移植肾输尿管全长坏死的诊断与治疗

目的　提高对肾移植术后移植肾输尿管全长坏死的认识 ,以期及早诊断和有效治疗。方法　对 1991年 1月～ 2 0 0 1年 4月收治的 5例移植肾输尿管全长坏死患者的诊断和治疗情况进行回顾性总结。 5例患者首发症状皆为漏尿 ,B超和核磁共振 (MRI)水成像是重要的辅助诊断方法。 1例患者 1次手术探查行移植肾肾盂自体输尿管吻合术 ;4例患者第 2次探查手术行移植肾肾盂与自体输尿管或肾盂吻合术。　结果　 5例患者末次手术后尿量为 15 0 0～ 30 0 0ml/d ,2周内血清肌酐 <15 0 μmol/L ,尿素氮 <8 5mmol/L。随访 6～ 12个月 ,全部患者皆无肾积水。　 结论　肾移植术后因漏尿行手术探查 ,发现末端输尿管坏死时 ,应该考虑到可能有输尿管全长坏死。自体输尿管或肾盂重建尿路是有效的治疗方法     

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.     

腹腔镜下肾盂输尿管吻合术治疗肾移植术后长段输尿管狭窄2例

本文回顾性分析2例肾移植受者术后并发长段输尿管狭窄病例的临床诊治过程。2例受者均诊断为输尿管狭窄, 发生部位均在中下段, 长度分别为3 cm和3.5 cm。2例受者的手术方案为腹腔镜下移植肾肾盂与自体输尿管吻合术。术后血清肌酐稳定(例1:135 μmol/L;例2:110 μmol/L), 移植肾功能恢复良好。术后3个月随访移植肾肾盂未见积水。本病例为今后肾移植术后长段输尿管狭窄受者的治疗提供借鉴。     

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.     

自体膀胱瓣管-移植肾肾盂吻合术处理输尿管坏死

目的探讨自体膀胱瓣管移植肾肾盂吻合术处理肾移植术后输尿管长段坏死的效果。方法13例患者肾移植术后发生输尿管长段坏死,将其膀胱皮瓣围绕输尿管内支架管(双J管)缝合成管状,以代替坏死的输尿管,上部修剪成斜形后,与移植肾肾盂吻合。留置双J管做支架管,切口留置胶管引流。结果13例患者均成功进行移植肾肾盂膀胱瓣管吻合术,其中1例术后7d发生严重肾周感染而切除移植肾,其余12例肾功能恢复良好,术后随访1年,2例出现返流,人、肾1年存活率分别为100%(13/13)、92.3%(12/13)。结论自体膀胱瓣管移植肾肾盂吻合术是治疗肾移植术后输尿管长段坏死的有效手段。     

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。     

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。     

移植肾输尿管梗阻的开放性手术治疗

目的：进一步了解和掌握移植肾输尿管梗阻开放性手术治疗的方法及其优劣。方法：移植并随访患者1231例，发生各种原因的输尿管梗阻58例，有51例为经开放性手术重建尿路，其中移植肾输尿管再植入膀胱14例，移植肾输尿管-自体输尿管吻合4例，移植肾盂-膀胱瓣输尿管成形(Boari flop)后吻合28例，移植肾盂-自体输尿管吻合5例。结果：术后早期梗阻均完全缓解，随访1年各种泌尿系并发症复发率21．6％(11／51)，其中5例再次手术，3例缓解，2例失败；另6例保守治疗移植肾功能稳定，效果满意。结论：①开放性尿路重建是一种直接有效的方法；②移植后早期的输尿管梗阻应尽早手术，后期进行性加重的梗阻需要择期手术，肾功能异常者活检是必要的；③各种术式都复发不同的泌尿系并发症，以移植肾输尿管再植入膀胱复发率较低(14．2％)，肾盂与自体输尿管吻合复发率较高(40．0％)，肾盂与膀胱吻合反流较多见。④每一种术式都有各自的适应证，了解各种术式的优劣，合理应用，才是最佳选择。     

