离断性肾盂成形术治疗先天性肾盂输尿管连接部梗阻

先天性肾盂输尿管连接部梗阻（UPJO）所致肾积水是小儿较常见的泌尿系畸形，发病原因包括肾盂输尿管连接部狭窄、瓣膜、息肉、高位输尿管口、迷走血管或副血管压迫等。临床症状无特异性，主要依靠影像学诊断，B超检查简便易行，可作为UPJO的初步筛选诊断。静脉尿路造影通过肾脏对特殊造影剂的摄取和经上尿路的排泄，     

肾核素动态显影在小儿先天性肾盂输尿管连接部梗阻中的应用

目的总结肾核素动态显影在小儿先天性肾盂输尿管连接部梗阻中的应用。方法2000年1月～2006年1月我院共收治52例先天性肾盂输尿管连接部梗阻、肾积水患儿,采用99Tcm-DTPA肾动态显影对52例患儿进行检查,测定肾小球滤过率(GFR),并对21例进行手术前后GFR比较。结果肾影像及肾图曲线随病情不同而出现特征性表现,GFR随病情的加重而出现显著性下降(P<0.01),术后GFR升高,与术前比较,差异有显著统计学意义(P<0.01)。结论99Tcm-DRPA肾动态显影可作为诊断小儿先天性肾盂输尿管连接部梗阻、术后病情观察的有效检查方法。     

小儿先天性肾盂输尿管连接部梗阻诊治265例

目的探讨离断性肾盂成形术在小儿先天性。肾盂输尿管连接部梗阻中的治疗效果。方法总结2006年至2007年收治的265例小儿先天性肾盂输尿管连接部梗阻患儿的临床资料。男226例，女39例。左侧183例，右侧65例，双侧17例。平均年龄4．5岁，其中年龄小于1岁34例。根据症状、超声、静脉尿路造影（IVU）或核磁水成像明确诊断，对重度肾积水患儿行肾核素扫描了解分肾功能。均行腹部横行小切口离断性肾盂成形术（Anderson—Hynes术式）。结果术后随访6个月，以梗阻症状消失、。肾盂变窄或肾实质增厚为治愈标准。病理诊断：肾盂输尿管连接部狭窄并高位输尿管最多见，占93．2％。265例（282侧）一次手术成功率为98．5％。结论新生儿肾积水多为生理性，有白行改善的可能，绝大多数不需要手术治疗。小儿先天性肾盂输尿管连接部梗阻的首要病因是。肾盂输尿管连接部狭窄。有明显梗阻症状、肾盂进行性扩张或。肾功能损害进行性加重者需手术治疗，首选离断性。肾盂成形术。     

小儿膀胱镜输尿管插管逆行造影检查术在肾输尿管先天畸形诊断中的价值

目的 评价小儿膀胱镜输尿管捕管逆行造影检查术在肾输尿管先天畸形诊断中的价值.方法 总结分析2806年8月-2008年11月本院收治的经小儿膀胱镜输尿管插管逆行造影检查术诊断为肾输尿管先天畸形的患儿病例资料.71例患儿中肾盂输尿管连接部梗阻(UPJO)43例(60.56%),其中狭窄35例,息肉5例,高位输尿管2例,下腔静脉后输尿管1例,并肾结石9例;输尿管末端狭窄17例(23.94%),并输尿管末端结石5例;输尿管中段狭窄6例(8.45%);肾发育不良3例(4.23%);重复肾重复输尿管畸形2例(2.82%).所有病例依据小儿膀胱镜逆行造影检查的术前诊断进行相应手术,术后随访49例,其中11例行逆行造影检查.结果 71例肾输尿管畸形术前均行小儿膀胱镜输尿管插管逆行造影检查术,术前诊断在术中均得到证实,符合率为100%.其中43例UPJO者均行Anderson-Hynes肾盂输尿管成形术,并肾结石9例,同期取净结石;3例肾发育不良和2例重复肾重复输尿管畸形行发育不良肾、重复肾及输尿管切除术;6例输尿管中段狭窄者行狭窄段输尿管切除、输尿管斜形吻合术;17例输尿管末端狭窄者行输尿管膀胱吻合术,并结石者同期取出.出院时疗效均满意.术后随访期间11例再次经小儿膀胱镜输尿管插管逆行造影检查,输尿管均通畅,全程显影,未见狭窄及扩张.结论 随着小儿膀胱镜输尿管插管逆行造影检查术的开展,使得肾输尿管先天畸形的术前正确诊断得到明显的提高,有利于手术方法 的正确选择,从而防止了术中的盲目探查;同时还可进行术后的有效随访.     

