腹腔镜下左肾静脉外支架固定术治疗左肾静脉压迫综合征的临床分析

目的 探讨腹腔镜下左肾静脉外支架固定术治疗左肾静脉压迫综合征的临床疗效.方法 左肾静脉压迫综合征患者5例.男4例,女1例.年龄20～35岁,平均25岁.肉眼血尿3例,活动后加重,合并蛋白尿1例;左腰酸痛伴左精索静脉曲张2例.术前彩色多普勒超声及CT三维血管重建均提示左肾静脉压迫明显.扩张段与受压段直径比值均＞3.膀胱镜检查3例可见左输尿管口喷血尿.5例均于全麻下行腹腔镜下左肾静脉受压段外支架固定术治疗,术中用人造血管固定于下腔静脉与生殖静脉之间形成血管外支架以克服左肾静脉受压.结果 5例手术均顺利完成.手术时间65～70 min,平均67 min.术中出血量10～15 ml,平均13 ml.术中术后无明显外科并发症,术后恢复顺利,术后5～6 d出院.肉眼血尿消失3例,左精索静脉曲张减轻2例.术后随访9～39个月,平均28个月,1例术前肉眼血尿、术后仍有轻微镜下血尿,4例尿常规检查正常.5例其余症状均消失,超声检查示左肾静脉血流通畅、受压现象消失.结论 腹腔镜下左肾静脉外支架固定术采用人造血管环绕左肾静脉抵抗肠系膜上动脉压迫,是治疗左肾静脉压迫综合征的一种可供选择的微创技术,手术简单、方便、安全有效,创伤小、痛苦少、恢复快.

Abstract：

Objective To report the experience in the use of laparoscopic extravascular stent for the treatment of the nutcracker syndrome. Methods Five patients (4 men and 1 woman) aged 20 to 35 years (mean 25) underwent laparoscopic extravascular stent of the left renal vein (LRV) for treatment of nutcracker syndrome associated with severe recurrent gross hematuria and left gonadal vein varices. All patients met the criteria for establishing the diagnosis of nutcracker syndrome. Ultrasonography, computed tomography, and magnetic resonance imaging revealed visible entrapment of the LRV between the superior mesenteric artery and aorta. Bleeding from the left ureteral orifice was detected by cystoscopy in 3 cases. An externally reinforced graft was selected to form an external stent around the LRV to relieve the compression. Results The mean operation time was 67 min (65-70min). No complications occurred during surgery. The postoperative follow-up was 9 to 39 months (mean 28). Total relief was achieved in 4 men without a relapse of symptoms and abnormalities were not found in urine tests. There was partial relief for the female patient due to microscopic hematuria after the operation. In all the 5 cases, Color Doppler ultrasonography showed that the blood outflow was smooth, the inner diameter and flow velocity of the aortomesenteric portion of the LRV were both decreased, and the gonadal vein varices had diminished in diameter. Conclusions The laparoscopic extravgscular stent of the renal vein could be a feasible approach for re-establishing free renal venous outflow in patients with nutcracker syndrome. This slightly invasive treatment could eliminate the symptoms of the condition.     

Unexplained hematuria during pregnancy: right-sided <Emphasis Type="Italic">nutcracker phenomenon</Emphasis>

We report a case of hematuria in a pregnant patient caused by right renal vein hypertension, as a result of compression of right renal, the inferior caval and the right gonadal veins because of posterior displacement of the pancreas caused by the presence of the gravid uterus. Hematuria resolved after a cesarean delivery. This condition has not been, to our knowledge, previously described.     

精索静脉髂外静脉分流术治疗胡桃夹综合征1例报道并文献复习

目的探讨胡桃夹综合征（NCS）的诊断及治疗方法。方法对1例NCS患者临床表现及诊断与治疗进行分析讨论。结果术后3月复查精子情况好转,蛋白尿消失,彩超示新建循环通路畅通。结论NCS临床表现复杂,诊断应将症状与辅助检查相结合,精索静脉髂外静脉分流是治疗NCS的方法之一。     

