自体肾移植术治疗长段输尿管缺损10例报告

目的：总结采用自体肾移植术治疗长段输尿管缺损的临床疗效和体会。方法对10例输尿管中上段结石患者,在经输尿管硬镜钬激光碎石时出现长段输尿管黏膜袖套状剥脱或全层撕脱,内镜下放置双 J 管失败,无法行输尿管端端吻合或再植,于损伤发生2 h 至9 d 后行自体肾移植术。结果1例术前肾功能严重减退患者术后7 d 出现移植肾栓塞,其余9例随访5～75个月,移植肾血流灌注良好,肾功能维持正常水平;1例术后4个月出现膀胱吻合口狭窄致自体移植肾中度积水,给予微创经皮肾穿刺造瘘引流;尿路感染1例,经抗感染治疗后好转,未见复发。结论针对医源性长段输尿管撕脱伤患者,及时施行自体肾移植可以有效恢复尿路完整性并保持肾功能,且并发症发生率低。     

单切口腹腔镜肾切取联合自体肾移植术治疗复杂医源性输尿管缺损

目的:探讨腹腔镜下肾切取联合自体肾移植术治疗复杂医源性输尿管缺损的应用。方法:回顾性分析腹腔镜下肾切取联合自体肾移植术治疗复杂医源性输尿管缺损患者围手术期及随访资料。结果:2例患者均经腹膜腔手术切取肾脏并经同侧下腹部Gibson切口取出,行工作台修整肾脏后经同一切口延长后完成自体肾移植手术均获得成功,2例患者手术时间分别为265min和325min,估计手术失血量分别为50ml和100ml,肾热缺血时间分别为2min和3min,无术中及术后输血,无术后尿瘘等并发症。术后1周血清肌酐较术前明显好转。随访2～30个月,患者移植肾功能良好,肾功能稳定,无肾积水及结石复发等。结论:腹腔镜肾切取联合自体肾移植术治疗复杂医源性输尿管缺损有效,创伤小,可在急诊环境下安全实施。而熟练的腹腔镜技术、肾移植技术和谨慎的围手术期管理是该术式安全实施的重要保障。     

自体肾移植术的临床应用

目的：探讨自体肾移植术在尿路及非尿路疾病中的应用价值。方法：应用自体肾移植术治疗9例患者，其中肾血管性高血压3例，腹主动脉瘤3例，肾肿瘤2例，输尿管肿瘤1例。结果：术后均未出现并发症，随访6～72个月，平均35个月。其中8例患者肾功能正常，1例肾肿瘤患者于术后13个月因肿瘤复发并颅内转移死亡。结论：自体肾移植术对某些特殊的尿路和非尿路疾病是有效的治疗手段。     

肾移植术后长段输尿管狭窄的诊断与开放性手术治疗

目的 总结肾移植术后发生长段输尿管狭窄的诊断方法与手术治疗经验.方法 分析11例肾移植术后发生长段输尿管狭窄患者的临床资料.患者发生长段输尿管狭窄的时间为肾移植术后2～6个月,临床表现为血肌酐升高、体重增加、尿量减少和移植肾区肿胀.所有患者均经B型超声、64层螺旋CT尿路造影(CTU)或磁共振尿路水成像(MRU)确诊,输尿管狭窄长度为3～7 cm.11例患者的治疗方法为:5例行膀胱壁瓣输尿管成形术;2例行供肾肾盂-自体输尿管吻合术;4例行供肾输尿管-自体输尿管吻合术.结果 11例长段输尿管狭窄的患者经开放性手术治疗后,均取得成功,恢复了尿路的通畅.手术时间为2.5～4 h,无明显手术并发症.术后尿量显著增加,血肌酐下降至75～156μmol/L,B型超声示移植肾积水明显减轻或消失.术后随访8～62个月,患者肾功能稳定,无再发狭窄.结论 对肾移植术后出现血肌酐升高等临床特点的患者,应考虑到输尿管狭窄的可能,及时采用B型超声进行常规的检查,采用CTU或MRU明确狭窄的长度及部位;明确诊断后应及时进行开放性手术治疗.肾移植术后的长段输尿管狭窄经早期诊断和及时治疗成功率较高.     

