肾移植术后榆尿管梗阻

１９７８年４月－１９９４年４月施行尸肾移植５９９例次，发生输尿管梗阻２９例，发生率为４．８％。梗阻原因中结石１６例（５５．２％），输尿管膀胱吻合口狭窄８例（２８％），其他为输尿管扭曲２例，血块２例，吻合口坏死完全梗阻１例。本组摘除移植肾８例，带肾存活１８例。     

肾移植后泌尿系并发症及其防治

我院自１９８９年２月至１９９４年６月共为５１例慢性肾功能衰竭终末期肾病患者施行同种异体肾移植术５２例次。术后并发尿路感染１０例（１９．８％），尿瘘７例（１３．８％），移植肾血管破裂１例，输尿管梗阻３例（５．８％），输尿管排异反应１例。并对泌尿系并发症的防治提出具体意见。     

移植后泌尿系并发症及其防治

我院自１９８９年２月至１９９４年６月共为５１例慢性肾功能衰竭终末期肾病患者施行同种异体肾移植术５２例次，术后并发尿路感染１０例（１９．８％），尿瘘７例（１３．８％），移植肾血管破裂１例，输尿管梗阻３例（５．８％），输尿管排异反应１例，并对泌尿系并发症的防治提出具体意见。     

机械吻合在食管外科中的应用：1605例经验总结

１９８０年８月至１９９４年２月应用机械方法对１６０５例食管癌和贲门癌切除后进行吻合。男１２８１例，女３２４例。年龄２８～８１岁，其中５０～６９岁１１８４例（７３．８％）。食管癌１０４４例，贲门癌５６１例。食管胃颈部吻合３５例；超胸顶吻合５８例；弓上吻合８３５例；弓下吻合６７７例。术后发生吻合口瘘１６例（ｌ％），其中颈部吻合口瘘发生率１４．３％（５／３５）；胸内吻合口瘘发生率０．７％（１１／１５７０），前６年胸内吻合口瘘发生率１．４％（８／５７５），近８年胸内吻合口瘘发生率０．３％（３／９９５）。术后发生吻合口狭窄１６例（１％），狭窄明显者经扩张后均恢复正常饮食。作者认为：机械吻合是减少胸内吻合口瘘的有效方法之一。     

食管重建术后吻合口狭窄的扩张治疗

作者自１９８３年５月至１９９３年５月期间应用食管扩张术治疗食管、贲门癌术后吻合口狭窄患者６５８例，共行扩张３２４０次，有效率达９６．５％。扩张５次以下明显好转占６１．６％，１０次以下叫显好转占８４．５％。术后发生并发症２７例，占４．１％。食管穿孔８例（１．２％），吻合口出血４例（０．６／），纵隔大１例（０．２％），局部损伤１４例（２．１％）。作者对食管扩张术的适应证，操作中注意事项及并发症进行了讨论。     

电化学治疗晚期食管癌梗阻和术后吻合口狭窄

１９９１年３月到１９９２年４月应用电化学疗法（ｅｌｅｃｔｒｏ－ｃｈｅｍｉｃａｌｔｈｅｒａｐｙ，ＥＣＴ）治疗有明显梗阻的食管癌病人２４８例和食管癌切除后吻合口狭窄病人３６例。全组病例均经食管钡餐造影、食管镜检查和部分ＣＴ扫描确诊。应用ＥＣＴ疗法是消除梗阻，使病人能进食，有效地改善营养状态，然后再根据具体需要辅以其它综合治疗，达到提高疗效的目的。２４８例食管癌梗阻的有效率为６７．７％（１６８／２４８），３６例吻合口狭窄的有效率为８８．９％（３２／３６），两组平均有效率为７０．４％（２００／２８４）。     

肿瘤转移和浸润致输尿管梗阻性肾功能衰竭的临床处理

为提高肿瘤转移和浸润引起的上尿路梗阻性肾功能衰竭的临床诊断和治疗水平，总结了１９８９年８月￣１９９７年７月临床处理３４例的结果。其中原发灶为胃肠道肿瘤１０例，膀胱癌７例，前列腺癌６例，宫颈癌４例，卵巢癌３例，其他肿瘤４例。梗阻部位在输尿管上段９例，经皮尿管下段２５例（７３．５％），其中输尿管膀胱交界处７例（２０．６％）。治疗采用双Ｊ管内引流９例，经皮尿管下段２５例（７３．５％），其中输尿管膀胱交界     

小肾癌(附34例报告)

