膀胱肌瓣输尿管成型术治疗肾移植术后输尿管尿瘘及狭窄

目的：评估肾移植术后移植肾输尿管发生尿瘘及狭窄的发生率,寻找危险因素,以及使用膀胱肌瓣输尿 管成型术治疗移植肾输尿管并发症的效果。方法：回顾性分析中南大学湘雅医院器官移植中心2010年1月至2015年1 月完成的270例肾移植受者的临床数据和危险因素。治疗方式包括膀胱肌瓣输尿管成型术、输尿管膀胱再植术及内镜 下放置DJ管等,并对手术方式及有效性进行分析。结果：肾移植术后移植肾输尿管尿瘘发生率为3.3%,危险因素为 供者高龄(P<0.05)、移植肾功能延迟恢复(P<0.01)、膀胱痉挛(P<0.05)及供肾动脉为多支(P<0.01)。其中4例行保守治疗 后痊愈,5例行膀胱肌瓣输尿管成型术治愈。输尿管狭窄发生率为4.4%,危险因素为供者高龄(P<0.05)、移植肾功能 延迟恢复(P<0.05)、膀胱痉挛(P<0.05)、尿瘘(P<0.01)及供肾动脉为多支(P<0.01)。4例行内镜下处理,其中2例行经皮 肾镜穿刺造瘘后顺行放置DJ管,2例输尿管镜逆行置入DJ管,均好转。8例行手术治疗,其中6例行膀胱肌瓣输尿管成 型术,2例行移植肾输尿管再植,术后均治愈。结论：移植肾输尿管并发症主要包括尿瘘和输尿管狭窄,总体发生率 较低,但对移植肾功能和患者生活质量均造成较大影响。输尿管并发症的危险因素包括供者高龄、移植肾功能延迟 恢复、膀胱痉挛及供肾为多支。输尿管尿瘘是输尿管狭窄的危险因素。膀胱肌瓣输尿管成型术是治疗移植肾输尿管 尿瘘和输尿管狭窄的有效方法。     

移植肾输尿管狭窄的开放手术治疗

目的:评价开放手术治疗移植肾输尿管狭窄的安全性和有效性.方法:对14例移植肾输尿管狭窄患者施行开放手术,其中再次输尿管膀胱吻合术11例,供肾肾盂自体输尿管吻合术2例,输尿管黏连松解术1例.术后平均随访(28.9±22.3)个月(10～92个月).结果:手术成功率为100%.14例患者均无手术并发症.术后血肌酐下降(266.2±171.7)μmol/L.除1例患者发生2次吻合口再狭窄外,其余13例在随访期间无再发狭窄.结论:在充分的术前准备下,手术治疗移植肾输尿管狭窄是安全有效的方法;对于梗阻严重、输尿管狭窄段较长的患者开放手术是首选的方法.     

移植肾功能延迟恢复并发输尿管狭窄病因分析与处理

移植肾功能延迟恢复（DGF）并发输尿管全程或长段狭窄是肾移植术后少见的并发症,其与DGF发生的原因密切相关。2005年8月至2009年3月在我院行肾移植的患者中,因术后DGF而并发输尿管全程狭窄3例,又经自体膀胱瓣一移植肾肾盂吻合术治疗而取得良好效果,现报告如下。     

移植肾输尿管狭窄防治的临床研究

目的探讨肾移植术后移植肾输尿管狭窄的防治措施及疗效评价。方法收治肾移植术后输尿管狭窄患者6例,通过B超及静脉肾盂造影了解狭窄的发生部位,并根据狭窄情况及肾功能的情况等选择合适的治疗方法,随访其近期及远期疗效。结果6例患者经手术治疗,恢复了移植肾肾盂与膀胱的通畅,移植肾功能均有明显的改善,近期及远期血肌酐水平有不同程度的下降,随访术后10个月无1例复发。结论及早发现肾移植后输尿管狭窄,依据狭窄部位和情况,选择合适的治疗方法,是挽救移植肾功能,提高肾移植成功率的重要措施。     