严重下尿路异常患者的肾移植(附三例报告)

目的　探讨下尿路异常患者的肾移植手术治疗方案及方法。　方法　 3例合并下尿路异常的肾移植患者均为男性。结核性膀胱挛缩 1例 ,4 5岁 ,行肾移植加移植肾输尿管皮肤造口术 ,免疫抑制方案为赛尼哌 (Zenapax) 他克莫司 (FK5 0 6 ) 霉酚酸酯 (MMF) 泼尼松 (Pred) ;神经原性膀胱2例 :例 1 ,2 4岁 ,同期行肾移植加回肠膀胱术 ,免疫抑制方案为Zenapax FK5 0 6 MMF Pred。例 2 ,34岁 ,分期行肾移植加回肠膀胱术 ,免疫抑制方案为Zenapax CsA MMF Pred。　结果　行移植肾输尿管皮肤造口术者术后恢复顺利。同期行肾移植加回肠膀胱术患者术后血便和尿瘘 ,积极治疗后好转 ;分期手术者无明显并发症。术后分别随访 2 3、5、4个月 ,移植肾功能正常 ,无严重并发症。　结论　合并下尿路异常的肾移植患者 ,应根据患者情况分期或同期完成肾移植术和尿流改道术 ,最大限度保障移植肾功能与输尿管引流通畅     

肾移植术后并发自体上尿路恶性肿瘤三例

恶性肿瘤的发生已成为目前肾移植术后的一个较严重的并发症 ,而并发自体上尿路恶性肿瘤的报道甚少 ,现报道3例如下。例 1 ,男性 ,39岁。因慢性肾功能衰竭、尿毒症于 1 997年 1月行肾移植术 ,手术顺利 ,肾功能恢复正常 ,术后服用环孢素Ａ、硫唑嘌呤、泼尼松。术后 1年 ,患者血肌酐升高 ,出现全程肉眼血尿 ,Ｂ型超声波检查发现左肾 (自体肾 )下极占位性病变。 1 999年 1 1月行左肾及输尿管切除术 ,术后病理诊断 :左肾髓质乳头状癌并输尿管内癌栓。术后继续服用免疫抑制剂 ,移植肾功能正常。例 2 ,男性 ,56岁。 6年前因慢性肾功能衰竭、尿毒症…     

腹腔镜手术治疗肾移植后自体上尿路上皮癌九例

目的 探讨腹腔镜治疗肾移植术后尿路上皮癌的效果.方法 1130例肾移植受者中9例(0.8％,9/1130)发生自体上尿路上皮癌,其中右侧输尿管肿瘤2例,右侧肾盂肿瘤2例,左侧肾盂肿瘤2例,左侧输尿管上段肿瘤1例,双侧上尿路同时或先后发生肿瘤2例(1例为双侧输尿管肿瘤,1例为右侧输尿管肿瘤合并左侧肾盂肿瘤).9例中,男性1例,女性8例.左侧肾盂和输尿管肿瘤采用经腹膜后途径腹腔镜肾脏和输尿管全切联合经尿道电切的方法治疗.右侧上尿路肿瘤采用70°斜卧位经腹腔途径肾脏和输尿管切除并膀胱袖状切除.术后通过膀胱灌注化疗.将钙调磷酸酶类免疫抑制剂转换为西罗莫司.结果 9例手术(包括2例双侧手术)均获得成功,术后病理检查结果均证实为尿路上皮癌.随访6个月至4年,未发现切口肿瘤种植转移.1例术后8个月死于尿路上皮癌肺转移,1例术后7个月发生乳腺癌,其他7例目前无瘤存活,肾功能均正常.结论 腹腔镜手术治疗肾移植术后自体尿路上皮癌效果较好,具有创伤小、恢复快等优点.左侧和右侧肿瘤应采用不同的手术方法.     