肾盂输尿管连接部梗阻合并同侧膀胱输尿管连接部梗阻的诊断与治疗

目的 肾盂输尿管连接部梗阻(ureteropelvic junction obstruction,UPJO)和膀胱输尿管连接部梗阻(ureterovesical junction obstruction,UVJO)这两个最常见的儿童泌尿系统病理状态同时存在较少见.本文对单侧UPJO合并同侧UVJO的诊断与治疗进行探讨.方法 回顾性分析上海交通大学医学院附属新华医院2012年1月至2015年7月间手术治疗的UPJO合并UVJO患儿.术前常规行泌尿系超声、同位素利尿肾图(DR)及排泄性膀胱尿道造影(VCUG)等检查.结果 我院共诊治单侧UPJO合并UVJO的43例患儿,失访2例.11例患儿术前明确诊断;41例患儿先行肾盂成形术+肾造瘘术,其中10例术后复查发现输尿管末端狭窄自行缓解,28例再次接受输尿管膀胱再植术,3例患儿行肾盂成形术+肾造瘘术后复查核素提示分肾功能低于10％,给予患肾切除;38例患儿术复查肾积水程度和肾脏功能均得到显著改善.结论 单侧UPJO合并UVJO的术前诊断非常困难,术中应仔细检查,避免遗漏同时合并存在的病理改变.术前尽量通过超声、DR及MR等影像检查作出明确诊断,进而制定个体化的治疗方案,能够获得满意的治疗效果.如术前明确有UPJO的存在,应选择首先进行肾盂成形术,术后根据检查结果决定是否行输尿管膀胱再植术.     

先天性肾盂输尿管连接部梗阻的诊断治疗

目的 探讨小儿先天性肾盂输尿管连接部梗阻（UPJO）致肾积水诊断和治疗的最佳方法。方法 对26例小儿UPJO致重度肾积水，采用B超与静脉尿路造影（IVU）相结合的诊断方法和离断式肾盂输尿管成形术（Anderson—Hynes手术）治疗，总结其效果。结果 所有病例经手术和病理检查证实诊断正确，手术经过顺利，术后恢复好。24例获随访6个月～2年，无血尿、尿频、腹部包块、腹胀等症状，尿常规正常，临床治愈。B超示扩张的肾较术前缩小、肾实质厚度增加；IVU示手术侧肾显影时间提前、杯口形态改善，其中20例输尿管显示良好。结论 B超和IVU相结合是诊断小儿UPJO极有效的方法；Anderson—Hynes手术是治疗UPJO的最佳术式。     

小儿先天性肾盂输尿管连接部梗阻126例

目的 探讨小儿先天性肾盂输尿管连接部梗阻的诊断及治疗方法。方法 回顾总结126例先天性肾盂输尿管连接部梗阻患儿的病例资料,分析其诊断、治疗方法及疗效。结果126例均行离断性肾盂成形术,一期治愈124例,2例术后10d试行夹管后感腰部胀痛、发热,予带管持续引流．延期3周拔除肾造瘘管,痊愈出院。全部病例术后随访6个月,临床症状消失．复查B超及IVP．均提示患肾形态缩小,肾实质厚度增加,造影剂显影和排泄状况好转。结论小儿先天性肾盂输尿管连接部梗阻可通过B超、IVP等检查,结合临床症状明确诊断。离断性肾盂成形术设计合理,成功率高。     

