移植肾并发输尿管梗阻的治疗

目的 探讨肾移植术后并发输尿管梗阻的治疗策略.方法 同种异体肾移植术后7 d～10年并发输尿管梗阻患者34例,其中3例移植输尿管部分坏死患者以开放手术治疗,其余31例采用经尿道逆行输尿管镜技术及经皮肾穿刺顺行输尿管镜技术进行碎石、内切开或扩张等方法解除梗阻,放置双J管内引流,观察患者肾功能改善情况.结果 3例开放手术清除坏死段输尿管后移植输尿管再吻合成功;1例输尿管内血凝块堵塞者成功清除血凝块;2例输尿管膀胱吻合口水肿、11例输尿管膀胱吻合口狭窄及6例吻合口上方狭窄患者行狭窄段扩张或内切开;6例输尿管结石及1例体外冲击波碎石术后石街患者行输尿管镜碎石、取石治疗;2例输尿管迂曲及2例尿漏患者行输尿管镜下置管术.术后随访18～50个月,29例引流通畅,肾功能恢复正常,血肌酐45～120μmol/L;5例肾功能恢复较差,血肌酐170～360 μmol/L;1例吻合口上方狭窄患者需定期更换支架管.结论微创技术治疗移植肾输尿管梗阻疗效好、安全.     

肾移植术后上尿路梗阻14例临床诊治体会

目的探讨肾移植术后上尿路梗阻的诊断及处理。方法回顾总结2000—2006年我院1090例肾移植患者中的14例移植后上尿路梗阻患者，其中输尿管膀胱吻合口狭窄9例，6例行膀胱输尿管二次吻合手术，1例移植肾周感染输尿管末段坏死采用移植肾近端新鲜存活输尿管与自体输尿管吻合，1例采用膀胱肌瓣代移植输尿管，1例采用输尿管镜下气囊扩张后放置双J管。出血相关性梗阻、输尿管扭曲和输尿管结石所致梗阻5例，均行开放手术。结果14例肾移植术后上尿路梗阻患者中2例切除移植肾，其余各例患者经开放手术及腔镜处理均成功挽救移植肾功能。再次手术后随访0．5—1年，血肌酐68-155μmol／L，B超未见移植肾扩张积水加重。结论新上尿路梗阻是肾移植术后常见亦是较为棘手的外科并发症，多数和外科手术操作有关，可以通过提高手术技巧避免。一旦发生上尿路梗阻，应根据梗阻原因采取相应的治疗方法及时处理。     

开放手术治疗肾移植术后输尿管梗阻的技术探讨

目的探讨肾移植术后移植肾输尿管狭窄的开放手术技巧与效果。方法首都医科大学附属北京友谊医院泌尿外科于2019年1月—2020年1月共行166例单肾移植,共发生5例肾移植术后输尿管狭窄,根据梗阻部位的不同采用了不同的开放手术术式进行治疗,回顾性分析这组患者的临床资料及预后。结果5例患者中,男性3例,女性2例,平均年龄42.6岁。其中2例患者原发病为Ⅱ型糖尿病,3例患者为肾小球肾炎。输尿管梗阻确诊的平均时间为肾移植术后143.8 d,行开放手术平均时间为肾移植术后209.8 d,确诊梗阻时平均血肌酐水平为271.94μmol/L。所有患者均因出现移植肾积水合并血肌酐进行性升高经影像学检查确诊,首先采取内支架或经皮肾造瘘紧急挽救肾功能。待肾功能恢复稳定后,根据梗阻段位置,3例患者行移植输尿管-膀胱再吻合术,1例患者行原输尿管-移植肾输尿管端端吻合术,1例患者行膀胱皮瓣翻转代输尿管术。5例患者开放手术平均时间为2.6 h,术中平均出血量为32 ml。开放手术后,5例患者均预后良好,开放手术后平均血清肌酐恢复至111.5μmol/L,尿量正常,无外科并发症发生。随访半年后,5例患者均未再发生输尿管梗阻。结论移植肾输尿管梗阻是肾移植术后常见外科并发症之一,腔内治疗中远期效果有限,根据不同梗阻部位选择不同术式进行开放手术,是治疗移植肾输尿管狭窄的有效方案。     

