上尿路结石并重度肾积水的处理方法

目的:探讨上尿路结石并重度肾积水的处理方法.方法:对79例上尿路结石并重度肾积水患者,先行患侧经皮肾穿刺造瘘解除梗阻,再根据情况择期行微创经皮肾镜取石术(mPCNL)、输尿管镜气压弹道碎石术(URL)、或开放手术取石及肾切除手术.结果:除肾切除患者外,积水肾功能均获不同程度改善,全部患者症状缓解,痊愈出院.结论:对于上尿路结石并重度肾积水,先行积水肾经皮肾穿刺造瘘,根据结石大小、部位、梗阻程度及肾功能情况,择期选PCNL、URL或开放手术取石,安全性好,疗效确切.     

上尿路结石并重度肾积水的治疗(附56例报告)

目的 探讨上尿路结石并重度肾积水的治疗方法.方法 对56例上尿路结石并重度肾积水患者,先行患侧经皮肾穿刺造瘘解除梗阻,再根据病情择期行微创经皮肾取石术(m PCNL),输尿管镜气压弹道碎石术(URL),切开取石术或肾切除术.结果 除肾切除患者外,积水肾功能明显改善,全部患者症状缓解,痊愈出院.结论 上尿路结石并重度肾积水,先行积水肾经皮肾穿刺造瘘,再根据病情(结石大小、部位、肾功能、全身状况)择期选择适宜手术方式,安全,效果好.     

小儿离断性肾盂成形术中同心双腔管的应用

目的总结小儿肾盂输尿管连接部梗阻（UPJO）的诊治经验。方法回顾分析56例小儿肾盂输尿管连接部梗阻患儿的临床资料，其中肾盂输尿管连接部狭窄42例．肾盂输尿管高位连接4例。迷走血管压迫7例，纤维条索压迫3例，行Anderson-Hynes离断性肾盂成形并同心双腔管肾造瘘45例，输尿管-肾下盏吻合并同心双腔管肾造瘘4例，单纯纤维条索松解术3例，肾切除4例。结果18例随访5—72个月，其中1例松解术后患者肾积水加重，其余病人肾积水明显减轻。结论Anderson Hynes肾盂成形并同心双腔管肾造瘘术是治疗UPJO的理想方式。     

肾脏、输尿管

腹膜后腹腔镜肾癌根治术的体会（附58例报告）；改良一步式经皮肾造瘘法应用疗效评价；后腹腔镜下肾盂成形术在小儿肾积水手术中的应用；小肾癌自然病程的相关风险因素研究；微创经皮肾镜取石术治疗马蹄肾结石的效果；     

经皮肾穿刺造瘘在梗阻性肾积水（脓）中的临床价值

目的：探讨经皮肾穿刺造瘘（PCN）在梗阻性肾积水（脓）中的临床应用价值.方法：对86例肾积水（脓）患者先行超声引导经皮肾穿刺造瘘引流.待肾功能改善、机体状况好转或经引流及造影确定诊断,其中结石引起的肾积水（脓）69例.非结石性肾积水（脓）17例,合并脓肾31例.52例行经皮肾镜取石碎石术,17例行后腹腔镜肾盂、输尿管切开取石术,6例行肾盂切开取石术后加行肾盂输尿管成型术;5例行输尿管狭窄段切除端端吻合术;3例行肾下盏-输尿管吻合术;3例行输尿管皮肤造瘘术.结果：86例患者均穿刺成功,及时解除梗阻,71例患者肾功能恢复正常;9例肾功能改善,维持在轻中度氮质血症水平;6例肾功能无改善.结论：PCN所建立的通道为缓解病情、病因诊断和二期手术打开方便之门,尤其是对急性梗阻性脓肾及结石梗阻性肾积水（脓）的诊治具有重要的应用价值.     