二维FASE技术MRU成像对小儿泌尿外科疾病诊断的意义

自 1996年 6月至今 ,我院采用高级转换快速自旋回波 (ＦＡＳＥ)序列为 32例小儿行ＭＲＵ(磁共振尿路造影 )检查 ,取得理想效果 ,现报道如下。资料与方法1.一般资料　本组 32例 ,男 19例 ,女 13例 ,年龄 16ｄ～ 13岁 ,平均 (5 .2±4.8)岁。其中新生儿 2例 ,婴幼儿13例 ,学龄前儿童 9例 ,学龄儿童 8例。病种为 :肾盂输尿管连接部梗阻 16例(1例并发肾盂结石 ,1例为脓肾 ) ,肾胚胎瘤 4例 ,先天性巨输尿管 3例、输尿管膨出 2例 ,重肾双输尿管伴输尿管异位开口 2例 ,多囊肾、双侧输尿管炎性狭窄、原发性膀胱输尿管反流、膀胱憩室、后尿道瓣膜症各 …     

利尿B超诊断小儿肾盂输尿管连接部梗阻

为了解利尿Ｂ超诊断小儿肾盂输尿管连接部梗阻（ＰＵＪＯ）的意义，对２５例（３４侧）小儿肾积水进行利尿Ｂ超检查，将检查结果与ＩＶＵ、肾盂测压、手术中所见病理改变及正常肾脏检查结果进行比较。结果显示利尿后ＰＵＪＯ患儿肾脏集合系统明显扩大，平均较利尿前扩大１０５％，利尿后９０ｍｉｎ仍不能恢复。同返流、输尿管远端或下尿路梗阻引起的肾积水及正常肾脏检查结果比较有显著性差异（Ｐ＜０．０５）。利尿Ｂ超可作为判断ＰＵＪＯ的方法之一。     

重肾双输尿管畸形下肾积水的临床处理

目的 探讨小儿少见的重肾双输尿管畸形下肾部积水功能受损病例的临床特点及治疗方法.方法 报告2004至2007年间我院收治的4例重肾双输尿管畸形下肾部积水功能受损病例,男3例,女1例,年龄为6个月至10岁,其中下肾部并发肾盂输尿管交界部梗阻性肾积水者3例,1例完全型双输尿管者作下肾离断性肾盂成形;另1例不完全型双输尿管者作下肾部肾盂与上输尿管端侧吻合术;下肾部肾巨大积水功能丧失1例作下肾切除.不完全型双输尿管畸形下肾部并发反流积水功能受损1例,作共同通道段输尿管膀胱再植术.结果 经术后6～18个月(平均12个月)随访,经B超、利尿性肾图(DR)及排尿性膀胱尿道造影(VCUG)检查,2例下肾部并发.肾盂输尿管交界部梗阻息儿积水缩小,肾功能提高,1例下肾部反流患儿反流消失.结论 重肾双输尿管畸形下肾部积水,功能受损病例较少见,为取得良好的手术治疗效果则术前需根据不同病例进行仔细地个性化评价.     

Multiple fibroepithelial polyps of the upper ureter in a 17-year-old boy--case report and review of the literature.

Benign tumours and primary malignant tumours of the ureter are uncommon in adults and extremely rare in children. The clinical symptoms are flank pain, urinary tract infection, and macro/micro-haematuria. There is an incomplete ureteral obstruction and filling defect on intravenous urography (IVU). Optimum treatment of this lesion results in renal preservation. Uretero-renoscopy is currently the best method available for the identification and histological diagnosis of ureteral polyps. Recommended operative procedures are pyeloureteric junction (PUJ) resection with Anderson-Hynes pyeloplasty, ureteric resection with end-to-end anastomosis or with uretero-cysto-neoanastomosis (UCNA), ureteric resection with renal autotransplantation. Ureteronephrectomy is not indicated. A case of ureteral polyps in a 17-year-old boy with the chief complaint of left flank pain is reported here. The excretory urogram and renal scan showed left hydronephrosis. Resection of the pyeloureteral junction, partial resection of the upper ureter containing the lesions--multiple branching 30-40 mm long polyps with a common basis--and Anderson-Hynes pyeloplasty were performed. The pathological diagnosis was benign fibroepithelial polyps of the ureter. Convalescence was uneventful and after 4 years of follow-up, excretory urogram and ultrasonography showed good renal function and improvement of hydronephrosis.     