全腹腔镜移植输尿管膀胱再植术处理肾移植术后输尿管狭窄

目的：评估全腹腔镜下移植输尿管膀胱再植术处理移植肾输尿管狭窄的安全性及有效性,总结腹腔镜下寻找移植肾输尿管的操作经验。方法：回顾性分析北京大学第三医院泌尿外科2017年11月收治的1例行腹腔镜下移植输尿管膀胱再植术治疗移植肾输尿管狭窄的病例,并复习相关文献。患者女性,54岁,主诉“肾移植术后肾积水5年”入院。查体：移植肾区略膨隆,无压痛。磁共振尿路造影（magnetic resonance urography,MRU）示移植肾及输尿管明显扩张,肾盂扩张最宽处约5 cm,肾盂肾盏均明显扩张,输尿管末段可见狭窄,输尿管内未见异常充盈缺损信号,初步诊断为移植输尿管末段狭窄。既往行两次多镜联合内镜下输尿管狭窄扩张术,拔除支架后移植肾积水无改善。入院后完善术前准备,在全身麻醉下行全腹腔镜下移植输尿管膀胱再植术。首先切断脐正中韧带、脐外侧韧带及腹膜返折,向远端游离膀胱前间隙,逐步游离膀胱左侧壁与耻骨间隙、膀胱前壁与耻骨间隙;其次,膀胱右侧壁游离从头侧至尾侧,仔细辨认周围结构,避免损伤移植肾的输尿管,在膀胱右侧壁与移植肾下极之间寻找移植肾输尿管,剪开输尿管末端,确认切开处近侧输尿管管腔无狭窄,采用Lich-Gregoir法（膀胱外法）行移植肾输尿管膀胱吻合术;最后,将吻合处周围表面膀胱组织与右侧盆壁固定,以减小张力。结果：手术顺利完成,手术时间210 min,术中出血量约30 mL,无手术并发症。患者术后肌酐稳定,术后第1天肌酐68 μmol/L,较术前下降（术前血清肌酐94 μmol/L）, 术后5 d出院。术后随访3个月,KUB(kidney ureter bladder radiography)提示输尿管支架位置良好,拔除输尿管支架后移植肾功能稳定,复查肌酐79 μmol/L,无发热、腰痛等症状,复查移植肾超声示移植肾肾盂略增宽0.7 cm,较前明显改善,移植肾血流正常。结论：报道采用全腹腔镜移植输尿管膀胱再植术处理肾移植术后输尿管狭窄的病例,该术式是治疗移植肾输尿管狭窄的安全、有效的治疗方法。与开放手术相比,腹腔镜手术对肾移植患者影响更小,具有恢复快、出血少、并发症少,术后疼痛轻,以及伤口微创、美观的优点。该术式手术难度较大,对术者腹腔镜技术要求较高,需要经验丰富的泌尿外科医生操作。     

肾移植术后近期输尿管梗阻的病因分析和治疗

目的:分析肾移植术后近期内移植肾输尿管梗阻发生的原因和治疗手段.方法:总结我科1993年2月～2007年8月共250例.肾移植患者,术后1～12周内发生输尿管梗阻导致移植肾积水共8例,占3.2%,其中2例血肿压迫;2例输尿管膀胱吻合口狭窄;1例输尿管过长扭转;1例移植肾旋转致输尿管扭转;1例吻合口漏;1例精索水肿压迫.结果:除1例吻合口漏患者保守治疗外,其余7例均再次手术解除梗阻,术后病情改善,移植肾功能恢复.结论:肾移植术后近期移植肾输尿管梗阻的原因多与外科因素有关;对手术各个环节加以注意,可以减少输尿管梗阻的发生.外科手术是解除术后输尿管梗阻的主要手段.     

膀胱粘膜瓣管与移植肾肾盂吻合术修复输尿管坏死的护理干预

目的总结自体膀胱粘膜瓣管与移植肾吻合术治疗肾移植术后输尿管坏死的护理方法。方法对7例患者肾移植术后输尿管长段坏死行自体膀胱粘膜瓣管与移植肾吻合术修复坏死的输尿管的护理进行了回顾性分析。结果7例患者术后,肾功能恢复良好痊愈出院。术后2年随访人、肾存活率均为100%。结论正确的护理配合是膀胱粘膜瓣管与移植肾吻合术成功的保证。可减少并发症的发生,也是提高肾移植人肾存活质量的重要环节。     