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。     

移植肾输尿管短缺肾移植术的尿路重建（附7例报告）

报告７例供肾输尿管短缺情况下肾移植术中尿路重建的方法。其中行供肾与受者输尿端端吻合４例，供肾肾盂与受者输尿管吻合２例，供肾肾盂与受者膀胱吻合１例。除１例供肾肾盂与受者输尿管吻合术后发生漏尿外，均愈合良好。随诊６～２４个月未发现吻合口狭窄。供肾肾盂与受者膀胱吻合１例，术后反复发生泌尿系感染。提示当移植肾发生输尿管短缺时，只要针对具体情况，采取灵活的手术方法，是可以在肾移植术中使尿路重建的。     

Pyelovesicostomy as a form of urinary reconstruction in renal transplantation

The development of ureteral obstruction or ureteral fistula formation in the renal transplant recipient usually requires surgical repair. This involves reconnecting the donor ureter to either the recipient ureter (ureteroureterostomy) or bladder (ureteroneocystostomy), or creating an anastomosis between the renal pelvis and recipient native ureter (pyeloureterostomy). Occasionally, the donor or recipient ureter is absent, necrotic or diseased so that a ureteroureterostomy, ureteroneocystostomy or pyeloureteral anastomosis cannot be performed. In 8 such cases we have performed a direct anastomosis between the donor renal pelvis and recipient bladder (pyelovesicostomy) with a followup of between 2 months and 11 years. In all 8 patients there has been no deterioration in renal function attributed to obstruction at the anastomotic site or to the free reflux between the bladder and renal pelvis. Because of the excellent short-term and long-term results of pyelovesicostomy, this procedure should be considered as an excellent alternative to pyeloureterostomy, ureteroureterostomy and ureteroneocystostomy in the reconstruction of the upper urinary tract of the renal transplant patient.     

Results of secondary ureteral implantation after kidney transplantation

Background

We reviewed our experience with ureteral complications and secondary ureteral implantation after kidney transplantation.

Methods

Between 1997 and 2005, 636 patients underwent kidney transplantation at our transplant center. Ureteral implantation was performed in the Lich?CGregoire technique. Thirty-one patients with ureteral complications after kidney transplantation and subsequent secondary ureteral implantation were analyzed for operative parameters and long-term transplant function.

Results

Twenty-seven patients had a ureteral stenosis and 4 patients a ureteral leakage. In 25 patients (81%), a resection of the distal transplant ureter followed by secondary ureteral implantation was performed. In 4 cases (13%), the native ureter was anastomosed to the transplant pelvis and in the remaining 2 cases (6%) to the transplant ureter. Three major complications occurred. At median follow-up of 5 years, 18/30 patients (60%) had a good transplant function and 12/30 patients (40%) had returned to dialysis. One patient with depression died from suicide.

Conclusions

Secondary ureteral implantation can be performed with acceptable morbidity and good long-term transplant outcome.     

肾移植中供肾输尿管异常的处理

目的：探讨肾移植术中供肾输尿管异常的手术处理方法。方法：回顾性分析18例供。肾输尿管异常的肾移植术中处理,包括损伤致输尿管过短8例,完全型双输尿管4例,不完全型双输尿管2例,输尿管结石2例,巨输尿管2例。根据具体情况采用输尿管膀胱吻合术、供受者输尿管端端吻合术和膀胱腰大肌悬吊术等方法再植输尿管。结果：术后恢复顺利,未发生移植肾功能延迟恢复和尿漏。随访3～8年,发生输尿管梗阻1例,行经皮。肾造口输尿管镜切开后治愈。发生尿路感染5例（其中2例为反复感染）。未见膀胱输尿管返流。结扎输尿管的原肾未出现胀痛和不适,B超检查未见肾积水。带输尿管结石移植肾未见结石复发。巨输尿管供肾移植后输尿管管径稳定,无明显增大。结论：供肾输尿管损伤和异常时采用不同的技术修复和再植输尿管,可减少并发症的发生。     

Ligation of the native ureter in renal transplantation.