尿液AQP2在先天性肾积水患儿中的检测和意义

目的研究单侧先天性肾盂输尿管连接处梗阻（pyeloureteric junction obstruction，PUJO）肾积水患儿尿液水通道蛋白2（Aquaporins-2，AQP2）测定在肾脏浓缩功能评价中的意义。方法选取12例正常儿童，26例单侧先天性PUJO肾积水患儿，其中轻度14例，重度12例，均经彩超、静脉。肾盂造影证实，并排除其它泌尿系统疾病；在严格设定条件下，收集正常对照组术前和梗阻解除术后第3天患肾24h尿液，同时收集术中。肾盂尿液，测定尿渗透压，并用酶联免疫吸附法（ELISA）测定尿液中AQP2。结果与正常对照组比较，积水组术中尿液AQP2和尿渗透压明显下降（P〈0．05），且重度积水组术中尿液AQP2与轻度积水组相比，明显降低（P〈0．05），但重度积水组和轻度积水组术中尿渗透压相比无显著差异（P〉0．05）；梗阻解除后，轻、重度积水组术中尿液AQP2与术后第3天相比，无显著差异（P〉0．05），而术后第3天两组尿渗透压却明显下降／P〈0．05），术后第3天重度积水组与轻度积水组尿液AQP2和尿渗透压相比较，显著下降（P〈0．05）；正常对照组与轻、重度积水组术后第3天尿液AQP2和尿渗透压之间存在一定相关性。结论小儿单侧先天性PUJO尿液AQP2和尿渗透压较正常对照组显著降低，且二者之间存在一定相关性。尿液中AQP2下降可能和尿液浓缩功能改变有关。     

MR imaging of kidneys: functional evaluation using F-15 perfusion imaging

BACKGROUND: Children with hydronephrosis are typically investigated by a combination of diuretic renal scintigraphy, ultrasound, and voiding cystourethrography. Unfortunately, there is no gold standard to assess obstruction. PURPOSE: The purpose of our study was to evaluate the utility of dynamic contrast enhanced MR urography in the investigation of children with hydronephrosis to define urinary tract anatomy, to calculate differential renal function and to assess urinary tract obstruction. MATERIALS AND METHODS: Dynamic contrast-enhanced MR imaging was performed in 40 children with unilateral hydronephrosis. There were 14 girls and 26 boys with an age range of 1 month to 14 years (mean 1.4 years). The information from traditional imaging modalities was compared to the information obtained from the single MR study. RESULTS: The anatomic imaging with MR urography was superior to other modalities. The split renal function was estimated with MR urography by calculating the volume of enhancing renal parenchyma and was comparable to renal scintigraphy ( r=0.98). By using surgery versus non-surgery as the decision point, with MR urography the sensitivity was 100%, specificity 71%, positive predictive value 86%, negative predictive value 100%, and diagnostic efficiency 90%. For renal scintigraphy the sensitivity was 96%, the specificity 56%, positive predictive value 76%, negative predictive value 90%, and diagnostic efficiency 79%. CONCLUSIONS: Dynamic contrast-enhanced MR urography provides superior anatomic and functional information when compared with ultrasound and diuretic renal scintigraphy. The information is gathered in a single study that does not use ionizing radiation. It is likely that MR urography will replace renal scintigraphy in the evaluation of hydronephrosis in children.     