肾穿刺造瘘引流肾盂输尿管成形术治疗小儿先天性肾盂输尿管连接部梗阻

目的:探讨提高治疗小儿先天性肾盂输尿管连接部梗阻(UPJO)疗效的新方法。方法:对38例(43侧)先天性UPJO肾积水患者,先行患肾穿刺造瘘引流,再行肾盂输尿管成形术治疗。结果:37例(42侧)肾盂成形术均获成功,痊愈出院;1例肾功能受损严重,行患肾切除术。随访0.5~5年,经B超及利尿性动态肾核素扫描证实,37例患肾结构与功能都有不同程度的好转和提高。结论:肾穿刺造瘘引流肾盂输尿管成形术,是治疗小儿先天性UPJO的有效方法;但常规IVP检查不显影不能作为肾切除的指征。     

妊娠合并巨大肾积水保肾治疗3例报告

目的 总结妊娠合并巨大肾积水保肾治疗的初步临床经验. 方法 3例妊娠合并巨大肾积水,2例经尿道膀胱镜下放置双J管内引流;1例因插双J管失败后B超引导下经皮肾造瘘外引流术.肾功能均改善,2例分娩后1个月、1例置J管失败经皮肾造瘘因妊娠高血压终止妊娠后1个月经腹腔途径腹腔镜下施行解除梗阻、肾盂成形、肾折叠固定术. 结果 一期引流术、二期腹腔镜手术均获成功.例1腹腔镜手术时间、术中出血量及术后住院时间为2.5 h、150 ml、5 d;术后3个月复查B超患肾积水消失;复查IVU 7 min显影.例2腹腔镜手术时间、术中出血量及术后住院时间为 3.5 h、50 ml、6 d;术后3个月复查B超患肾轻度积水（肾窦分离2.0 cm）;复查IVU 7 min已显影.例3腹腔镜手术时间、术中出血量及术后住院时间为 4.0 h、110 ml、8 d;术后3个月复查B超患肾中度积水（肾窦分离2.8 cm）;复查IVU 60 min肾盏少许棉絮状显影.3例分别随访4、2、1年,未发现吻合口狭窄,患肾功能一直保持稳定. 结论 妊娠合并巨大肾积水先放置双J管内引流或肾造瘘外引流,待分娩后肾功能改善,二期采用腹腔镜保肾治疗是有效、可行的微创治疗手段.     

恶性肿瘤致输尿管梗阻的微创外科处理

目的:探讨恶性肿瘤所致输尿管梗阻的有效微创外科处理方法。方法:回顾性分析2007年8月~2013年3月诊治的28例恶性肿瘤所致输尿管梗阻患者的临床资料。患者先采用膀胱镜下留置输尿管支架管术解除梗阻,如膀胱镜下留置输尿管支架管术失败或仍无法解除梗阻则改行经皮肾造瘘术解除梗阻。输尿管支架管每6个月更换,肾造瘘管每月更换。结果:14例患者成功采用膀胱镜下留置输尿管支架管术,其中输尿管留置支架管双侧11例,单侧3例;11例患者因留置输尿管支架管术失败改行单侧经皮肾造瘘术;3例患者膀胱镜下留置单侧输尿管支架管,术后尿液引流不良、无法解除输尿管梗阻,改行单侧经皮肾造瘘术。26例术前肾功能受损患者中20例术后四周肾功能恢复正常,6例患者术后肾功能稳定在氮质血症期(术后血肌酐191.2~330.0μmol/L,术后血尿素氮5.24~8.75mmol/L)、电解质正常,泌尿系超声提示术侧肾脏轻度积水或无积水。每3个月复查KUB未见输尿管支架管结石附着,肾造瘘管引流通畅。随访1~45个月,死亡9例,无因肾功能衰竭死亡患者。结论:恶性肿瘤致输尿管梗阻患者,膀胱镜下留置输尿管支架管术和经皮肾造瘘术两种微创外科技术可以有效解除输尿管梗阻。膀胱镜下留置输尿管支架管术可作为首选方法,对梗阻段输尿管较长、肿瘤浸润输尿管壁、多部位梗阻患者,膀胱镜下留置输尿管支架管引流不能有效解除梗阻,需行经皮肾造瘘术。     