自体肾移植治疗输尿管癌的探讨

目的：探讨输尿管癌自体肾移植治疗的理论基础和优点。方法：对9例输尿管癌患者行自体肾移植术治疗．切除输尿管癌上方3cm正常输尿管及下方输尿管全长．并做膀胱输尿管入口处的袖套状切除术；患侧肾行同侧髂窝肾移植、输尿管膀胱再吻合术。结果：9例输尿管癌包括T34例和T24例中．各有1例膀胱癌复发，其余无尿路上皮肿瘤复发．其生存率1年为100％，2年为88．8％．5年为66．7％。结论：自体肾移植术对输尿管癌患者的治疗效果基本等同于传统的根治性肾输尿管切除术(包括膀胱袖套状切除)．对于孤立肾及双肾功能不良的患者也是个好的手术方式，为以往不能行保留肾功能的高分期孤立肾及双肾功能不良的输尿管癌患者争取到手术机会。为输尿管上段肿瘤患者也提供了一个可选择的保肾手术方式。     

回肠代输尿管术后并发症并文献复习(附1例病例)

目的 通过1例回肠代输尿管术治疗输尿管撕脱围手术期的处理, 讨论手术及术后并发症,为临床工作提供借鉴和指导.方法 根据本院1例急诊行回肠代输尿管术治疗输尿管长段缺损及处理术后尿路感染的经验, 结合文献进行分析讨论.结果 术后随访15个月,血肌酐、血气分析、电解质无明显异常,术后前4个月肠黏液排出较多,术后多次CT均提示尿路排泄通畅,肾功能保持良好,肾积水明显缓解,但术后发生尿路感染近7个月才完全控制.结论 回肠代输尿管在输尿管长段损伤同时又倾向于保留患肾时是较好的重建尿路的手术方式,其改善或维持肾功能疗效肯定;但患者术后尿路感染不能避免,还需要进一步的探索.     

肾移植术后输尿管并发症17例临床分析

目的 总结肾移植术后输尿管并发症的诊治经验.方法 回顾分析济南军区总医院诊治的17例肾移植术后输尿管并发症患者的临床资料.结果 17例患者伴有不同程度的少尿和局部肿胀不适等症状,实验室检查血清肌酐（Scr）升高,彩色多普勒超声（彩超）检查示移植肾积水、移植肾输尿管扩张,经磁共振水成像或计算机断层摄影术（CT）尿路成像明确诊断.其中输尿管膀胱吻合口狭窄15例,输尿管坏死2例.治疗经过：14例行开放性手术,包括行移植肾输尿管膀胱重新吻合术12例,移植肾输尿管-自体输尿管吻合1例,移植肾输尿管游离、重新放置输尿管支架管1例.3例行非开放性手术治疗,包括输尿管皮肤造瘘1例、腔内球囊导管扩张术1例、软膀胱镜下逆行输尿管支架管插管治疗1例.疗效：14例开放手术治疗患者与1例输尿管皮肤造瘘患者的移植肾肾盂与膀胱的连接部恢复通畅,移植肾功能均明显改善.另2例非开放手术治疗患者,包括1例腔内球囊导管扩张术及1例行软膀胱镜下逆行输尿管支架管插管术患者术后复发,行开放手术治疗.结论 彩超及磁共振成像水成像或CT尿路成像等影像学检查是确诊移植肾输尿管并发症的主要方法.肾移植术后输尿管并发症应以预防为主,确诊后视具体情况行开放性手术或非开放性手术治疗,开放手术治疗的疗效较佳.     