经皮顺行输尿管支架植入在移植肾输尿管梗阻中的应用11例

目的 探讨经皮顺行输尿管支架植入治疗移植肾输尿管梗阻的有效性和安全性.方法 2009年3月至2011年3月间11例肾移植输尿管梗阻患者,其中急性梗阻2例,慢性梗阻9例.11例梗阻的原因为移植肾输尿管膀胱吻合口狭窄5例,结石梗阻2例,原因不详4例.术前以超声评估移植肾及集合系统,选择合适穿刺部位,在X线透视下完成顺行肾盂和输尿管造影;明确梗阻位置后,通过穿刺针植入斑马导丝直至膀胱,再经膀胱镜从尿道引出斑马导丝,沿斑马导丝顺行植入输尿管支架管,X线下观察输尿管支架上端进入肾盂后,拔除斑马导丝,再次透视,确认支架管位置.移植肾肾盂造瘘管引流1～2周后拔除,输尿管支架在术后半年至1年内取出.在术后1周、1个月、3个月、6个月行B型超声及肾功能检查,之后每隔半年检查.结果 11例中10例手术成功,1例因输尿管狭窄段过长置管失败.输尿管支架植入手术耗时为(54±27) min,患者血清肌酐由术前(326±147) μmol/L下降至术后(89±49) μmol/L.随访6～27个月,患者均未发生并发症.结论 经皮顺行输尿管支架植入治疗移植肾输尿管梗阻是一种安全、有效的方法.     

医原性输尿管损伤后狭窄梗阻的手术治疗

目的　探讨不同类型输尿管损伤引起狭窄、梗阻的再手术方法。　方法　总结 13例输尿管损伤所致输尿管狭窄、梗阻的临床资料 ,其中肾输尿管手术后 8例 ,输尿管镜术后 4例 ,外伤所致1例 ,均曾行一次或多次手术修补未获成功。再次手术包括输尿管肾下盏吻合 1例 ,输尿管端端吻合8例 ,输尿管膀胱角吻合 2例 ,回肠代输尿管术 1例 ,输尿管膀胱再吻合术 1例。　结果　 13例均手术治愈 ,术后 3～ 4周拔除输尿管支架 ,4～ 6周拔除肾造瘘管。随访 6个月～ 6年 ,IVU和B超检查输尿管通畅无狭窄、无肾积水。　结论　治疗输尿管损伤引起的输尿管狭窄梗阻应选择适当时机和术式 ,彻底切除瘢痕 ,并作无张力吻合 ,对长段输尿管中下段缺损使用输尿管膀胱角再植、回肠代输尿管术     

移植肾输尿管梗阻的外科处理

目的：提高对移植肾输尿管梗阻的治疗水平。方法：回顾性分析16例移植肾输尿管梗阻的临床资料。6例急性梗阻患者中，2例因髂窝血肿压迫者行血肿清除术；2例血凝块堵塞者，1例逆行留置输尿管导管，另1例行输尿管再植术；2例结石者行体外冲击波碎石治疗。10例慢性梗阻患者中，7例输尿管远端狭窄，行输尿管再植术；3例输尿管中、远段狭窄，行自身输尿管与移植肾肾盂吻合术。结果：16例经外科处理后，移植肾功能明显改善，随访观察半年无复发。结论：移植肾输尿管梗阻经及时恰当的外科处理，疗效满意，对慢性梗阻患者，应根据术中输尿管探查情况，选用输尿管再植术或自身输尿管与移植肾肾盂吻合术。     

移植肾输尿管膀胱吻合口梗阻的腔内手术处理

目的　探讨微创性经皮肾穿刺顺行输尿管镜技术和经尿道逆行输尿管镜技术治疗移植肾输尿管膀胱吻合口梗阻的可行性与疗效。方法　对移植肾输尿管膀胱吻合口梗阻的16例患者,采用微创性经皮肾穿刺顺行输尿管镜技术和经尿道逆行输尿管镜技术对吻合口狭窄或闭锁进行内切开与扩张,放置输尿管内支架管内引流,并观察患者肾功能的改善情况。结果　1 例患者经尿道逆行插入输尿管镜,行气囊扩张后,放置输尿管内支架管内引流;13 例患者经皮肾穿刺顺行插入输尿管镜,行梗阻段内切开与扩张,放置输尿管内支架管内引流;2例因吻合口闭锁长度超过1 cm,改开放手术。术后随访1~24 个月,13 例引流通畅,肾功能恢复正常,血肌酐为45~113μmol/L;3 例肾功能恢复较差,血肌酐为158~315μmol/L。结论　微创性经皮肾穿刺顺行输尿管镜技术和经尿道逆行输尿管镜技术处理移植肾输尿管膀胱吻合口梗阻,疗效较好,操作简便、安全。     

膀胱壁瓣输尿管成形术治疗移植肾输尿管长段坏死(附5例分析)