PURPOSE: Native ureteral ligation may be required in renal transplantation when ureteroureterostomy is performed. Native nephrectomy has been done to avoid the complication of hydronephrosis after native ureteral ligation. We reviewed the records of renal transplant recipients who underwent native ureteral ligation to determine the incidence of post-ligation symptoms and need for native nephrectomy. MATERIALS AND METHODS: We retrospectively reviewed 1,275 renal transplants performed from January 1986 through September 1999, including 278 cases (22%) of native ureteral ligation. The majority of patients had anuria or oligouria before transplantation, although 3 were not dialysis dependent. Followup was 1 to 140 months. Charts were reviewed for flank pain, infection and the need for native nephrectomy. RESULTS: Six of 278 patients (2.2%) required native nephrectomy 7 to 82 months after transplantation with flank pain as the indication in all. The cause of renal failure was polycystic disease in 3 of the 6 cases, unknown in 2 and diabetes in 1. The patient with diabetes had papillary necrosis and bleeding in the nephrectomized kidney. None of the 278 patients had infection and early post-ligation flank pain developed in only 1 (0.4%). CONCLUSIONS: The native ureter may be safely ligated during renal transplantation. Late nephrectomy may be required in a small percent of cases, most commonly in those of polycystic disease. The need for nephrectomy is most often related to the original renal disease.     

Ureteroureterostomy and pyeloureterostomy without native nephrectomy in renal transplantation

A series of 23 patients, receiving full immunosuppression following renal transplantation, underwent a uretero- or pyelo-ureterostomy with ligation of the native ureter and no nephrectomy. In 5 patients this was carried out at the time of transplantation because of a short donor ureter and in 18 patients, at a median of 47 days after transplantation, following ureteric complications. With a median follow-up of 22 months, no complications have been seen in relation to the native kidney. Ureteroureterostomy was successful in all but 3 patients. A ureteroureterostomy without native nephrectomy is a safe and effective treatment for the management of ureteric complications following renal transplantation.     

Perfect outcome of kidney recipients with ureteral stenosis after treatment with open surgery under magnetic resonance urography localization

BackgroundTo evaluate the outcome of kidney recipients with ureteral stenosis after treatment with open surgery under magnetic resonance urography (MRU) localization.MethodsWe assessed 2,256 consecutive kidney transplant recipients between October 2010 and December 2018. Ureteral stenosis was detected by ultrasound, confirmed and positioned by Magnetic Resonance Urography. All patients underwent open ureteral reconstruction. The ureteral stenosis was located according to the location on the MRU during the operation. Surgical complications and recurrence rate were recorded in the stenosis group. Outcomes were compared with those of a matched control group of transplant recipients with no history of ureteric stenosis.ResultsThe incidence of ureteral stenosis in our center was 3.1% (70/2,256). Sixty-four cases (91.4%) were confirmed to have distal stenosis and were reconstructed with ureterovesical re-implantation; six cases (8.6%) were confirmed to have mid-distal stenosis and were subjected to ureteroureterostomy with the use of native ureter. The overall success rate was 100% and the graft function was salvaged in all cases. There was no recurrence of stenosis after a mean follow-up of 38.9±26.3 months. The complication rate was 5.7%. The 110-month graft survival and patient survival were not significantly different between the stenosis and control groups.ConclusionsMRU is an effective method for non-invasive and accurate diagnosis of ureteral stenosis in kidney transplant recipients. Open ureteral reconstruction surgery under MRU localization for treatment of ureter stenosis after kidney transplantation had a high success rate, low recurrence rate and high safety.     

腔静脉后输尿管三种手术方式的比较

目的：探讨腔静脉后输尿管的最佳治疗方式.方法：回顾性分析21例腔静脉后输尿管患者的治疗方法：14例行传统开放手术,其中1例行右肾切除术;3例行后腹腔镜下输尿管复位矫形术;4例行经腹腔手术,其中3例行腹腔镜下输尿管复位矫形术,1例行腹腔镜辅助下肾盂癌根治术.结果：21例手术均获成功.输尿管复位矫形术的开放组、后腹腔镜组和腹腔镜组平均手术时间分别为1.5 h、3.6 h和2.1 h;术中出血量分别为150m1、80 ml和70 ml;平均术后住院时间分别为7.5天、5天和6天.未出现围术期并发症.术后4～6周拔除双J管.随访6个月～4年,B超和（或）IVP复查无吻合口狭窄,输尿管梗阻均明显缓解.16例术前有右腰酸胀不适感症状者完全缓解.结论：采用腹腔镜下输尿管复位矫形术治疗腔静脉后输尿管应成为临床首选方式.经腹腹腔镜较后腹腔镜在腔静脉后输尿管段粘连严重的治疗和手术视野方面有一定优势.     