离断性肾盂成形术治疗肾盂输尿管连接部梗阻

1临床资料 肾盂输尿管连接部梗阻(UPJO)是原发性肾积水的主要原因.我院自2000年1月至2002年12月采用离断性肾盂成形术治疗UPJO 40例.其中男性27例,女性13例;年龄8～34岁,平均20岁,12岁以下5例;左侧31例,右侧8例,双侧1例.病史3d～4年,有腰痛史31例,肉眼血尿8例,腹部包块6例,并发肾结石11例,高血压4例.B超提示肾积水,肾盂输尿管连接处以下输尿管不扩张.IVU提示患侧中度至重度肾积水,肾盂输尿管连接处以下输尿管不显影,对侧肾无异常.手术采用经12肋下斜形切口显露UPJO部位.术中发现梗阻原因为:管腔狭窄28例,纤维索带及异位血管压迫8例,功能性梗阻4例.对纤维索带或异位血管压迫者先行离断.切开肾盂将肾脏减压,在病变的远侧离断输尿管,近端离断肾盂.根据肾盂形态和扩张程度设计裁剪多余肾盂,输尿管断端斜形切开1.5cm,冲洗肾盂及输尿管远端,放入支架引流管,用5-0肠线作肾盂输尿管无张力漏斗状吻合.肾周脂肪覆盖吻合口并用1、2针固定,肾盂附近放置多侧孔橡皮管引流.其中6例放置肾造瘘支架管,34例放置双J管.支架管在术后4～8周内拔除.拔管前均复查B超,患侧肾积水明显减轻,肾皮质增厚,患侧肾功能改善.     

人工肾积水穿刺肾造瘘在治疗复杂性肾结石中的应用

目的探讨经皮穿刺肾造瘘术中建立人工肾积水在无积水复杂性肾结石治疗中的价值。方法对26例复杂性肾结石患者建立人工肾积水后于B超引导下行经皮肾穿刺造瘘取石术。男18例，女8例。年龄19～67岁，平均39岁。左侧12例，右侧10例，双侧4例。单发鹿角状结石8例，多发结石18例。结石长径3.0～6.5cm，平均3.8cm。逆行输尿管插管并通过此管向肾盂注入生理盐水形成人工肾积水，在B超引导下行肾盂穿刺，建立经皮肾盂通道。结果24例（92％）穿刺成功，2例失败改为经X线下肾盂造影定位穿刺成功。放置造瘘管28侧（93％）。术中出血40～1200ml，输血6例。结论对于无肾盂积水的复杂性肾结石，建立人工肾积水后在B超引导下穿刺肾盂造瘘，经皮肾盂穿刺成功率较高，是解决无积水肾微创手术的有效方法。     

小儿肾积水IVU不显影肾血流动力学检测的临床意义

目的 探寻小儿肾积水IVU不显影患肾血流动力学改变与肾损害程度的关系. 方法 采用彩色多普勒超声(CDFI)测量48例小儿单侧肾积水不显影患肾肾主动脉(MRA)、叶间动脉(IRA)及弓状动脉(ARA)的阻力指数(RI),并与健肾测量结果比较,同时计算阻力指数比率(RIR=病肾RI/健肾RI),分别与超声测量的患肾实质厚度、面积及患肾组织学检查进行相关性分析. 结果 健肾MRA、IRA、ARA的R1分别为0.62±0.03、0.61±0.05、0.64±0.03,患肾分别为0.67±0.05、0.69±0.11、0.71±0.10,患肾各级肾血管的RI间差异无统计学意义(P＞0.05),但与相应健肾RI比较差异有统计学意义(P＜0.05).患肾各级肾血管的RIR分别为1.11±0.10、1.13±0.14、1.14±0.09,差异均无统计学意义(P＞0.05).患肾各级肾血管的RI、RIR均随实质厚度、面积减小而增加,其中患肾IRA的RIR与病肾实质面积呈密切负相关(r=-0.735,P＜0.01).患肾各级肾血管的RIR与病理分级均呈正相关(P＜0.05),其中IRA的RIR与病理分级相关性最密切(r=0.795,P＜0.01). 结论 CDFI肾血流动力学检测是判定小儿肾积水不显影肾损害程度的简单有效方法之一,特别是叶间动脉的阻力指数比率更有意义.     