目的探讨膀胱壁瓣输尿管成形术治疗移植肾输尿管长段坏死的疗效。方法肾移植术后移植肾输尿管全长坏死患者5例，发生坏死时间平均为移植术后3．2(2周～2．5个月)，坏死长度平均8．2(6．8～10．3)cm，均有不同程度的移植肾功能损害。所有患者行坏死段切除并膀胱壁瓣输尿管成形术。结果5例患者术后随访6个月～2年，均恢复正常尿道排尿，移植肾功能恢复正常并稳定存活。结论膀胱壁瓣输尿管成形术治疗移植肾输尿管长段坏死效果较满意。     

成人先天性巨输尿管症的诊断治疗

目的探讨成人先天性巨输尿管症（CM）的诊断治疗.方法回顾性分析19例成人CM的临床资料.男6例,女13例,平均年龄36岁.左侧11例,右侧5例,双侧3例.B超、IVU、RGP及MRU等检查,输尿管全段扩张伴肾盂积水16例,患肾无功能4例,仅输尿管下段扩张3例,扩张输尿管最大管径3.3 cm,无输尿管狭窄.尿道膀胱造影（MCUG）及尿动力学检查,无神经性膀胱及膀胱输尿管返流.结果 19例患者中行肾输尿管切除2例,肾造瘘2例,1例1年后行输尿管膀胱再植术,术后5年无异常,另1例4个月后行肾输尿管切除.保守观察3例,随访11～19年,病变无进行性加重.间断性双J管置入3例,随访5～9年,肾功能正常.输尿管裁剪修整,膀胱再植9例,6例随访3～17年无异常;吻合口狭窄及膀胱输尿管返流各1例,再次术后随访6年无异常;1例术后3年行患肾及输尿管切除.结论成人CM诊断主要依据影像学和尿动力学检查,治疗原则为及早手术、去除病因、解除梗阻、保留和恢复肾功能,输尿管裁剪修整、膀胱再植术为有效手术方法.     

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.     

Results of pyeloureterostomy after ureterovesical anastomosis complications in renal transplantation

OBJECTIVES: The most frequent urologic complications after renal transplantation involve the ureterovesical anastomosis (ie, leakage, stenosis, and reflux), with a frequency of 1% to 30% in different series. We present the results of pyeloureterostomy using the recipient's ureter. METHODS: From 1988 to 1996, 570 cadaveric renal grafts were performed at our institution. A Lich Gregoir ureterovesical anastomosis was used in every case. Complications involving the anastomosis occurred in 19 cases (3.3%), with 10 stenoses (1.7%), 6 cases of leakage (1.1%), and 3 of reflux (0.5%). The mean donor age was 36.2 years, and the mean duration of cold ischemia was 29.4 hours. The mean recipient age was 41.3 years. Corrective surgery was performed 0.09 years (range 0.01 to 0.22) after transplantation for leakage, 1.13 years (range 0.14 to 5.11) for stenosis, and 5.55 years (range 0.51 to 9.71) for reflux. The recipient's ureter was stented with a ureteral catheter before median laparotomy, except in 3 cases of early leakage (less than 3 days). The recipient's ureter was cut, without the need for ipsilateral nephrectomy, and sutured to the graft pelvis. A nephroureterostomia stent (Gil Vernet stent) (12 cases) or a double J ureteral stent (7 cases) was used for urinary drainage. RESULTS: One graft was lost on day 1 through renal vein thrombosis. Percutaneous nephrostomy was performed on day 2 to clear an obstruction of the double J ureteral stent in one case, and a double J ureteral stent was inserted on day 2 because the nephrouretrostomia stent was incorrectly positioned in another case. Pyelographic controls on day 15 were normal in every case. The mean follow-up was 2.25 years (range 0.24 to 6.1) (2.9 years for leakage, 2.08 years for stenosis, and 1.44 years for reflux). One patient died with a functional graft 3 years after surgery. One graft was lost 4 years after surgery through chronic rejection. There were no complications affecting the ipsilateral kidney. No further ureteral complications occurred after surgery. The mean creatinine level 3 years after surgery was 1.59 mg/dL. CONCLUSIONS: Pyeloureterostomy is a safe and permanent treatment for complications of ureterovesical anastomosis and gives excellent results. The technique requires stenting of the recipient's ureter and graft drainage with a nephroureterostomia stent or a double J ureteral stent.     

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.     

Late ureteral obstruction after kidney transplantation

Abstract Today, the incidence of urological complications following renal transplantation is 2 %-10 %. Most of these complications occur within the 1st year and affect the distal ureter. We report on two patients who developed very late ureteral obstruction, 14 and 18 years after transplantation. Both patients had rejection episodes 1 and 10 months prior to the ureteral stenosis. Histological examination of one resected ureter revealed findings strongly suggestive of a rejection process. Open surgery with antirefluxive reimplantation into the bladder was successful in both patients, with a postoperative observation time of 20 and 8 months, respectively. We conclude that a percutaneous nephrostomy may be required in patients with rising creatinine and incipient hydronephrosis even long after transplantation has been performed.     

