输尿管膨出的微创手术治疗

目的评价输尿管膨出的微创手术治疗方法及其疗效。方法回顾性总结22例输尿管膨出经尿道电切手术治疗输尿管膨出的临床资料。结果22例患者手术一次成功21例，术后定期B超、膀胱造影随诊，随诊时间6—60个月。1例异位输尿管膨出合并重复肾、输尿管畸形患者存在术后膀胱输尿管返流，再次行开放手术后痊愈。结论经尿道电切术是治疗输尿管膨出简单、有效、微创的治疗方法。     

腹腔镜输尿管膀胱再植术治疗重复肾输尿管异位开口4例报告

目的:探讨腹腔镜输尿管膀胱再植术治疗重复肾输尿管畸形伴异位输尿管开口的临床应用价值。方法:回顾性分析2013年1月~2014年8月,我院采用术前预置输尿管支架管联合腹腔镜输尿管膀胱再植术治疗4例重复肾输尿管异位开口患者的临床资料。结果:所有手术均顺利进行,手术平均时间150min,术中平均出血量25ml,平均住院时间12d,术后1例患者发热,其余患者无并发症发生;术后随访2~12个月,所有患者均无漏尿、输尿管反流和梗阻发生。结论:术前预置输尿管支架管联合腹腔镜输尿管膀胱再植术治疗重复肾输尿管异位开口,具有术中出血少、术后恢复快、住院时间短、并发症少等优点,是一项安全有效的手术。     

成人输尿管囊肿13例报告

目的总结成人输尿管囊肿的诊治经验。方法对住院手术的13例输尿管囊肿患者的临床资料进行回顾性分析。结果所有病例均经B超、静脉肾盂造影（IVU）及膀胱镜检查确诊,采用开放手术治疗者2例,采用经尿道输尿管囊肿电切术治疗者11例。术后平均随访8月,疗效确切。结论对成人输尿管囊肿直径≤3．0cm者宜行腔内手术,而对于直径〉3cm及合并严重的重复肾、重复输尿管畸形者宜采用开放性手术,并行输尿管再植抗返流。     

重复肾输尿管合并输尿管囊肿的诊疗进展

重复肾是常见的泌尿系畸形,这种畸形常无临床症状。部分病人被发现是由于肾积水、膀胱输尿管返流或尿失禁。重复肾常伴有重复输尿管和输尿管囊肿。重复输尿管常伴输尿管返流或输尿管异位开口。目前,诊断重复肾输尿管、输尿管囊肿的方法主要有以下几种:B超、排泄性尿道造影、螺旋CT尿路成像(CTU)和磁共振尿路成像(MRU);治疗的方法主要是通过手术。本文主要对重复肾输尿管伴输尿管囊肿的诊断及治疗最新进展作一概述。     

成人重复肾畸形并肾积水的诊疗分析

目的分析总结成人重复肾畸形并肾积水的诊疗方案。方法回顾性分析40例成人重复肾畸形并肾积水患者的临床资料,其中男性11例,女性29例,年龄18～77岁。并发重度肾积水29例,轻度肾积水11例。结果 29例重度肾积水患者均行肾部分切除术,其中开放手术23例,腹腔镜手术6例;11例轻度肾积水患者中5例行输尿管膀胱再植术,5例行输尿管囊肿电切术,1例行肾盂成形术。40例患者中3例出现术后并发症。结论成人重复肾畸形并重度肾积水者应行肾部分切除术,腹腔镜较之开放手术具有创伤小、出血少、恢复快等优点;轻度肾积水者可通过解除膀胱输尿管返流、输尿管口囊肿、肾盂输尿管连接部梗阻等改善肾功能。     

钬激光治疗输尿管口囊肿

目的探讨钬激光治疗输尿管口囊肿的疗效。方法2004年4月~2006年6月钬激光治疗输尿管口囊肿10例12侧,其中单纯输尿管口囊肿9侧,合并输尿管口结石3侧。结果手术均一次成功,平均手术时间47min,术后平均住院5d。术后定期B超、膀胱造影随诊1~3年,无复发,无输尿管反流。结论钬激光治疗输尿管口囊肿疗效确切、可靠。     

女童重复肾输尿管开口异位合并漏尿的诊治

目的 总结女性重复肾输尿管开口异位合并漏尿的诊治经验. 方法 重复肾输尿管异位开口合并漏尿女童25例.年龄2～12岁,平均7岁.右侧15例、左侧10例,其中双侧重复肾仅1侧输尿管开口异位1例.均因会阴部漏尿并外阴痒痛就诊,经查体、影像学检查确诊.其中重复肾重度积水无功能4例,重复肾存在分泌功能21例.无功能重复肾4例行重复肾及输尿管全长切除,余21例行重复输尿管下段膀胱再植术. 结果 25例手术均成功,无漏尿及输尿管残端综合征发生.4例重复肾切除者术后12个月IVU显示患侧残肾形态及功能正常,21例重复输尿管膀胱再植者术后3个月膀胱造影显示再植输尿管无反流20例,12个月复查IVU息侧肾脏及重复肾形态功能良好;1例术后6个月重复肾积水加重,功能丧失,再次手术切除重复肾及输尿管. 结论 B超、IVU、MRU是诊断重复.肾输尿管开口异位合并漏尿的重要手段,螺旋CT多维成像能清晰显示患肾及重肾输尿管结构及其走向.手术是治疗该病的主要方法,术前应着重了解重复肾功能、输尿管形态及走向.手术方式应以解除梗阻、解决漏尿及保护患肾及重复肾功能为原则.     