经皮顺行通道联合经尿道逆行通道双向内镜微创手术治疗移植肾输尿管梗阻

目的:探讨经皮顺行通道联合经尿道逆行通道内镜微创手术治疗移植肾输尿管梗阻的方法及效果。方法:回顾北京大学第三医院泌尿外科2007年2月至2013年3月收治的8例术后移植肾输尿管梗阻病例,均采用经皮顺行通道联合经尿道逆行通道双向内镜微创手术完成。其中男3例,女5例,平均年龄44岁(30～64岁),移植肾输尿管梗阻出现时间距肾移植手术1个月至12个月。临床表现:肌酐升高4例,无尿2例,尿瘘2例。梗阻段位于输尿管末段7例,中段1例。3例病例一期急诊行肾造瘘术,二期再行内镜微创手术处理;其余5例病例同期行移植肾造瘘及经皮顺行通道联合经尿道逆行通道双向内镜治疗。结果:8例病例血清肌酐自术前(237±43)μmol/L降至术后(121±29)μmol/L(P<0.05),未出现出血、感染等手术并发症。合并尿瘘的2例患者术后尿瘘愈合。手术成功6例,另2例未成功解决梗阻仅留置移植肾造瘘,其中1例6个月后发生再狭窄,再狭窄发生率17%(1/6)。结论:经皮顺行通道联合经尿道逆行通道双向内镜微创手术作为移植肾输尿管梗阻,特别是肾移植术后早期梗阻病例首选的治疗手段,手术后效果良好。     

肾移植术后输尿管狭窄的外科处理

目的 探讨并总结肾移植术后输尿管狭窄的诊治经验.方法 回顾性分析1993年12月至2007年4月1 223例次肾移植术后发生输尿管狭窄的发病情况、诊断、处理及结果.结果 1 223例次肾移植术后发生输尿管狭窄19例(1.6%).其中13例为输尿管膀胱吻合口狭窄,5例经移植肾输尿管膀胱再植治愈,8例经移植肾输尿管与自体输尿管吻合治愈.其余6例为输尿管-输尿管吻合口狭窄,采用输尿管镜下冷刀切开、球囊扩张治愈.所有患者均无手术并发症,肾功能均得到恢复,术后平均随访52个月,均未再次发生输尿管狭窄. 结论造成肾移植术后输尿管狭窄原因复杂,外科手术是解除狭窄的主要方法,处理得当,对移植肾功能的恢复无明显影响.     

应用自体肾盂与移植肾盂吻合术治疗移植肾的输尿管全长坏死(附1例报告)

异体肾移植术后,由于供肾、输尿管损伤或血供受损以及免疫抑制剂的使用,可以发生输尿管局部或全长的坏死。造成严重的尿漏,感染,甚至移植肾切除及危及患者生命。应用自体肾盂与移植肾盂作对端吻合术治疗移植肾的输尿管全长坏死所致肾盂高位尿瘘,是一种有效的方法。我科1989年11月治疗1例,获得良好效果,报告如下。一、手术方法: 1.切除移植肾侧之自体肾,注意保留肾门组织,输尿管上段少作游离。紧靠肾盏剪开,保留肾盂呈“喇叭口”状。     

Value of D-Dimers in patients with acute aortic dissection

Objective: To evaluatel the value of D-dimers in patients with acute aortic dissection (AAD). Methods: This study consisted of 16 patients with AAD and 27 non-AAD patients. Serum D-dimets were measured by Sta-Liatest D-DI immunoturbidimetric assay. Results: D-dimer level was higher (P ＜ 0.001) in patients with AAD(7.91 ± 5.52 μg/ml) than that in non- AAD group(1.57±1.24 μg/ml). D-dimer was positive (＞0.4 μg/ml) in all patients with AAD and in 10 control group patients (37%). Among patients with acute AAD, D-dimers tended to be higher in Stanford A than in Stanford B (8.67 ± 4.31 μg/ml vs. 3.24±1.27 μg/ml, P ＜0.01). D-dimer values tended to be higher in more extended disease(3.84 ± 1.65 μg/ml, 8.57 ± 3.58 μg/ml and 11.87 ± 5.69 μg/ml in thoracic aorta, thoracic and abdominal aorta, thoracic and abdominal aorta and iliacal arteries, respectively, P ＜ 0.05 for both 8.57 ± 3.58 and 11.87 ± 5.69 vs. 3.84 ± 1.65 ). Including the control group into the analysis, we found a sensitivity of 100%, a negative predictive value of 100%, and a specificity of 66% and a positive predictive value of 64% for D-dimer in diagnosis of AAD in our patients with suspected AAD. Conclusion: D-dimer was elevated in patients with AAD. A negative D-dimer test result could be useful in excluding AAD.     