Expanded experience with laparoscopic nephrectomy and autotransplantation for severe ureteral injury

PURPOSE: Complex injuries of the upper ureter with significant loss of length are difficult to manage. Traditional options include nephrectomy, bowel interposition and autotransplantation. The advent of laparoscopic donor nephrectomy has created a new option when preservation of functioning renal parenchyma is desirable. We update our experience with severe iatrogenic ureteral injuries requiring laparoscopic nephrectomy and autotransplantation. MATERIALS AND METHODS: Seven patients with severe ureteral injuries were referred for definitive management. In all cases preoperative evaluation demonstrated comparable split renal function and anatomy not amenable to routine reconstruction. Transperitoneal laparoscopic nephrectomy and autotransplantation to the ipsilateral pelvis were attempted. RESULTS: Of the patients 5 had a history of nephrolithiasis with intervention resulting in the ureteral injury and 5 underwent prior endoscopic or open management of the defects. All cases were associated with dense perinephric and perihilar fibrosis. Operative and warm ischemic times averaged 508 and 5 minutes, respectively. After ex vivo graft preparation, ureteral and vessel length and quality were adequate for transplantation in 6 cases. In the other patient the renal pelvis was not amenable for reconstruction. Urinary drainage consisted of ureteroneocystostomy in 2 cases and ipsilateral ureteroureterostomy in 4. There were no intraoperative complications and all grafts functioned immediately. Hospitalization averaged 6.4 days. At a mean followup of 17 months imaging studies demonstrated functioning renal autographs with a mean decrease in serum creatinine of 5%. CONCLUSIONS: Laparoscopic nephrectomy in conjunction with autotransplantation is a viable option for severe proximal ureteral loss. Acceptable perioperative morbidity and excellent graft function were obtained in all cases when the kidney was transplanted. Close cooperation with a transplant team is crucial to coordinate graft harvest, ensure appropriate organ preparation and select the optimal urinary anastomosis.     

Renal autotransplantation and extracorporeal reconstruction for complicated benign and malignant diseases of the urinary tract

Renal autotransplantation was performed in five patients and extracorporeal vascular reconstruction was required in two of these cases. One had a carcinoma of the mid-ureter with a solitary kidney. Two patients had ureteral injury. One was iatrogenic from a prior operation, and the other had intrinsic ureteral disease secondary to schistosomiasis. The fourth patient had renovascular hypertension with disease extension into the interlobar renal arteries and a single kidney. The final patient had a large, renal arteriovenous malformation and polycystic kidneys. All have functioning grafts at follow-up ranging from 10 to 36 months. There is no evidence of tumor recurrence after 30 months in the patient with ureteral malignancy. The patient with renovascular hypertension has adequate blood pressure control with medication 12 months after surgery. His creatinine which had risen in the post-operative period to 4.2 mg/dl, has returned to its pre-operative valve of 1.8 mg/dl. None of the other four patients had any post-operative decline in renal function. These cases illustrate that the technique of nephrectomy, extracorporeal surgery, and renal autotransplantation can be applied to a variety of benign and malignant diseases of the kidney and ureter not amenable to conventional in-situ correction, thus allowing maximal preservation of renal parenchyma. We also have demonstrated that the procedure can be successfully performed in the presence of significant infectious risk (Case 2: indwelling nephrostomy), and retroperitoneal infection (Case 3: schistosomiasis). We feel that this procedure is currently underutilized.(ABSTRACT TRUNCATED AT 250 WORDS)     

Laparoscopic retroperitoneal live donor right nephrectomy for purposes of allotransplantation and autotransplantation

