and ureteral strictures.     

The long-term outcome of bilateral Cohen ureteric reimplantation under a common submucosal tunnel

OBJECTIVE: To analyse the results of bilateral Cohen reimplantation under a common submucosal tunnel, over an 18-year period. PATIENTS AND METHODS: We retrospectively examined 102 children (35 boys and 67 girls, median age 5.5 years, range 0.5-13.5) who underwent bilateral antireflux ureteric reimplantation from 1983 to 2000 with a modified Cohen technique, re-implanting both ureters under a common submucosal tunnel in the mid-trigonal area, to treat primary vesico-ureteric reflux (VUR, 99 patients) or obstructive megaureter (three). The mean (range) follow-up was 10.6 (2-18) years. RESULTS: The operation was successful in 198 of 204 (97%) ureters. One patient had vesico-ureteric stenosis in one ureter and was re-operated successfully. In two ureters in two different patients there was transient stasis after surgery caused by oedema within the tunnel, which gradually resolved. Two ureters in two other patients had reflux after surgery, which resolved spontaneously after 12 and 24 months, respectively. A 6-month old baby had anuria after surgery because of acute compression of both ureters within a narrow tunnel; this patient was re-operated, the tunnel widened and the obstruction resolved. None of 82 patients who had reached school age by the time of their last follow-up showed signs of voiding dysfunction. CONCLUSIONS: The modified bilateral Cohen reimplantation with both ureters under a common submucosal tunnel offers very good long-term results in curing VUR or obstructive megaureter. Crossing one ureter upon the other within the tunnel does not predispose to long-term obstruction. From these results we recommend it as a reliable technique for surgically treating bilateral VUR or obstructive megaureter.     

The influence of the rapid rise of intraluminal pressure of the upper urinary tract on ureteral action potentials

The present investigation was undertaken in order to examine the ureteral action potentials following transient rapid rise of the intraureteral pressure. In 21 adult mongrel dogs, physiological saline and 5% formalin were injected into the left and right obstructed ureters, respectively to produce rapid rise of intraureteral pressure to 60 cmH2O for 7 minutes, and then ureter was released from obstruction. In these experiments, recordings of ureteral electromyogram and intraureteral pressure were made. Histological changes of pelvi-ureteral system were also observed microscopically. Results 1. After injection of physiological saline, discharge intervals were significantly shortened, but normal discharge intervals were restored when the ureters were released from obstruction. Under conditions of reobstruction, the discharge intervals were shortened and intraureteral pressure inducing the shortest discharge interval was 50 cmH2O. 2. After injection of formalin, discharge intervals were significantly shortened, and the action potentials disappeared in 1 minute 28 seconds to 4 minutes 51 seconds after the injection in 18 out of the 21 ureters. No discharge was observed at 7 minutes after the injection in 16 out of the 18 ureters. In 14 out of the 16 ureters, however, the action potentials were restored when the ureters were released from obstruction or after the obstruction was readministered. Under conditions of reobstruction, discharge intervals were shortened, and intraureteral pressure inducing the shortest discharge interval was 20 cmH2O. 3. Histologically, the loss of epithelium, as well as edema and vasodilatation in lamina propria, were observed only in the mucosa of the middle portion of the ureters receiving formalin. The results of the present study show that a transient rapid rise of intraluminal pressure of the upper urinary tract caused by the injection of physiological saline or formalin, dose not have a significant effect on the ureteral action potentials, and that disappearance of the action potentials is refered to pharmacological action of formalin.     

Feasibility of total intravesical endoscopic surgery using mini-instruments in a porcine model

BACKGROUND AND OBJECTIVES: The aim of minimally invasive approaches to vesicoureteral reflux, such as endoscopic trigonoplasty, is to lower the morbidity of open procedures without compromising the results. Initial successes have not been sustained, mainly because of trigonal splitting, which results in the ureteral orifices returning to their preoperative positions. This study was designed to address trigonal splitting by mobilizing the ureters before repositioning them and to evaluate the feasibility of accomplishing this intravesically with 2- to 3-mm endoscopic mini-instruments. METHODS: Bilateral vesicoureteral reflux was surgically created in 10 minipigs. After radiologic confirmation of success 4 weeks later, modified trigonoplasty was performed by endoscopic intravesical mobilization of both ureters and incision of the trigonal mucosa using 2-mm instruments. The ureteral orifices were then advanced toward the midline and sutured in place. The initial surgical techniques were modified to permit the entire procedure to be performed endoscopically in the last four minipigs. Cystograms and intravenous urograms were obtained 4 weeks later. RESULTS: Two minipigs died postoperatively. Six of the remaining eight had persistent reflux, including three of the four in the group treated completely by endoscopic means. None of the dissected ureters showed evidence of stricture or necrosis. CONCLUSIONS: Although the procedure was not successful in correcting reflux in this model, this study demonstrates the feasibility of endoscopic ureteral mobilization. With current instrumentation, there is no significant technical obstacle to complete intravesical endoscopic surgery, including ureteral reimplantation.     