Renal function and (NA+ + K+)-ATPase in chronic unilateral hydronephrosis in dogs

Recovery of various parameters of kidney function after varying periods of complete unilateral ureteral obstruction was studied in dogs under hydropenic conditions. Changes of PAH and inulin clearance appeared to be parallel. After one week of obstruction, renal clearances of PAH and inulin were decreased to seven per cent of values measured before the obstruction period, after two weeks to four per cent and after three or four weeks to two per cent. Within 10 to 28 days after release of obstruction by cutaneous ureterostomy, PAH and inulin clearance increased to 66 per cent after one week, to 50 per cent after two weeks, to 10 per cent after three weeks with no change after four weeks of obstruction. Na+ content in the hydronephrotic kidney differed from contralateral kidneys only in the inner medulla. The affinity for ouabain (dissociation constant, KD, normal = 3.85 X 10(-9) M; hydronephrotic = 3.05 X 10(-9) M; contralateral = 7.05 X 10(-9) M) was significantly higher only in the outer medulla of contralateral kidneys. Turnover number (normal = 3.6; hydronephrotic = 5.1; contralateral = 3.4 X 10(3) min.-1) in hydronephrotic or contralateral outer medulla was not significantly different from normal. Changes in kinetic constants (association rate constant, k+1, normal = 4.49 X 10(4) M-1 sec.-1; hydronephrotic = 4.13 X 10(4) M-1 sec.-1; contralateral = 5.97 X 10(4) M-1 sec.-1; dissociation rate constant, k-1, normal = 1.03 X 10(-4) sec.-1; hydronephrotic = 1.29 X 10(-4)sec.-1; contralateral = 1.39 X 10(-4) sec.-1) were considered to be too small to be relevant. Similar changes of KD, k+1 and k-1 were observed in the renal cortex. The osmotic concentrating capacity correlated well with (Na+ + K+)-ATPase activity (r = 0.85) and number of 3H-ouabain binding sites (r = 0.89) in renal outer medulla. The results indicate that recovery of osmotic concentrating capacity depends on the length of obstruction, and that a reduction of (Na+ + K+)-ATPase molecules in the thick ascending limb of the loop of Henle is a primary factor in the decrease in the concentrating capacity of chronic unilateral hydronephrotic kidneys.     

Cystic lesions of the fetal kidney: diagnosis and prediction of postnatal function by fetal urine biochemistry.

Fetal urine was aspirated under ultrasound control from 21 large cystic renal masses in 18 pregnancies of 20 to 35 weeks gestation. None were associated with bladder or ureteric dilatation. At postnatal investigation, 12 kidneys were demonstrated to be hydronephrotic (5 with no or poor function) and 9 multicystic. Urinary concentrations of sodium (Na+), calcium (Ca++), and phosphate (PO4--) were significantly higher in the multicystic group than in the hydronephrotic, whereas urea and creatinine levels were lower. Determination of urinary PO4-- enabled differential diagnosis with no false-positive or false-negative cases. Among hydronephrotic kidneys, no biochemical parameter accurately predicted postnatal function, although creatinine was increased in all three nonfunctioning kidneys. In hydronephrotic kidneys, urinary Na+ concentration increased with advancing gestational age (r = .66; P < .02), suggesting that the duration of hydronephrosis has a negative effect on renal function.     

Maximum urinary concentration ability in patients with idiopathic hydronephrosis

The maximum urinary concentration ability and renal parenchymal function of each kidney were investigated in 34 patients with unilateral hydronephrosis. The ability to concentrate urine was not reduced in 10 hydronephrotic and 24 contralateral kidneys. The concentration ability was moderately reduced in 14 hydronephrotic and 10 non-hydronephrotic kidneys and severely impaired in 10 hydronephrotic kidneys. A reduced concentration ability was found almost entirely in hydronephrosis complicated with upper urinary tract infection or renal calculi. Hydronephrotic kidneys without these complications showed a normal concentration ability in 10 of 11 cases. Parenchymal function was reduced in only 10 hydronephrotic kidneys, 7 of which had had upper urinary tract infections and 3 of which had renal stones. It is our opinion that uncomplicated cases of unilateral hydronephrosis should not be operated upon unless necessitated by signs and symptoms. Measurement of the maximum urinary concentration ability might be helpful in setting the correct indication for surgery in borderline cases.     