PURPOSE: We report the technique of and initial experience with retroperitoneal laparoscopic live donor right nephrectomy for purposes of renal allotransplantation and autotransplantation. MATERIALS AND METHODS: A total of 5 patients underwent retroperitoneoscopic live donor nephrectomy of the right kidney for autotransplantation in 4 and living related renal donation in 1. Indications for autotransplantation included a large proximal ureteral tumor, a long distal ureteral stricture and 2 cases of the loin pain hematuria syndrome. In all cases a 3-port retroperitoneal laparoscopic approach and a pelvic muscle splitting Gibson incision for kidney extraction were used. In patients undergoing autotransplantation the same incision was used for subsequent transplantation. RESULTS: All procedures were successfully accomplished without technical or surgical complications. Total mean operating time was 5.8 hours and average laparoscopic donor nephrectomy time was 3.1 hours. Mean renal warm ischemia time, including endoscopic cross clamping of the renal artery to ex vivo cold perfusion, was 4 minutes. Average blood loss for the entire procedure was 400 cc. Radionuclide scan on postoperative day 1 confirmed good blood flow and function in all transplanted kidneys. Mean analgesic requirement was 58 mg. fentanyl. Mean hospital stay was 4 days (range 2 to 8), and convalescence was completed in 3 to 4 weeks. CONCLUSIONS: In the occasional patient requiring renal autotransplantation live donor nephrectomy can be performed laparoscopically with renal extraction and subsequent transplantation through a single standard extraperitoneal Gibson incision, thus, minimizing the overall operative morbidity. Furthermore, these data demonstrate that live donor nephrectomy of the right kidney can be performed safely using a retroperitoneal approach with an adequate length of the right renal vein obtained for allotransplantation or autotransplantation.     

Renal autotransplantation: current perspectives.

Autotransplantation, with or without an extracorporeal renal operation, has been done 39 times in 37 patients. Indications for the procedure included several ureteral injury in 4 patients, failed supravesical diversion in 2, renal carcinoma in a solitary kidney in 1, renovascular hypertension in 1 and donor arterial reconstruction before renal transplantation in 29. Success was obtained in all but 2 procedures, both of which involved previously operated kidneys with severe inflammation and adhesions involving the renal pelvis and pedicle. Based on our experience and a review of currently available literature we believe that renal autotransplantation and extracorporeal reconstruction can provide the best solution for patients with severe renovascular and ureteral disease not correctable by conventional operative techniques. The technique can be of particular value in removing centrally located tumors in solitary kidneys and in preparing donor kidneys with abnormal arteries for renal transplantation. The role of autotransplantation in the management of advanced renal trauma and calculus disease is less clear. A long-term comparison of patients treated by extracorporeal nephrolithotomy versus conventional lithotomy techniques will be necessary before a conclusion is reached in these disease categories.     

Renal autotransplantation for the treatment of complex renovascular hypertension

OBJECTIVE: In individuals with complicated renal vascular disease, renal autotransplantation has been used as an alternative to percutaneous transluminal angioplasty, which may be unsuccessful or hazardous in these situations. We evaluated the outcomes of renal autotransplantation. PATIENTS AND METHODS: Between February 1989 and December 2005, we performed 5 renal autotransplantation procedures. The surgical strategy included renal explantation, ex vivo renal preservation, ex vivo reconstruction of the renal artery if necessary, and renal heterotopic autotransplantation. RESULTS: The study subjects (3 men and 2 women) exhibited one of the following indications for surgery: fibromuscular dysplasia (2 patients), Takayasu's arteritis (1), or atherosclerosis (2). All patients exhibited uncontrolled hypertension before renal autotransplantation. Renal arteries of patients were anastomosed either to the external or internal iliac arteries or to both when there were multiple renal arteries. The renal vein was anastomosed end-to-side to the external iliac vein, and ureteral reimplantation was not performed. Mean posttransplantation follow-up was 9.8 +/- 5.7 years (range, 1-16 years). Mortality and morbidity were not observed during the follow-up, and hypertension and renal function normalized or improved in all 5 patients. CONCLUSIONS: Renal autotransplantation is a highly effective procedure to treat complex renovascular lesions; ex vivo renal repair is a safe and effective surgical procedure in the clinical setting.     