移植肾输尿管梗阻的诊断与治疗：（附13例报告）

为了提高对移植肾输尿管梗阻患者的诊断与治疗水平，对在５３６例次肾移患者中发现的１３你输尿管梗阻患者进行临床总结分析，其中输尿管狭窄性梗阻１０例，输尿管结石性梗阻３例。分析认为，肾移植术后早期排斥反应、伤口深部感染及漏尿可能与发生移植肾输尿管狭窄性梗阻有关，而肾移植术后高尿酸血站与输尿管结石形成有关。提出Ｂ超、肾图、经皮顺行造影和肾盂内压测定为诊断移植肾输尿管梗阻的手段；对于输尿管狭窄性梗阻患者，早     

Late ureteral obstruction after kidney transplantation

Today, the incidence of urological complications following renal transplantation is 2%–10%. Most of these complications occur within the 1st year and affect the distal ureter. We report on two patients who developed very late ureteral obstruction, 14 and 18 years after transplantation. Both patients had rejection episodes 1 and 10 months prior to the ureteral stenosis. Histological examination of one resected ureter revealed findings strongly suggestive of a rejection process. Open surgery with antirefluxive reimplantation into the bladder was successful in both patients, with a postoperative observation time of 20 and 8 months, respectively. We conclude that a percutaneous nephrostomy may be required in patients with rising creatinine and incipient hydronephrosis even long after transplantation has been performed.     

近期移植肾输尿管狭窄的原因探讨及防治

目的：探讨肾移植术后近期移植肾输尿管狭窄的原因及其防治。方法：收治肾移植术后近期输尿管狭窄患者8例，通过B超及手术探查了解狭窄梗阻的发生部位，并根据狭窄周围探查情况，推断造成狭窄的原因。结果：经手术探查发现，造成狭窄的原因多样，且多与手术操作不当有关。8例患者经手术重建输尿管膀胱通道，病情改善，移植肾功能恢复。术后观察10个月无复发。结论：肾移植术后近期移植肾输尿管狭窄的原因多与术中操作不当有关；若在输尿管膀胱吻合术中注意某些环节，则可减少部分输尿管狭窄的发生。     

全膀胱切除术后输尿管梗阻的诊断和微创治疗

目的　总结全膀胱切除术后输尿管梗阻的诊断和微创处理方法。　方法　全膀胱切除术后输尿管梗阻患者 12例。原发病膀胱肿瘤 10例、结核性小膀胱 1例、放射性膀胱炎 1例。术后输尿管贮尿囊吻合口狭窄 9例、吻合口以上梗阻 3例。均采用MRI和肾镜下肾盂输尿管插管造影诊断。行手术治疗 11例 ,其中镍钛合金记忆金属网支架术 6例 ,输尿管支架术 4例 6侧 ,输尿管贮尿囊吻合术 1例。　结果　 12例均诊断明确。 11例术后随访 3个月～ 5年。IVU示患肾功能恢复正常、肾积水消失 9例 ,肾积水减轻 2例。肌酐及尿素氮正常。 1例膀胱癌患者术后 6个月死于肿瘤肺转移。　结论　MRI和肾镜下的肾盂输尿管插管造影是最有价值的检查手段 ;输尿管支架术、输尿管镍钛记忆合金支架术手术简单、创伤小、效果好。     

Transplant ureteral obstruction masquerading as recurrent rejection episodes: management by percutaneous antegrade balloon dilatation

We report a 52-year-old male renal transplant recipient who had three "rejection episodes." The first of these responded to conventional antirejection therapy; however, the next two episodes showed incomplete responses to treatment for rejection. At subsequent presentation with deteriorating renal function, ureteral obstruction was evident and was relieved with percutaneous antegrade balloon dilatation with a return of his plasma creatinine to normal. Obstruction of the ureter was a major component in our patient's course given the lack of response to conventional antirejection therapy and the normalization of renal function with relief of the documented ureteral stenosis. This case illustrates that ureteral obstruction can mimic rejection in the renal transplant recipient. Management of ureteral stenosis in transplant patients with percutaneous antegrade balloon dilatation appears to be an effective procedure and can supplant the need for open surgical procedures.     

Fibrosis of a renal transplant ureter.

Ureteral obstruction following renal transplantation, although not a common occurrence, is a serious complication because of the single functioning kidney. Obstruction may be caused by ureterovesical stenosis, retroperitoneal fibrosis or adhesions, clot formation, pelvic lymphoceles or kinking of the ureter. A case is presented in which there was progressive partial ureteral obstruction caused by fibrosis and stricture of the transplant ureter, which were probably owing to rejection episodes.