移植肾输尿管上段并发症的处理四例

目的 探讨移植肾输尿管上段并发症的处理方法。方法 4例不同原因所致的移植肾输尿管并发症，在无法行膀胱输尿管吻合的情况下，经腹腔或腹膜外途径。将受者输尿管与供肾肾盂吻合，内置双“J”管，经过充分的内，外引流，达到治疗输尿管病变的目的。结果 4例中有3例可正常排尿，1例尚需进一步治疗，随访2个月至1年，人，肾存活良好。结论 对于移植肾输尿管上端病变，采用自身输尿管与供肾肾盂吻合是一种处理较复杂移植肾输尿管病变的好方法。     

Management of ureteral stenoses and urinary fistulas following kidney transplantation]

The treatment of strictures and fistulas at the lower ureter after kidney transplantation was simple and could be achieved by reimplantation into the bladder. Proximal urinary fistulas caused early abdominal symptoms. The i.v. urogram showed a dilated renal pelvis without drainage into the ureter. The anatomical findings were in all cases strictures or total obstruction of the ureter beneath the pelvic junction and a rupture of the renal pelvis or calix. Adequate therapy consisted of ureteroureterostomy with the recipient ureter and nephrostomy splintage.     

肾移植术后并发双侧自体肾盂和输尿管移行细胞癌16例

目的 总结肾移植术后发生双侧自体肾盂、输尿管移行细胞癌的诊治经验.方法 回顾性分析16例肾移植术后发生双侧自体肾盂、输尿管移行细胞癌患者的资料.首次发现上尿路肿瘤的时间为移植后(56.2±33.0)个月.2例同时发现双侧上尿路肿瘤,其余14例双侧上尿路肿瘤先后发现的时间间隔为(8.6±6.7)个月.临床症状和检查阳性结果以血尿和自体肾积水为主.均行自体上尿路根治性切除术,术后行膀胱灌注化疗.结果 16例手术均成功.32次自体肾、输尿管的病理检查结果均为移行细胞癌,包括单纯肾盂肿瘤4次,单纯输尿管肿瘤9次,合并肾盂、输尿管肿瘤19次.23次肾盂肿瘤的分级为1级8例,2级11例,3级4例;28次输尿管肿瘤的分级为1级6例,2级10例,3级12例.术后随访(26.8±25.1)个月,1例出现肺部转移后死亡;1例发生腰背部软组织转移性移行细胞癌,局部切除;其他患者未发现肿瘤复发及转移.结论 肾移植后自体上尿路移行细胞癌的常见表现为血尿合并自体肾积水,该肿瘤侵袭性较强,对于膀胱及一侧自体上尿路同时存在移行细胞癌者,应行对侧自体肾上尿路预防性切除术.

Abstract：

Objective To investigate the clinical features of bilateral native pelvic and ureteral transitional cell carcinoma (TCC) in renal transplant patients. Methods A retrospective analysis was carried out on 16 patients with bilateral native pelvic and ureteral TCC after kidney transplantation.The mean time between transplantation and diagnosis of upper urinary TCC was 56. 2 ± 33. 0 months.Two patients were suffered from bilateral upper urinary TCC at the same time. The mean interval between 2 upper urinary tract operations of the remaining 14 cases was 8. 6 ± 6. 7 months. Hematuria and hydronephrosis of native kidneys were the main symptoms and targets in checkup. Intravesical chemotherapy was postoperatively given. Results All operations were performed successfully. All specimens obtained from the operations were pathologically diagnosed as TCC. The TCC location involved pure native pelvis (n = 4), pure native ureter (n = 9), and pelvis combined with ureter (n = 19). Pelvic TCC pathological grades included grade 1 in 8 cases, grade 2 in 11 cases, and grade 3 in 4 cases; Ureteral TCC grades included grade 1 in 6 cases, grade 2 in 10 cases, and grade 3 in 12 cases.Patients were followed up for 26. 8 ± 25. 1 months. One patient died of lung metastasis. (One case of lumbar soft tissue transfer was given local excision. The remaining patients had no recurrence and metastasis. Conclusion Renal transplant patients with hematuria and native renal hydronephrosis should be highly vigilant of the occurrence of upper urinary tract TCC. TCC after renal transplantation is invasive. Prophylactic contralateral nephroureterectomy should be performed on the recipients having TCC at the bladder and one side of native upper urinary tract.