Endoscopic treatment of ureteric strictures: acucise, cold-knife endoureterotomy and wall stents as a salvage approach

OBJECTIVE: To evaluate the factors influencing the results of endoureterotomy using cold-knife and cutting balloon dilatation, and permanent ureteral wall stents in patients with benign ureteral strictures after different operations affecting the ureter. MATERIALS AND METHODS: Over a 4-year period, in 18 patients, endoscopic cold-knife and Acucise endoureterotomies were performed in 13 and 7 renal units, respectively. Eight Memoterm permanent ureteral wall stents were inserted into 7 patients when endoureterotomy failed. Successful outcome was defined by the absence of re-stricture assessed both clinically and radiologically. RESULTS: The strictures were secondary to ureterolithotomy in 6, ureteroscopy in 3, gynecological procedures in 4, abdominal surgeries in 2, transplantation in 2 and continent urinary diversion in 1. The right and left ureters were unilaterally affected in 5 and 11 patients, respectively (5 of them had a solitary kidney), while the remaining 2 patients had bilateral ureteral strictures. We achieved total ureteral patency of 3 (43%) and 7 (54%) renal units with Acucise and cold-knife incision, respectively. Obstructive uropathy was resolved in 6 renal units (75%) of 8 using ureteral wall stents. CONCLUSION: Endoureterotomy with cold-knife or Acucise cutting balloon dilatation is effective in the treatment of iatrogenic ureteral strictures, but only in a selected group. Based on our results, the favorable prognostic criteria for endoureterotomy are the length (< or =1.5 cm), the nonischemic nature of the stricture and adequate renal function. As a salvage approach, permanent self-expanding ureteral wall stents with a 75% success rate may provide a satisfactory outcome for decompression of an obstructed system.     

Treatment of iatrogenic postoperative ureteral strictures with Acucise endoureterotomy

OBJECTIVES: To determine factors influencing the outcome of Acucise endoureterotomy in patients with iatrogenic postoperative ureteral strictures after different open surgical procedures. MATERIAL AND METHODS: Acucise endoureterotomy was performed in 18 patients with ureteral strictures after pyeloplasty (n = 5), renal transplantation (n = 5), ureteroenteric anastomosis (n = 3), calicoureterostomy (n = 1), ureterocystoneostomy (n = 1), hysterectomy (n = 1), ureterorenoscopy (n = 1) and transurethral resection of the ureteral orifice (n = 1). Success was determined as relief of clinical symptoms, improvement of renal function or improvement of radiographic findings. RESULTS: The overall success rate was 61% (mean follow-up: 21.5 months). Six out of 18 patients showed relevant side effects. Neither the localization of the stricture nor the duration of postoperative ureteral stenting but the length of the stricture had influence on the postoperative outcome. Decreased renal function to less than 25% of the total function was always associated with failure of the treatment. The time period between the ureteral injury and the appearance of the ureteral stricture had influence on the outcome of the treatment. CONCLUSIONS: Acucise endoureterotomy is effective in the treatment of postoperative ureteral strictures, but only in selected cases. The selection criteria are the time period from the primary operation to the appearance of the stricture (>6 months), the length of the stricture (<1.5 cm) and the renal function (>25% of the total function). In other cases, open surgical treatment of the ureteral stricture may provide better results.     

Distal ureteral replacement with tubularized porcine small intestine submucosa

Extensive ureteral injury can result from renal stone disease, iatrogenic injury, or penetrating trauma. A significant ureteral stricture can be repaired using various techniques, including the psoas hitch, Boari flap, transureteroureterostomy, ileal ureter, or renal autotransplantation. We describe a woman with a 5-cm, ischemic uretero-Indiana pouch stricture that developed after cystectomy and urinary diversion. Severe pelvic fibrosis prevented adequate mobilization of the ureter and Indiana pouch and would not permit any of the above-mentioned procedures. We report the first human use of tubularized small intestine submucosa to successfully replace a 5-cm strictured segment of distal ureter.