Research of combined liver-kidney transplantation model in rats

Objective： To set up a simple and reliable rat model of combined liver-kidney transplantation. Methods： SD rats served as both donors and recipients. 4℃ sodium lactate Ringer＇s was infused from portal veins to donated livers,and from abdominal aorta to donated kidneys, respectively. Anastomosis of the portal vein and the inferior vena cava （IVC） inferior to the right kidney between the graft and the recipient was performed by a double cuff method, then the superior hepatic vena cava with suture. A patch of donated renal artery was anastomosed to the recipient abdominal aorta. The urethra and bile duct were reconstructed with a simple inside bracket. Results： Among 65 cases of combined liver-kidney transplantation, the success rate in the late 40 cases was 77.5%. The function of the grafted liver and kidney remained normal. Conclusion： This rat model of combined liver-kidney transplantation can be established in common laboratory conditions with high success rate and meet the needs of renal transplantation experiment.     

BLOOD PRESSURE CHANGE WITH AGE IN SALT-SENSITIVE TEENAGERS

Objective To observe blood pressure change with age in salt-sensitive teenagers whose salt sensitivity were determined by repeated testing.Methods Salt sensitivity was determined through intravenous infusion of normal saline combined with volume-depletion by oral diuretic furosemide in 55 teenagers. After five years, salt sensitivity was re-examined and subject blood pressure was followed up. Blood pressure changes in salt-sensitive teenagers were compared to that of non-salt sensitive teenagers over five years.Results After 5 years, the repetition rate of salt sensitivity determined by intravenous saline loading is 92.7%. In teenagers with salt sensitivity on the baseline, both the systolic blood pressure increments and increment rates were much higher than non-salt sensitive teenagers (12.7±12.1 mmHg vs. 2.8±5.2 mmHg, P＜ 0.01; 12.2%± 12.0% vs. 2.5% ±4.4%, P＜ 0.001,respectively). There was a similar trend for diastolic blood pressure (8.4 ± 6.4 mmHg vs. 3.7 ± 6.4 mmHg, P = 0.052; 13.2% ±10.6 % vs. 6.8%± 10.1%, P = 0.053, respectively).Conclusions Salt sensitivity determined by intravenous saline loading showed good reproducibility. Blood pressure increments with age were much higher in salt-sensitive teenagers than non-salt sensitive teenagers, especially in terms of systolic blood pressure.     

安心颗粒对急诊经皮冠状动脉介入术后生活质量影响的研究

目的：评价使用安心颗粒对急诊经皮冠状动脉介入术（PPCI）术后生活质量的影响.方法：将160例接受PPCI的急性ST段抬高型心肌梗死患者随机分为安心颗粒组（术前顿服安心颗粒8.8g,术后安心颗粒4.4 g/次,每日2次）和对照组（仅接受基础药物治疗）.所有患者均服用阿司匹林、氯吡格雷和阿托伐他汀.分别在入院时、出院前1d、出院后180 d时,应用心肌梗死多维度量表（MIDAS）、中文版SF-36评价量表对患者生活质量评分.并观察术后30 d以内的出血并发症、血小板减少症发生情况.结果：入院时和出院前1d,两组患者的心肌梗死MIDAS、SF-36量表评分比较无差异（P＞0.05）;出院后180 d时,与对照组比较,安心颗粒组MIDAS、SF-36评分明显减低（P＜0.05）;组内与入院时比较,两组出院前1d、出院后180 d时,MIDAS、SF-36评分均降低（P＜0.05）.两组患者在随访期间均无大量出血、少量出血、重度和极重度血小板减少症发生,安心颗粒组有4例、对照组有7例发生不明显出血（P＞0.05）.两组发生轻度血小板减少症的患者数比较无差异（P＞0.05）.结论：PPCI使用安心颗粒,能改善急性ST段抬高型心肌梗死患者的生活质量,且不增加出血风险.     

The comparative studies of the influences of Urapidil and Nicardipine on sino-atrial node function, atrio-ventricular node function and hemodynamics

Objective:To investigate the influences of urapidil and nicardipine on rabbit sinus function,atrio-ventricular node function and hemodynamics.Methods:Thirty-two Angora's rabbits were selected and randomly divided into four groups.U1 group:urapidil 0.25 mg/kg;U2 group:urapidil 0.5 mg/kg;N1 group:nicardipine 10 μg/kg;N2 group:nicardipine 20 μg/kg.All these medicine were administrated within 30 seconds.Measurements were taken before and after the administration of urapidil or nicardipine for the following data:mean blood pressure(MAP),heart rate(HR),sino-atrial conduction time(SACT),maximal sinoatrial recovery time(SNRTmax)corrected sinus node recovery time(CSNRT),index of sinus node recovery time(SNRTI),Wenckebach A-V conduction frequency (WB),and P-R interval.Results:Significant MAP and HR changes were identified in all of the four groups before and after administration of both urapidil and nicardipine.No significant changes could be found in the rest of the parameters.Intergroup analysis showed that SACT and CSNRT of N1 and N2 groups were shorter than those of the U2 group(P＜0.01);the MAP decreased(P＜0.01)and the HR increased drastically(P＜0.01).Conclusions:Neither urapidil(0.25 mg/kg,0.5 mg/kg)nor nicardipine(10μg/kg,20μg/kg)has any significant influence on rabbit sinus function or rabbit atrio-ventricular node function.Nicardipine could be a better choice than urapidil for parafunctional sinus node patients.     