Renal pelvis volume during diuresis in children with hydronephrosis: implications for diagnosing obstruction with diuretic renography

PURPOSE: We measured the volume of the renal pelvis during diuretic renography (DR) in children with normal and hydronephrotic kidneys to determine if changes in pelvic volume could affect the accuracy of DR in diagnosing obstruction. MATERIALS AND METHODS: We studied 18 patients 1 month to 10 years old with unilateral hydronephrosis ultimately proved to be either obstructive or nonobstructive. Simultaneous DR and ultrasound were performed with patients supine using the gamma camera. Ultrasound measurements of the renal pelvis in 3 dimensions, obtained before and at intervals after diuretic injection, were used to calculate renal pelvic volume. The contralateral normal kidneys were used as controls. RESULTS: Between 15 and 60 minutes after diuretic injection the renal pelvis enlarged to a maximum volume in all hydronephrotic and normal kidneys and then gradually decreased in size. Mean average increase in volume for hydronephrotic kidneys ranged from 46% in obstructed kidneys to 88% in nonobstructed kidneys. Volume expansion caused dilution of isotope within the renal pelvis, which resulted in prolongation of elimination half-time (T1/2) in 42% of nonobstructed hydronephrotic kidneys sufficient to register an obstructed washout pattern. However, there were no differences in the initial pelvic volume or the rate or extent of increases or decreases in pelvic volume that would permit nonobstructed hydronephrotic kidneys to be distinguished from obstructed ones. CONCLUSIONS: The renal pelvis enlarges during diuresis in children with hydronephrosis. This enlargement causes dilution of isotope within the renal pelvis during DR, which prolonged the isotope washout rate or T1/2 sufficiently to produce an obstructed washout pattern in more than 40% of hydronephrotic kidneys that were ultimately proved to be nonobstructed. This misdiagnosis of obstruction is particularly likely to occur in children younger than 2 years because pelvic volume expansion is so exaggerated. Consequently, T1/2 appears to be particularly vulnerable to inaccuracy in diagnosing obstruction in this age group, and, therefore, it should not be relied on as an operative determinant.     

Cortical interstitial cell interactions induce sensitivity of hydronephrotic kidney to bradykinin

The mechanism of the increased prostaglandin production and induction of sensitivity to bradykinin by the cortex of the hydronephrotic rabbit kidney was investigated using tissue culture techniques. Cortical interstitial cells from normal, unilaterally hydronephrotic and contralateral kidneys were grown in tissue culture. Cells derived from hydronephrotic kidneys, but not normal or contralateral, increased PGE2 production when incubated with bradykinin. Of the two cell types, fibroblasts and macrophages, grown from hydronephrotic explants, neither increased prostaglandin production when grown alone in tissue culture. Recombining the two cell types restored bradykinin responsiveness. Bradykinin responsiveness could be induced in either normal or contralateral cell cultures when macrophages from the hydronephrotic kidney were added to cultures of cells from normal or contralateral cortex. The data indicate unique characteristics of hydronephrotic macrophages are involved in the induction of bradykinin responsiveness in the cortex of the ureter-ligated kidney.     

Increased transforming growth factor-β1 and tubulointerstitial fibrosis in rats with congenital hydronephrosis

OBJECTIVES: Most of our knowledge concerning renal obstruction has been derived from experimental animal models, and it is not yet well defined in spontaneous hydronephrosis. The aim of our study is to evaluate the roles of transforming growth factor-beta1 (TGF-beta1) and apoptosis in congenital hydronephrotic kidneys in comparison with experimental models. METHODS: We made histological studies on kidneys from 6-week-old Wistar-Imamichi rats with congenital unilateral hydronephrosis as well as surgical models of complete or partial unilateral ureteral obstruction. The severity of hydronephrotic kidneys was evaluated on routine hematoxylin and eosin (H&E) stained sections, and the tubulointerstitial fibrosis analyzed morphometrically on Masson's trichrome stained sections. Renal tubular atrophy was assessed on periodic acid Schiff (PAS) stained sections, and tubular cell apoptosis assessed with TUNEL technique. The renal TGF-beta1 level was determined by a sandwich enzyme-linked immunosorbent assay (ELISA). RESULTS: We observed a significant loss of kidney weight with profound compensatory growth of the contralateral kidney in rats with congenital hydronephrosis. Most of the hydronephrotic kidneys were markedly enlarged with dilatation of the collecting system, renal parenchymal thinning, tubular atrophy, interstitial infiltration and fibrosis. The renal TGF-beta1 level was markedly elevated in hydronephrotic kidneys as compared with normal controls (326.01 +/- 30.64 pg/mg protein vs 227.81 +/- 11.07 pg/mg protein, P < 0.01). The tubular apoptotic score in hydronephrotic kidneys was also significantly higher than normal controls (2.17 +/- 0.50/HPF [high power field]vs 0.14 +/- 0.04/HPF, P < 0.01). The increased TGF-beta1 and apoptotic status paralleled the histological changes of tubulointerstitial fibrosis and tubular atrophy. Similar findings were also obtained in experimental obstructive models. CONCLUSION: In comparison with surgical models of partial and complete ureteral obstruction, our data provide solid morphological and molecular evidences of renal obstruction in rats with congenital hydronephrosis.     