自１９８５～１９９６年诊治３ｃｍ以下肾癌３４例。其中无任何临床症状由体检发现者２３例（６７．６％），血尿５例（１４．７％），腰痛４例（１１．８％）血尿及腰痛均有者１例，因慢性肾功能不全经Ｂ超检查发现１例。行根治性肾切除２９例，单纯性肾切除２例，行肾肿瘤剜除术２例，术前误诊为肾盂癌而行肾输尿管全长切除１例。病理结果：透明细胞癌３２例（９４．１％），颗粒细胞癌１例，混合型（透明细胞癌＋颗粒细胞癌）癌１例。ＰＴ１１０例，ＰＴ２２４例。３０例（８８．２％）获得随访，平均随访时间３８．７个月。无癌存活者２９例，术后存活超过５年者７例，其中１例术后第６年死于肺转移     

15年肾移植的临床经验

１９７８年４月至１９９４年３月共实施尸体肾移植５９１例，６０６次。迄今人存活５１０例（８６．３％），死亡９６例（１６．２％），肾脏存活４３４例（７３．４％），摘除移植肾７６例（１２．８％）。术后应用Ａｚａ，泼尼松（Ｐｒｅｄ），环磷酰胺，环孢素（ＣｓＡ）、ＡＴＧ、ＯＫＴ３免疫抑制剂。发生超急性排斥９例次，急性排斥反应２１２例次，慢性排斥反应５８例次。本组带肾存活最长１３年３个月，术后１、３、５、１０年肾存活分别为４２０例（８５．７％），２２２例（７７．４％），１１８例（６９．８％），１例（１６．７％）。就怎样合理地选用免疫抑制剂，术后并发症发生的原因，长期存活的经验进行讨论。     

胆总管十二指肠吻合术治疗良性胆道梗阻的远期疗效观察

为了探讨胆总管十二指肠吻合术的疗效，对随访时间１０年以上，应用胆总管十二指肠吻合术（ＣＤＤ）治疗胆道良性梗阻的４６例随访结果进行了分析。结果显示：疗效优２６例（５６．５％），良１３例（２８．３％），差７例（１５．２％）。优良率８４．８％，与同期胆总管空肠Ｒｏｕｘ－ｅｎ－ｙ吻合１７１例的优良率８６．５％相比，无显著差异（Ｐ＞０．０５）。提示：对于胆道良性梗阻，特别是高危老年病人，ＣＤＤ仍是一种安全有效的术式；胆总管扩张达１．５ｃｍ以上，吻合口达２．５ｃｍ以上，吻合口上方各级胆道无残留病变是取得远期良好效果的基本条件。     

Causes of renal forniceal rupture

Study Type – Diagnostic (exploratory cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Renal forniceal rupture is a common finding in patients with ureteral obstruction. It is thought to be due to increased renal pelvis pressure from backup of urine, causing one or more renal fornices to leak urine. This phenomenon has not been systematically studied. Herein we retrospectively review the causes and associated clinical findings in over 100 cases of renal forniceal rupture.

OBJECTIVE

? To perform a retrospective review aiming to identify causes of renal forniceal rupture.

PATIENTS AND METHODS

? A retrospective review was performed of the longitudinal medical record and CT records for patients identified as having renal ‘forniceal rupture’ or ‘calyceal rupture’ using a radiological database.

RESULTS

? In total, 108 patients were identified with the CT diagnosis of renal ‘forniceal’ or ‘calyceal’ rupture. ? Forniceal rupture was caused by ureteric stones in 80 cases (74.1%), malignant extrinsic ureteric compression in nine cases (8.3%), benign extrinsic ureteric compression in two cases (1.9%), pelvic‐ureteric junction obstruction in two cases (1.9%), vesico‐ureteric junction (VUJ) obstruction in one case (0.9%), bladder outlet obstruction in one case (0.9%) and iatrogenic causes in four cases (3.7%). ? No definitive cause was found in nine cases (8.3%). For patients in whom a ureteric stone was the cause of forniceal rupture, the level of obstruction was proximal ureter in 24.3% of cases, distal ureter in 17.6% of cases and VUJ in 58.1% of cases. ? Mean (sd ) stone size was 4.09 (2.0) mm. Mean (sd ) stone size was 5.34 (1.87) mm for proximal stones, 4.08 (1.69) mm for distal stones and 3.53 (1.96) mm for VUJ stones (P= 0.005). ? Urinary tract infection was present in five out of 97 patients (5.2%) in whom data were available for analysis.

CONCLUSION

? The most common aetiology of renal forniceal rupture is obstruction caused by distal ureteric stones followed by malignant extrinsic ureteric compression.     

Ureteric complications of renal transplantation.