Dynamic Changes in Serum Estradiol and Progesterone levels in Patients of Premenstrual Syndrome with Adverse Flow of Liver-qi

Objective:To probe into the influence of changes of ovarian hormones on the pathogenesis of the specific sub-type premenstrual syndrome(PMS)and reveal partial microcosmic mechanisms of adverse flow of liver-qi.Methods:Estradiol(E2)and progesterone(P)levels in serum were determined at different phases of menstrual cycle by radioimmunoassay.Results:In the group of PMS with adverse flow of liver-qi.the secretive peak value Of E2 and P at the follicular phase significantly decreased,and the secretive peak value at the luteal phase did not come into being.Conclusions:Low E2 and P secretive peak at the follicular phase and absence of secretive peak at the luteal phase is one of the microcosmic mechanisms of PMS with adverse flow of liver-qi.One of the pathophysiologic mechanisms of specific sub-type PMS is probably the continuous low level of E2and P.     

Real-time Three-dimensional Echocardiography in Assessment of Left Ventricular and Right Ventricular Volumes

Real-time three-dimensional echocardiography (RT3DE)is a new ultrasound technique that enables dynamic threedimensional visualization and quantification of the heart in real time. Investigation of feasibility and methodology of RT3DE in determining left ventricular (LV) and right ventricular (RV) volumes, RT3DE was performed in 35 normal adults using Philips SONOS 7500 system with a 2-4 MHz matrix array transducer. The 60°×60° "pyramid" volume database was obtained and analyzed on a TomTec echo workstation. Both LV and RV volumes were calculated with four 3DE methods (i.e. apical 2, 4, 8, and 16-plane) through manually tracing ventricular endocardial borders in end diastole and end systole. Stroke volumes were then calculated. LV volume was also measured by 2DE Simpson's rule using GE VIVID 7 ultrasound machine.     

SCREENING FOR A 21-CHROMOSOME ABNORMALITY IN PREIMPLANTED EMBRYOS OF ELDERLY WOMEN

Increasing maternal age is the only etiological factor unequivocally linked to Down's syndrome in humans. The occurrence rate of newborns with Down's syndrome is about 1/220 in women over 35 years old. However, the occurrence rate in embryos fertilized in vitro, of the elder woman is unclear. Using FISH we screened the number of chromosome 21 in preimplanted embryos of 5 elderly women (average age, 38.4 years) to study the feasibility and necessity of screening trisomy 21 in embryos in patients over 35 years old at the in vitro fertilization (IVF) center.     

Scientific principles and rigorous processes should be followed in developing clinical guidelines for therapeutic interventions of integrative medicine

A clinical guideline for the therapeutic interventions of integrative medicine may be defined as a written document which states a series of recommendations on therapeutic interventions of integrative medicine for a special disease or condition. The guideline may provide assistance to medical professionals in making clinical decisions aimed at improving the clinical outcome of patients and reducing the costs of medical care（~＇4~. Recommendations issued by a guideline should be based on the best available evidence in both Western and Chinese medicine. For fulfilling this purpose, the development of clinical guidelines for therapeutic interventions in the field of integrative medicine should follow scientific principles and undergo a rigorous processes.     

Expression of OPGmRNA and ODFmRNA in the patients of hip fracture due to osteoporosis

Objective：To investigate the gene expression of osteoprotegerin（OPG） and osteoclast differentiation factor（ODF） in the bone tissue of patients with hip fracture due to osteoporosis. Methods：OPGmRNA and ODFmRNA in the bone tissue in 50 cases of osteoporosis sufferers（over 50 years old） with hip fracture（Observer Group） and 30 cases of hip facture sufferers with no osteoporosis（Control group） were analyzed with the Semi-Quantitative RT-PCR method. Results：The mRNA expressed of ODF, OPG were both high in the patients with hip fracture. In the control group, the expression of OPG mRNA was observed, while the expression of ODF mRNA was very slight. Conclusion：Aged patients contained all signals including OPG, ODF that are essential for inducing osteoclastogenesis and promoting bone resorption.