Renal cortical drug and xenobiotic metabolism following urinary tract obstruction

Renal cortical metabolism of drugs and xenobiotics was assessed with microsomes prepared from normal, contralateral and 4-day postobstructive hydronephrotic kidneys. Microsomal mixed-function oxidase and prostaglandin H synthase systems were determined in control and 3-methylcholanthrene-treated rabbits. Cytochrome P450 content and biphenyl-4-hydroxylase activity but not cytochrome c reductase activity were reduced in the hydronephrotic kidney. 3-Methylcholanthrene treatment increased cytochrome P450 content and biphenyl-4-hydroxylase and acetanilide-4-hydroxylase activities in normal, contralateral, and hydronephrotic kidneys. However, even after 3-methylcholanthrene treatment, hydronephrotic kidney cytochrome P450 content and acetanilide-4-hydroxylase activity were not more than 20% of the corresponding normal kidney values. Prostaglandin H synthase metabolism of benzidine was observed in the hydronephrotic kidney but was at the limit of detection in normal or contralateral kidneys with or without 3-methylcholanthrene treatment. Characteristics of benzidine metabolism were consistent with the hydroperoxidase rather than the fatty acid cyclooxygenase activity of prostaglandin H synthase. Therefore, hydronephrosis alters the drug and xenobiotic metabolic profile of the renal cortex from a primarily mixed-function oxidase-dependent system to one with the potential for metabolism by the hydroperoxide component of prostaglandin H synthase.     

小儿肾积水术后短期肾盂内压力的恢复

【摘要】〓目的〓探讨先天性肾积水小儿行离断式肾盂输尿管成形术后肾盂内压力的恢复规律。方法〓回顾性分析30例单侧肾盂输尿管连接部狭窄行离断式肾盂输尿管成形术的患儿。术中放置肾造瘘管。手术后14天内,每天测量肾盂内压力、膀胱内压力、患侧尿量。结果〓术后第一天,患侧肾盂内压力即降低至和膀胱内压力无明显差异。术后7天左右,肾盂内压力短暂升高,之后再次降低并保持稳定。患肾尿量于术后7天左右短暂性增多。结论〓术后7天左右,吻合口存在“功能性”梗阻。肾造瘘管或者输尿管支架管至少应该放置1周。     

Efficient Utilization of the Expanded Criteria Donor (ECD) Deceased Donor Kidney Pool: An Analysis of the Effect of Labeling

We investigated the effect of the expanded criteria donor (ECD) label on (i) recovery of kidneys and (ii) acceptance for transplantation given recovery. An ECD is age ≥ 60, or age 50–59 with ≥ 2 of 3 specified comorbidities. Using data from the Scientific Registry of Transplant Recipients from 1999 to 2005, we modeled recovery rates through linear regression and transplantation probabilities via logistic regression, focusing on organs from donors just‐younger versus just‐older than the ECD age thresholds. We split the sample at July 1, 2002 to determine how decisions changed at the approximate time of implementation of the ECD definition. Before July 2002, the number of recovered kidneys with 0–1 comorbidities dropped at age 60, but transplantation probabilities given recovery did not. After July 2002, the number of recovered kidneys with 0–1 comorbidities rose at age 60, but transplantation probabilities contingent on recovery declined. No similar trends were observed at donor age 50 among donors with ≥ 2 comorbidities. Overall, implementation of the ECD definition coincided with a reversal of an apparent reluctance to recover kidneys from donors over age 59, but increased selectiveness on the part of surgeons/centers with respect to these kidneys.