Of 507 consecutive recipients of renal allografts, 45 developed a urological complication. In 39 patients (7.7%) ureteric problems were implicated and these comprised 30 cases of obstruction and 9 cases of ureteric necrosis presenting as urinary leakage. In 7 patients ureteric obstruction resolved following a period of nephrostomy decompression; 10 patients were reconstructed surgically and this was successful in 8, with 2 patients requiring further surgical procedures. Ten patients were successfully treated by percutaneous stenting after dilatation of the stricture. Stenting failed in 4 patients and in 1 patient caused rupture of a calix. All 10 stents have now been removed and there is no recurrence of stricture (follow-up 32.0 +/- 8.6 months). Of the remaining 3 grafts, 2 were removed and the other graft had percutaneous removal of a ureteric calculus. The 1-year survival rate of allografts in the ureteric complication group was 84.6%; in the recipients without a urological complication it was 81%. It was concluded that an active approach to ureteric problems following renal transplantation results in the rescue of the majority of allografts.     

The urological complications of renal transplantation: a series of 1535 patients

OBJECTIVE: To determine the incidence of urological complications of renal transplantation at one institution, and relate this to donor and recipient factors. PATIENTS AND METHODS: A consecutive series of 1535 renal transplants were audited, and a database of donor and recipient characteristics created for risk-factor analysis. An unstented Leadbetter-Politano anastomosis was the preferred method of ureteric reimplantation. RESULTS: There were 45 urinary leaks, 54 primary ureteric obstructions, nine cases of ureteric calculi, three bladder stones and 19 cases of bladder outlet obstruction at some time after transplantation. The overall incidence of urological complications was 9.2%, with that for urinary leak or primary ureteric obstruction being 6.5%. One graft was lost because of complications, and there were three deaths associated directly or indirectly with urological complications. There was no association with recipient age, cadaveric vs living-donor transplants, or cold ischaemic times before organ reimplantation, although the donor age was slightly higher in cases of urinary leak. There was no association with kidneys imported via the UK national organ-sharing scheme vs the use of local kidneys. The management of these complications is discussed. CONCLUSION: The incidence of urological complications in this series has remained essentially unchanged for 20 years. The causes of these complications and techniques for their prevention are discussed.     

Orthostatic acute renal failure in a renal transplant

Complications due to ureteric obstruction are an occasional cause for renal transplant dysfunction. Here we report an unusual case of orthostatic renal failure in a renal transplant recipient. Our patient had the previously reported predisposing risk factors including: female sex, obesity, and lax abdominal musculature. It is important to recognize this unusual complication of renal transplantation early in order to preserve long-term graft function. Received: 23 December 1996 Received after revision: 6 May 1997 Accepted: 13 May 1997     

FURTHER EXPERIENCE WITH AN EXTERNAL URETEROVESICAL ANASTOMOSIS IN RENAL TRANSPLANTATION

Review of the results of the use of an external ureterovesical anastomosis in 266 renal transplantations showed that urinary fistulae occurred in 34 patients (12.8%), and ureteric obstruction in six (2.3%). The fistulae were due to technical failure of the anastomosis in 13 patients, to distal ureteric necrosis in 13, to total ureteric necrosis in six, and to other causes in two. Fistula management was successful in 26 cases (76.5%), but multiple operations were often necessary and wound complications frequent (41.2%). The continuing high incidence of urological complications following ureterovesical anastomosis has resulted in increasing use of ureteroneocystosfomy as the primary form of urinary reconstruction after transplantation in this unit.     

Further experience with an external ureterovesical anastomosis in renal transplantation.

Review of the results of the use of an external ureterovesical anastomosis in 266 renal transplantations showed that urinary fistulae occurred in 34 patients (12.8%), and ureteric obstruction in six (2.3%). The fistulae were due to technical failure of the anastomosis in 13 patients, to distal ureteric necrosis in 13, to total ureteric necrosis in six, and to other causes in two. Fistula management was successful in 26 cases (76.5%), but multiple operations were often necessary and wound complications frequent (41.2%). The continuing high incidence of urological complications following ureterovesical anastomosis has resulted in increasing use of ureteroneocystostomy as the primary form of urinary reconstruction after transplantation in this unit.     

Altered primate glomerular development due to in utero urinary tract obstruction

BACKGROUND: In utero urinary tract obstruction is an important cause of newborn and childhood renal failure. Ureteric obstruction during active nephrogenesis results in cystic renal dysplasia; the earlier and longer the obstruction the more severe the histopathological changes of dysplasia. We have reported on a non-human primate model of non-surgical in utero fetal ureteric obstruction that accurately reflects the human equivalent of obstructive renal dysplasia. A striking feature of this model is the effect of obstruction on normal glomerular development and podocyte survival. METHODS: To study the effect of urinary obstruction on glomerular development, kidneys were studied from fetuses undergoing unilateral ureteric obstruction by ultrasound guided injection of alginate beads as early as 75 days gestation (term gestation = 165 +/- 10 days). These kidneys displayed all the features of human obstructive cystic dysplasia, had reduced weights, and significant deficiencies in terminal ureteric duct branching. RESULTS: A combination of histochemistry, histomorphometry, and immunocytochemistry was used to demonstrate deficient cortical ureteric duct development and branching, reduced glomerular number, and altered glomerular basement membrane formation with in utero urinary tract obstruction. CONCLUSIONS: These data suggest that urinary tract obstruction during active nephrogenesis results in a defect in ureteric duct branching morphogenesis, and altered vascularization of the glomerulus with consequent podocyte dropout and decreased glomerular number. These abnormalities reflect human renal dysplasia, which is associated with compromised postnatal renal function and, thus, should be predictive of postnatal outcome.     