腹壁下静脉-精索静脉分流术治疗男性胡桃夹综合征不育患者的疗效观察

目的探讨显微镜下腹壁下静脉-精索静脉分流术治疗男性胡桃夹综合征患者的疗效。 方法我们收集了2015年9月至2018年3月,吉林大学中日联谊医院8例伴有胡桃夹综合征导致的精索静脉曲张的男性不育患者的临床资料。8例患者均为体型瘦高的男性青年,平均年龄为28.5岁,其中血尿患者6例,腰痛患者1例,全部患者精子质量低下。全部患者都接受了显微镜下腹壁下静脉-精索静脉分流术的治疗。比较术前及术后的左肾静脉峰值流速比（PV比）、精子平均数量及活率、术后自然受孕率。 结果手术时间85～105 min,术后平均住院时间为（7±0.5）d。术后随访1年,血尿消失的患者5例（83.3%）,1例腰痛的患者症状缓解。术后PV比值较术前显著降低（P<0.01）。术后3、6、12个月精子总数较术前显著提高（P<0.05）。术后3、6、12个月精子活率较术前显著提高（P<0.05）。75%的患者配偶（6/8）在术后自然受孕。 结论显微镜下精索静脉-腹壁下静脉分流术治疗伴有胡桃夹综合征导致的精索静脉曲张男性不育患者是一种安全有效的手术方式。     

左肾静脉下移术治疗左肾静脉压迫综合征(附3例报告)

目的 探讨改进治疗左肾静脉压迫综合征（即胡桃夹综合征-NCS）的手术方法。方珐对3例明确诊断为左肾静脉压迫综合征的患者采用左肾静脉下移与下腔静脉端侧吻合术。结果术中肾动脉阻断时间分别为20min、21min及16min。肉眼血尿消失时间分别在术后第3天、第5天及第4天，镜下血尿消失时间分别在术后第5天、第7天及第6天。随访4—6月，血尿均未复发。结论左肾静脉下移与下腔静脉行端侧吻合治疗左肾静脉压迫综合征，疗效满意。     

左肾静脉压迫综合征合并肾小球疾病26例报告

目的探讨彩超诊断左肾静脉压迫综合征的慢性肾脏疾病患者肾组织病理变化和临床特点。方法回顾性分析26例左肾静脉压迫综合征伴肾小球疾病患者的临床病理资料。结果多数病例通过体检发现,部分以活动（或劳累）后出现肉眼血尿、浮肿、泡沫尿、腰酸（或腰痛）以及排尿不适为表现,尿相差显微镜红细胞分类为肾小球源性或混合性血尿,且平卧位即出现尿检异常。临床表现为血尿合并蛋白尿11例,发作性肉眼血尿7例,肾病综合征4例,单纯血尿3例,单纯蛋白尿1例。肾组织病理表现多样化：IgA肾病9例,系膜增生性坚小球病变8例,局灶节段系膜增生性肾炎4例,乙肝病毒相关性肾炎4例,膜性肾病1例。结论左肾静脉压迫综合征合并肾小球疾病在临床上并不少见;其临床及病理均呈现多样性;当临床上遇到左肾静脉综合征不能解释的血尿及蛋白尿时．应积极进行肾活检,避免漏诊而延误病情和治疗。     

胡桃夹综合征并发IgA肾病临床分析

目的 了解胡桃夹综合征并发IgA肾病的临床特点及提高其相应诊治水平。 方法 回顾分析14例胡桃夹综合征并发IgA肾病患者（病例组）及同期36例单纯胡桃夹综合征患者（对照组）的临床资料。所有胡桃夹综合征病例均由彩色多普勒超声和磁共振血管成像（MRA）诊断;IgA肾病均由病理证实。记录两组实验室、影像学资料并进行t检验分析。 结果 两组患者性别、年龄、血压差异无统计学意义。病例组Scr值高于对照组[（81.2±21.3） μmol/L比（61.2±11.8） μmol/L,P < 0.01],尿蛋白量较多[（1.1±0.6） g/d比（0.3±0.2） g/d,P < 0.01],血尿更明显（尿红细胞计分2.3±0.9比1.5±1.3,P < 0.05）。彩色多普勒超声显示两组左肾静脉狭窄处及近肾门处血流速度和内径差异无统计学意义;磁共振血管成像提示两组患者肠系膜上动脉与腹主动脉之间的夹角差异无统计学意义。 结论 对持续存在血尿和蛋白尿、异常红细胞比例较高的胡桃夹综合征患者应考虑存在并发慢性肾炎特别是IgA肾病的可能,应及早行肾活检明确诊断。     