Surgical or conservative treatment of congenital hydronephrosis. Ten years' experience

BACKGROUND: Controversy exists concerning the ideal management of hydronephrosis diagnosed in the perinatal period. Different opinions depend on the absence of an accurate tool and of well-defined cut-off values for each test. For these reasons we retrospectively evaluated our management protocol. METHODS: Two-hundred and seventy-two patients with single system hydronephrosis were evaluated. Patients with bilateral hydronephrosis or with other renal or ureteral abnormalities were excluded. Diagnosis and grading of hydronephrosis were done by ultrasound. Before 1995, grade II or greater hydronephrosis was also evaluated with diuretic intravenous urography, but in cases studied afterwards, a functional evaluation of the obstruction was reached with well tempered diuretic renogram. Indications for surgery were considered: recurrent urinary tract infections, grade IV hydronephrosis, obstructive drainage pattern and differential renal function less than 40%. Patients managed non-operatively received serial re-evaluation with US-scan, urine test and functional tests if necessary. RESULTS: Hydronephrosis was on the right side in 98 cases (36%), and on the left side in the other 174 (64%). There were 129 grade I hydronephrosis (47%), 46 grade II (17%), 57 grade III (21%), 40 grade IV (15%). Fifty-seven (21%) cases of hydronephrosis underwent surgery: 49 (86%) showing obstructive pattern at functional tests, 40 (70%) presenting a differential renal function less than 40%, 5 (8%) because recurrent urinary tract infections, 40 (70%) affected by grade IV hydronephrosis. No children received nephrectomy. Average postoperative follow-up was 2.8 years: pelvic dilatation improved or remained unchanged but the obstructive pattern at functional tests always disappeared after surgery. The average follow up in the observational group of 163 patients (60%) was 4.1 years. In 149 (91%) pelvic dilatation improved, but in 14 (9%) it remained unchanged. CONCLUSIONS: The ideal management of congenital hydronephrosis is still debated since the natural history of these disease is not still completely understood and there is no accurate tool to assess these renal units. We believe that grade IV hydronephrosis always need surgery as well as those ones with recurrent urinary tract infections, longer drainage time or a differential renal function less than 40%. On the other hand grade I hydronephrosis never need surgery. Mild grade hydronephrosis can be safely managed non-operatively with a meticulous follow-up and undergoing surgery only when signs of deterioration occur.     

Antegrade balloon dilation of postoperative ureterovesical junction obstruction in children

Obstruction of the ureterovesical junction is an uncommon but well-recognized complication of ureteral reimplantation that traditionally has been treated by surgical correction [1, 5–9]. We report our experience with antegrade balloon dilation (ABD) of these strictures in two children. Obstruction was confirmed by diuretic renogram and pressure perfusion studies prior to ABD. Clinical follow-up was done at 3 months and 14 months, and ultrasonographic studies revealed resolution of the hydronephrosis. In addition, diuretic renograms showed complete washout of radiotracer. Morbidity was limited to episodes of pyelonephritis that readily responded to medical management. ABD of ureteral strictures is a relatively simple procedure with a potential for a high success rate and low morbidity. This modality should be considered as the first line of treatment in patients with distal ureteral obstruction after reimplantation.     

Comparison Between Diuretic Urography (IVP) and Diuretic Renography for Diagnosis of Ureteropelvic Junction Obstruction in Children

Background:

Ureteropelvic junction obstruction (UPJO) is one of the most common causes of urinary tract obstruction in children. Several methods are used to diagnose upper urinary tract obstruction including renal ultrasonography (US), intravenous pyelogram (IVP), diuretic renography (DR), magnetic resonance urography (MRU) and antegrade or retrograde pyelography. Nowadays it is suggested to use diuretic renography as the best method for diagnosing of UPJO. There is no comparative study between IVP and DR scan for diagnosis of UPJO in children.

Objectives:

The aim of the present study was to compare IVP with furosemide injection and diuretic renography in diagnosis of clinically significant UPJO.