Urological complications following renal transplantation

A total of 1016 consecutive renal transplants performed between 1976 and 1990 were analysed retrospectively to determine the incidence of urological complìcations and possible predisposing factors. Some 189 episodes of ureteric obstruction and/or urinary leak occurred in 143 patients (overall incidence 14.1 %). The median annual rate of urinary leak was 5.1%; that of ureteric obstruction was 4.5% pre-1986 and 16.1% post-1986. Sixty-three episodes of urinary leak occurred in 54 patients from 1 day to 3 months post-transplant and 60% involved the distal ureter. Thirty were treated primarily by reconstructive surgery, ten required nephrectomy and three died of associated sepsis. A total of 126 episodes of ureteric obstruction occurred in 104 patients from 1 day to 12 years post-transplant and 86% involved the distal ureter. Prior to 1986, 10/11 patients with ureteric obstruction were treated by reconstructive surgery, but since then 88 (95%) have been treated by percutaneous nephrostomy, with or without stenting, with only one graft lost and no deaths. Children had a significantly increased incidence of ureteric obstruction (P<0.001) whilst male recipients had an increased incidence of urinary leak (P=0.04). More patients with ureteric obstruction than those without had two or more episodes of rejection (P=0.03). No single cause for the increased incidence of ureteric obstruction since 1986 has been identified. Continued attention to technical detail and further study of this trend is warranted.     

Is routine ureteric stenting needed in kidney transplantation? A randomized trial

BACKGROUND: Whether routine ureteric stenting in low-urological-risk patients reduces the risk of urological complications in kidney transplantation is not established. METHODS: Eligible patients were recipients of single-organ renal transplants with normal lower urinary tracts. Patients were randomized intraoperatively to receive either routine stenting or stenting only in the event of technical difficulties with the anastomosis. All patients underwent Lich-Gregoire ureteroneocystostomy. RESULTS: Between June 1994 and December 1997, 331 kidney transplants were performed at a single center, 305 patients were eligible, and 280 patients were enrolled and randomized. Donor and recipient age, sex, donor source, whether first or subsequent grafts, ureteric length, native renal disease, and immunosuppression were similar in each group. In the no-routine-stenting group 6 of 137 patients (4.4%) received stents after randomization for intraoperative events that in the surgeon's opinion required use of a stent. In an intention-to-treat analysis there was no difference between groups in the primary outcome cluster of obstruction or leak [routine stenting 5 of 143 (3.5%) vs. no routine stenting 9 of 137 (6.6%); P=0.23], or in either of these complications analyzed separately. All urological complications were successfully managed without major morbidity. Living donor organs and shorter ureteric length (after trimming) were univariate risk factors for leaks, although increasing donor age was associated with obstruction. CONCLUSIONS: Routine ureteric stenting is unnecessary in kidney transplantation in patients at low risk for urological complications. Careful surgical technique with selective stenting of problematic anastomoses yields similar results.     

Partial unilateral ureteric obstruction alters regional renal blood flow

Summary Complete unilateral ureteric obstruction decreases ipsi-lateral and increases contra-lateral renal blood flow, with shunting of intrarenal blood flow from outer to inner cortical zones. We tested the hypothesis that partial unilateral ureteric obstruction would also result in alterations in renal perfusion patterns. In five dogs, the left ureter was partially obstructed for 4 weeks and then reimplanted into the bladder for a further 4 weeks. Whitaker tests confirmed partial ureteric obstruction. Renal blood flow was assessed at each stage by distribution of radioactively labelled microspheres prior to and following ureteric obstruction and after reimplantation. Partial unilateral ureteric obstruction significantly decreased total blood flow to the ipsi-lateral kidney (51% vs 26%;P<0.05) and increases total blood flow to the contralateral kidney (49% vs 74%;P<0.05). In the ipsilateral kidney, partial ureteric obstruction induced a significant decrease in outer cortical blood flow (57% vs 76%;P<0.01) and a concomitant increase in inner cortical blood flow (35% vs 18%;P<0.02). A similar, albeit less marked, shunting of blood from outer to inner cortex was seen in the contralateral kidney. Relief of sbstruction after 4 weeks did not restore the renal circulation to its pre-obstruction profile. We speculate that the alterations in intrarenal blood flow may be hormonally mediated.