腹腔镜下左肾静脉外支架固定术治疗左肾静脉压迫综合征的疗效分析

目的 探讨腹腔镜下左肾静脉外支架固定术治疗左肾静脉压迫综合征的临床疗效.方法 左肾静脉压迫综合征患者8例,男5例,女3例.年龄13 ～31岁,平均27岁.血尿病史3 ～46个月,均合并蛋白尿.8例彩色多普勒超声检查:左肾静脉狭窄段内径1.0～3.0 mm,平均2.4mm;扩张段内径5.3 ～ 14.9 mm,平均9.1 mm.扩张段与狭窄段比值均＞3.8例CT三维血管重建检查:左肾静脉受压明显,血流速度0.52 ～1.15 m/s,平均0.75 m/s;腹主动脉与肠系膜上动脉夹角9.3.～23.8.,平均18.6°.膀胱镜检查6例,均可见左侧输尿管口喷血.8例均行腹腔镜下左肾静脉外支架固定术治疗,术中将长5～8 cm直径1 cm的带外支撑环的e-PTFE人造血管固定于下腔静脉与肾门之间的左肾静脉外,以抵抗肠系膜上动脉的压迫,减轻肾静脉受压. 结果 8例患者手术顺利.手术时间55 ～140 min,平均63 min.术中出血量10 ～ 30 ml,平均14 ml.术中术后未发生外科并发症.术后恢复顺利,住院5～7 d,平均6d出院.术后随访3～20个月,血尿消失后未复发7例,7例尿常规检查正常.1例仍间断出现镜下血尿.8例彩色多普勒超声复查显示左肾静脉狭窄段内径6.5～8.7 mm,平均7.4 mm;扩张段与狭窄段比值1.1 ～1.4,平均1.3;流速0.23 ～0.42 m/s,平均0.31 m/s;腹主动脉与肠系膜上动脉夹角为51°～65°,平均57°. 结论 腹腔镜下人造血管外支架固定术是治疗左肾静脉压迫综合征的一种新术式,术中需暂时阻断肾动脉,无需离断左肾静脉或肠系膜上动脉等血管,设计巧妙,创伤小,恢复快,疗效满意.     

肾静脉外支架固定术治疗左肾静脉压迫综合征

目的 探讨肾静脉外支架固定术治疗左肾静脉压迫综合征的临床疗效.方法 左肾静脉压迫综合征患者8例.男7例,女1例.平均年龄16(6～25)岁.血尿病史6～36个月,合并蛋白尿2例.均行彩色多普勒超声检查,左肾静脉狭窄段平均直径2.2 mm、最大流速0.7 m/s,扩张段平均直径8.6 mm、最大流速0.2 m/s,扩张段与狭窄段直径比值均3(正常比值<2).CT三维血管重建检查5例示腹主动脉与肠系膜上动脉夹角30°～40°(正常值45°～60°).膀胱镜检查5例可见左输尿管口喷血尿.8例均行肾静脉外支架同定术治疗,取一段长5～10 cm、直径1 cm的人造血管纵行切开,环绕左肾静脉一端至肾门,另一端越过肠系膜上动脉与主动脉间夹角形成一隧道样外支架以减轻肾静脉受压.结果 8例手术均顺利完成.平均手术时间150 min.平均术中出血量50ml.术中术后无明显外科并发症,术后恢复顺利,平均9 d出院.肉眼血尿消失6例、减轻2例.彩色多普勒超声检查7例显示左肾静脉血最大流速0.4～0.7 m/s、无明显受压.术后随访2～24个月,平均10个月,除1例时有活动性肉眼血尿、超声检查显示左肾静脉仍有受压征象外,余7例症状消失、尿常规检查正常、超声检查示左肾静脉血流通畅、受压现象消失.结论 左肾静脉外支架固定术采用人造血管环绕肾静脉抵抗肠系膜上动脉压迫,设计巧妙、损伤小、疗效满意,是治疗左肾静脉压迫综合征的理想方法.     

A rare anomaly of left renal vein drainage into the left common iliac vein: A case report

IntroductionHerein, we describe a case of sigmoid colon cancer with a rare anomaly of the left renal vein located between the inferior mesenteric artery (IMA) and the left common iliac artery.Case presentationA 57-year-old woman with sigmoid colon cancer underwent three-dimensional computed tomography angiography for a preoperative assessment; the results revealed a rare variant of the left renal vein. There were two left renal veins: one retroaortically drained into the inferior vena cava, and the other was located between the IMA and the left common iliac artery and drained into the left common iliac vein. Laparoscopic sigmoid colectomy was performed safely while carefully avoiding any injury to the left renal vein located posterior to the IMA.DiscussionSeveral variations of the left renal vein have been reported, such as retroaortic or circumaortic left renal veins. The variants of renal vessels, which are frequently overlooked in the preoperative assessment, is rarely affected in colorectal surgery. However, if the surgeon is unaware of such renal vessel anomalies, an injury can occur, resulting in severe bleeding.ConclusionIt is important that surgeons identify retroperitoneal vessel variants before performing colorectal surgery.     