Regeneration of the canine urinary bladder mucosa after complete surgical denudation

To study the site of origin of epithelial regeneration in the urinary bladder after surgical denudation, we completely obliterated the bladder mucosa in 17 dogs, using the neodymium: YAG laser. Bladder-mapping studies showed that the regenerating cells arose from the epithelium of the terminal ureters and urethra. Experimental construction of isolated bladder pouches confirmed these findings and demonstrated that urine flow was not essential for reepithelialization. These results are relevant to the treatment of patients with multifocal carcinoma in situ of the bladder. Although the entire bladder can be denuded successfully, the studies demonstrate that the procedure might fail if the sources of epithelial regrowth, the distal ureters and urethra, contain untreated carcinoma in situ.     

An original antireflux ureteroileal implantation technique: long-term followup

An original ureteroileal reimplantation technique in which the ureter is placed in a sulcus created in the ileal mucosa was performed on 51 patients (97 ureters). Followup ranged from 3 to 8 years. As determined by excretory urography, retrograde ileography and urine bacteriology studies the method was effective in 85 per cent of the patients, with a low rate of stenosis (1.5 per cent). The use of this technique, initially limited to patients with the U-shaped continent ileal bladder, has been broadened to include those who undergo various reconstructive or urinary diversion procedures that require ureteroileal reimplantation.     

Clinical results of tubeless cutaneous ureterostomy by Toyoda's method

Tubeless cutaneous ureterostomy by Toyoda's method was conducted in 67 ureters from 43 patients during the last 9 years. Subjects included 30 males and 13 females, with an average age of 61.4 years. Most of them were afflicted with malignant tumors in the bladder, rectum, prostate, or uterus. For bilateral ureterostomy, the double-barrel method was performed in which the stoma was made at the same site in both the right and left ureters. Among 60 ureters in which pre- and postoperative changes in the renal pelvis could be traced by IVP, satisfactory results were obtained in 16 of 20 ureters treated by unilateral surgery. Of the 40 ureters treated by the double-barrel method, moderate or severe pyeloectasis was observed in 3 of the 20 ureters on the side of the stoma, while moderate pyeloectasis was seen in 3 of 20 ureters of the side opposite the stoma, and severe pyeloectasis or loss of renal function was noted in 5. Thus, renal function on the side opposite the stoma was frequently influenced by the procedure. A patient who died of disseminated intravascular coagulation syndrome soon after the operation was excluded from analysis. Tubeless cutaneous ureterostomy could be conducted in 39 of 42 patients (92.8%), excluding one whose stoma and its periphery were covered with severe inflammatory granulation and 2 with ureteral constriction.     

Usefulness of ultrasonography in follow-up of postoperative pelviureteric dilatation in children

To determine the availability of ultrasonography in follow-up of postoperative pelviureteric dilatation, 35 children, who had previously been operated on in some part of the urinary tract, were examined by both excretory urography and ultrasonography. Of 59 kidneys shown to be with a dilated collecting system on excretory urography, 58 were correctly detected by ultrasonography, with a sensitivity of 98.3%. The grade of dilatation of the collecting system diagnosed by ultrasonography was corresponded to that by excretory urography in 99 of 123 kidneys [80.5%). At the level of the lower calyx, 40 of 43 ureters which measured 5 mm or greater in diameter on excretory urogram, were detected by ultrasonography. Thirty of 36 ureters posterior to the bladder with a diameter of over 5 mm were also detected by ultrasonography. The diameters of the ureters measured by ultrasonography were well correlated with those on excretory urogram. These results suggest that the availability of ultrasonography is so high that it could substitute for excretory urography in follow-up of postoperative hydronephroureter in children.     

Aids in diagnosis of suspect ectopic ureters in female patients

When suspected ectopic ureters cannot be visualized by conventional methods, such as excretory urogram, nephrotomograms, or by intravenous indigo carmine, then direct injection of vaginal, suburethral, or paraurethral "swellings," which are in effect dilated terminal ureters, may confirm the diagnosis.     

Treatment of vesicoureteral reflux by endoscopic injection of blood

We have developed a new endoscopic procedure for correction of experimental and clinical reflux. It was technically feasible to correct successfully experimentally produced vesicoureteral reflux in dogs by endoscopic injection of blood. Thirteen ureters (10 patients) with grade I-III vesicoureteral reflux were treated by endoscopic injection of patient's heparinized blood behind the ureteral orifice. Before drawing out the needle, small amounts of thrombin and protamine were injected to prevent the leakage of the injected blood. Eight of thirteen treated ureters showed complete absence of reflux. The technique has both advantages and disadvantages. Advantageous points are that it is technically simple and injection can be done a few times when reflux has not disappeared. Furthermore, no complications such as distant migration of injected materials and escape from the bladder mucosa have been observed. A disadvantageous point is that the treatment has not been successful in every case.     