Patients and Methods:

This was a cross sectional study performed in 153 UPJO suspected children (121 boys, 32 girls) based on US findings in cases presented with urinary tract infection (UTI), prenatal hydronephrosis, abdominal/flank pain, abdominal mass and hematuria. Renal ultrasound was used as an initial screening tool for detection of urinary tract abnormality. Vesicoureteral reflux (VUR) was ruled out by voiding cystourethrography (VCUG). Serum creatinin, blood urea nitrogen, urinalysis and urine culture was screened in all cases. IVP with furosemide and DR were performed as soon as possible after the mentioned workup.

Results:

During a five year period, 46 out of 153 patients were diagnosed as UPJO based on diuretic renography: the age ranged from 4 months to 13 years (mean: 3.1 ± 0.78 years). There was a significant higher (76%) proportion of UPJO in the boys and in the left side (78%). The sensitivity of IVP with furosemide injection in diagnosis of UPJO was 91.3% whereas DR was accepted as standard for diagnostic procedure in diagnosis of UPJO.

Conclusions:

Although DR is accepted as the best method for diagnosis of UPJO, we found a small sensitivity difference between IVP and DR in kidneys with normal or near normal function. In many settings such as small cities lacking facilities for advanced isotope imaging technology, use of IVP with diuretic maybe an acceptable procedure for diagnosis of UPJO.     

胃管作支撑引流管在小儿肾盂成形术中的应用

目的 离断式肾盂成形术是治疗小儿肾盂输尿管连接处梗阻的最常见手术，但在术后尿液引流方式，吻合口是否需要支撑等问题上仍存在争议。我们回顾性总结7年来采用胃管作支撑引流管行离断式肾盂成形术的300余例患儿资料。方法 1994年6月至2001年9月，采用胃管作支撑引流管行离断式肾盂成形术300例。共304侧，均为肾盂输尿管连接处梗阻患儿，其中又侧4例。19例患儿（19侧）另放置了肾造瘘管。术后随访B超，IVU，利尿性肾图，尿常规等，随访期6个月至7年，结果 3例患儿（0.98%)出现肾盂输尿管连接处再狭窄。2例术后出现尿路结石，其余患儿随访显示吻合口通畅，肾功能得到保存或提高，未见尿路感染。结论 胃管作为支撑引流管应用于肾盂成形术是可靠的，具有反应小，引流完全，术后处理简便，可行冲洗，造影，测压检查等诸多优点。     

肾积水患儿的肾功能评估与结局预判

儿童肾积水目前的诊疗方案以保守观察为主,出现明确手术指征的肾积水患儿才进行手术治疗。然而,该诊疗方案历经几十年仍存在争议,各项检查对梗阻和肾功能受损的诊断能力、手术干预的指征和时机等问题尚未达成共识。目前肾积水的主要检查手段包括超声、同位素肾图、核磁共振等。基于对患者数据的观察分析得出的临界值、比值、分级和积分系统有助于判断哪些先天性肾盂输尿管连接部梗阻(ureteropelvic junction obstruction,UPJO)情况需要手术,而哪些可以继续观察随访;目前没有哪一项指标在诊断的敏感度和特异度上占据绝对优势。机器学习等较新的数据分析方法也正在被应用于肾积水的诊断,帮助提高超声和肾动态显像的诊断价值。此外,对尿液生物标志物诊断价值的探索工作也正在开展。本文将总结儿童肾积水的诊断方法在肾功能评估和结局预测中的价值,并对其最新进展进行评述。     

MRU在小儿泌尿系梗阻的诊断意义

目的 比较泌尿系梗阻的各种影像学诊断方法，讨论磁共振尿路造影(MRU)对泌尿系梗阻的诊断意义。方法 分析23例患儿术前行MRU检查的资料，与B超、静脉尿路造影(IVU)、逆行尿路造影、CTU等影像学诊断资料进行对比。结果 23例B超检查15例显示明确，静脉尿路造影有7例不显影或显影不清，CTU检查12例，其中8例显影，4例显影不清楚。MRU检查23例，均显影清楚。结论 MRU能显示无功能性肾脏集合系统，还有无需碘造影剂的优点，在儿童泌尿系梗阻辅助检查中有着重要作用。