肾病综合征合并肾静脉血栓形成:病因及抗栓治疗进展

肾病综合征患者具有明显的高凝倾向,肾静脉血栓形成是其常见且严重的并发症之一。文中阐述了肾病综合征患者高凝状态的病理生理学基础,对肾静脉血栓的抗栓治疗也做了详尽的综述。     

The ivemark syndrome: prenatal diagnosis of an uncommon cystic renal lesion with heterogeneous associations

Renal dysplasia has been reported in association with a number of anatomical abnormalities, including pancreatic dysgenesis and hepatic anomalies. The combination of renal, hepatic, and pancreatic dysplasia (RHPD), also known as Ivemark syndrome, is rare and uniformly fatal. We report here the gross and histological findings in 4 cases of combined RHPD, 2 of which were detected by prenatal ultrasonography. Evaluation of these 4 and the other 20 reported cases shows that combined RHPD has considerable variability in the histological findings and in organ involvement. In addition, nearly half were associated with anomalies in other organ systems, and 11 of the 24 were familial. In this study, ultrasonographic and histological abnormalities were seen as early as 18.5 weeks gestation in 1 case.     

显微镜下小切口行精索静脉-腹壁下静脉转流术治疗胡桃夹综合征的临床疗效观察

目的观察显微镜下腹股沟小切口行精索静脉高位结扎及精索静脉-腹壁下静脉转流术治疗胡桃夹综合征的临床疗效,评估手术方法的可行性、安全性及有效性。 方法选择我院门诊初诊左侧精索静脉曲张的患者,经阴囊彩超、肾静脉-泌尿系彩超、肾功能、尿常规及CT等检查确诊为胡桃夹综合征8例,腰硬联合麻醉下腹股沟小切口行显微精索静脉高位结扎术及精索静脉-腹壁下静脉转流术,术后随访6个月。 结果8例患者手术均获得成功。手术切口2～3 cm。腰腹痛、阴囊坠胀不适等临床症状明显改善或消失。尿常规恢复正常。精子浓度和（a+b级）精子活力明显改善（P<0.05）。复查彩超提示所有患者精索静脉曲张均治愈。左侧精索静脉-腹壁下静脉吻合口血流通畅。腹主动脉前狭窄段左肾静脉峰值流速较术前明显变缓。肾门扩张段与腹主动脉前狭窄段左肾静脉管径的比值较术前明显变小（P<0.05）。 结论显微镜下腹股沟小切口行精索静脉高位结扎术及精索静脉-腹壁下静脉转流术治疗胡桃夹综合征临床效果确切、操作相对简单、创伤小、安全性高,值得临床推广。     

Entrapment of left renal vein in children with orthostatic proteinuria

We found that patients with orthostatic proteinuria had entrapment of the left renal vein (LRV) by the aorta and superior mesenteric artery (SMA). Of 15 patients studied, ultrasonographic examination showed 13 cases of typical LRV entrapment with prestenotic dilatation, and 2 cases of mild LRV compression between the aorta and SMA. Intra-arterial digital subtraction angiography and monitoring of pull-back pressure from LRV to the inferior vena cava (IVC) were performed on 2 patients with 4+ proteinuria. Accumulation of contrast medium was seen with mild back-flow to the collateral veins, and pressure gradients between LRV and IVC were 4 mmHg and 8 mmHg, respectively. Eighty school-children formed a control group and were investigated ultrasonically. Nine showed typical LRV entrapment, among whom 3 had moderate to massive orthostatic proteinuria. The discovery of LRV entrapment in patients with orthostatic proteinuria gives definite evidence of LRV congestion and may be possibly a cause of massive protein secretion from the left kidney.     

左肾静脉压迫综合征的诊断与治疗

目的探讨左肾静脉压迫综合征的临床特点及其诊断、治疗方法。方法回顾性分析3例男性左肾静脉压迫综合征患者的临床资料。临床表现主要为反复发作肉眼血尿,1例合并左侧精索静脉曲张。膀胱镜下均可发现左侧输尿管口喷血尿,B超及CT三维重建示腹主动脉与肠系膜上动脉夹角处左肾静脉明显受压,肾静脉近端扩张。3例均行左肾静脉下移与下腔静脉端侧吻合术。结果3例患者术前均明确诊断。术后血尿消失,痊愈出院。术后5个月及8个月复查B超、CT三维血管重建,3例患者肾脏大小均正常,左肾静脉通畅,受压现象消失,尿常规正常。结论左肾静脉压迫综合征临床特点为肾静脉高压,反复发作肉眼血尿或镜下血尿。左肾静脉下移与下腔静脉端侧吻合术是治疗该病的有效方法。