In vivo labelling of alpha-adrenoceptor-binding sites and membrane-bound extraneuronal transport sites in the urinary bladder of the rat by 3H-ST-1059 and 3H-phentolamine. An autoradiography study

An attempt was made to trace alpha-adrenoceptor-binding sites in the lower urinary tract tissue of the rat by means of analyzing the distribution of radioactivity in autoradiograms of freeze-dried or glutaraldehyde-fixed tissue following intravenous injection of an alpha-agonist, 3H-ST-1059, or an alpha-antagonist, 3H-phentolamine. Both drugs were rapidly excreted into the urine and reabsorbed by the bladder mucosa. This is evidenced by the presence of high amounts of silver grains superimposed onto the epithelium and bordering the lamina propria structures 10-30 min after intravenous injection of 3H-ST-1059 or 3H-phentolamine in rats not subjected to ligation of their ureters. In rats that underwent ligation of their abdominal ureters prior to intravenous injection of 3H-ST-1059 or 3H-phentolamine, silver grains were preferentially localized over the plasmalemmata of smooth muscle cells and fibroblasts of the detrusor and trigonum of the urinary bladder. Phentolamine and phenoxybenzamine but not propranolol counteracted the labelling of the plasma membranes of smooth muscle cells, fibroblasts and striated muscle fibres of the pelvic floor by low doses of 3H-ST-1059 and 3H-phentolamine, suggesting that both drugs have affinity to alpha-adrenoceptor-agonist and alpha-adrenoceptor-antagonist binding sites. Since phentolamine and phenoxybenzamine as well as hydrocortisone pretreatment also attenuated the accumulation of radiolabel in the perikarya of the three types of cells mentioned, both drugs--at the concentration used--are also substrates for membrane-bound carriers, such as uptake two according to Iversen. A more selective in vivo demonstrationof alpha-agonist-binding and alpha-antagonist-binding sites requires drugs of higher specific activity than available at present.     

带蒂大网膜修复严重输尿管损伤及其机制的实验研究

目的 探讨带蒂大网膜修复严重输尿管损伤的作用机制. 方法 20只健康成年杂种犬随机分为实验组及对照组,每组10只,均建立严重输尿管损伤动物模型,端端吻合输尿管后实验组采用带蒂大网膜包裹损伤输尿管,对照组未采用大网膜包裹.术后不定期观察有无尿瘘及输尿管坏死.术后12周观察术侧输尿管损伤愈合情况,取吻合口及周围组织行病理学检查,镜下观察血管再生情况,免疫组化检测血管内皮生长因子(VEGF)及其受体KDR的表达. 结果 术后实验组无尿瘘,对照组2只因尿瘘反复腹腔感染死亡.术后12周实验组输尿管吻合口处黏膜及平滑肌层完全再生,血管再生现象明显,VEGF及KDR表达阳性细胞密度分别为(12.65±0.02)%和(10.23±0.03)%.对照组吻合口愈合不良并狭窄,思侧肾严重积液(脓),无明显血管再生,VEGF及KDR表达阳性细胞密度仅为(1.54±0.03)%、(2.65±0.04)%,明显低于实验组(均P<0.05). 结论 带蒂大网膜有促进严重输尿管损伤修复作用,可能通过VEGF及KDR表达升高促进血管再生而实现.     

Water and electrolyte absorption in ileal segments surgically transposed to the urinary bladder in the cat

Net transport of water and electrolytes was studied in ileal segments which had been exposed to urine during three months in seven cats. During surgery, a 5 cm long ileal segment was interposed between the ureters and the urinary bladder. At the same time a control segment (5 cm) was indicated with silver clips. After three months, the net transport of water and electrolytes was studied using a continuous perfusion technique with an isotonic and with a hypertonic, urine-like perfusate. Microscopic examination of the mucosa showed a significant reduction of villus height in the transposed segments compared to the controls (p less than 0.05). With the isotonic perfusate there was a net absorption of water in the control segments, and a net secretion in the transposed segments, the difference being statistically significant (p less than 0.05). When the hypertonic perfusate was used, a net secretion occurred in both control and transposed segments. Net transport of electrolytes (Na+, K+, Cl-) was in the same direction as water transport in both control and transposed segments. The results indicate that there does not seem to be any risk of water or electrolyte reabsorption by intestinal mucosa which has been exposed to urine.