输尿管开口异位的外科治疗体会（附51例报告）

目的：总结输尿管开口异位的诊断方法和外科治疗经验,提高对该病的诊疗水平。方法：回顾性分析1997年5月～2012年6月就诊的输尿管开口异位患者51例临床资料,对各种手术方法以及术后情况进行比较讨论。结果：行输尿管膀胱再植术33例,肾输尿管切除术3例,上半重复肾肾输尿管切除术7例,异位输尿管囊肿切除术8例。术后获得随访患者35例,随访时间0．5～8年。仅1例患者仍有尿失禁,但程度较术前明显减轻。1例患者仍有泌尿系感染发作（每年l～2次）,16例输尿管再植患者复查B超患。肾积水较术前减轻。结论：输尿管开口异位多合并有重复集合系统、异位肾脏发育不良、输尿管末端囊肿等上尿路畸形,术前需明确输尿管异位开口部位和相应肾脏功能,据此制定合适的手术治疗方案。     

成人输尿管囊肿11例报告

目的：总结成人输尿管囊肿的诊治经验。方法；对住院手术治疗的１１例本病虱临床资料进行分析。结果：均经Ｂ超，ＩＶＵ及膀胱镜检查确诊。开放手术２例，经尿道输尿管囊肿电切开术９例。１０例获术后随访，疗效确切。结论：对囊肿直径≤３．０ｃｍ者宜行经尿道电切开术，面对直径〉３．０ｃｍ及合并严重的重复肾重复输尿管畸形者应采取开放性手术，并行输尿管再植抗反流。     

经尿道电切开窗术治疗小儿输尿管囊肿

目的 总结经尿道电切开窗治疗小儿输尿管囊肿的经验及疗效。方法 1988—2003年采用经尿道电切开窗治疗小儿输尿管囊肿88例共134个。年龄2个月～13岁，男37例，女51例。双侧46例，单侧42例。术前症状：排尿困难42例、泌尿系感染13例、腹痛22例、血尿6例、尿道口囊肿脱出9例、膀胱输尿管返流（VUR）3例。合并双侧重肾双输尿管25例、单侧重肾双输尿管20例、肾／半肾积水18例、囊肿内结石4例、输尿管异位开口1例。膀胱镜直视下囊肿切开：直径≤2cm囊肿采用基底部横切口，〉2cm囊肿采用顶部纵切口，双侧囊肿同时切开。其中2例电切2次，其余均为1次切开。结果随访6个月～15年。VUR13例：VUR〉IV度4例，1年后行抗返流性输尿管膀胱再植痊愈；9例4年内VUR消失。肾／半肾积水18例：15例3年内、3例10年后积水消失。88例患儿术后1年囊肿均消失。结论 经尿道电切开窗治疗小儿输尿管囊肿是一种安全、简单、有效的微创疗法。     

小儿输尿管膨出症的治疗

目的探讨各种方法治疗输尿管膨出症的疗效,寻找影响预后的有关因素。方法 31例输尿管膨出症,男4例,女27例;左侧15例,右侧12例,双侧4例。其中单一输尿管膨出2例,重肾并输尿管膨出29例。VCU检查18例,3例发现中—重度反流,31例均行超声和IVU及CT检查。结果术后随访0.5～3 a,2例单一输尿管膨出症行膨出切除输尿管膀胱再植术,29例重肾中,4例经膀胱行输尿管膨出切除输尿管膀胱再植术。3例中—重度反流,2例行输尿管膨出切除加上半肾切除术,1例行上半肾切除术,术后因反流持续存在,需再次手术;其余22例均行上半肾切除术,术后2例因严重尿路感染行输尿管残端切除术。结论输尿管膨出的治疗应根据输尿管膨出的类型、肾功能、有无反流决定手术方式,对于大多数重肾,单纯上半肾切除预后良好,若术前VCU检查有中—重度返流,应行完全重建术。     

MANAGEMENT OF ECTOPIC URETEROCELE ASSOCIATED WITH RENAL DUPLICATION: A COMPARISON OF PARTIAL NEPHRECTOMY AND ENDOSCOPIC DECOMPRESSION

PURPOSE: We compared the efficacy of primary endoscopic decompression versus partial nephrectomy for treating ectopic duplex ureteroceles. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with renal duplication and upper pole ectopic ureterocele. Patients were classified according to the initial radiological evaluation. The operation performed was arbitrarily chosen by the surgeon. RESULTS: A total of 54 patients had unilateral upper or bilateral upper pole ureterocele with no associated vesicoureteral reflux. Partial nephrectomy was performed in 26 patients, of whom 4 (15%) required additional surgery for new onset ipsilateral lower pole reflux. Endoscopic decompression was performed in 28 patients, of whom 18 (64%) required additional treatment due to reflux into the ipsilateral lower pole ureter and ureterocele in 9, reflux into the ureterocele only in 4, ipsilateral lower pole reflux only in 3 and persistent ureterocele obstruction in 2 (p<0.01). An ectopic ureterocele with vesicoureteral reflux into 1 or more moieties was identified in 111 patients, including 56 of 67 (84%) treated with partial nephrectomy and 37 of 44 (84%) treated with endoscopy who have persistent reflux or required further surgery for reflux resolution. CONCLUSIONS: In patients with an ectopic ureterocele and no vesicoureteral reflux partial nephrectomy should be considered the treatment of choice. However, when the initial cystogram reveals vesicoureteral reflux, partial nephrectomy and endoscopic ureterocele decompression have identical definitive cure rates of only 16%. The majority of the latter patients require continued observation and/or additional surgery for managing persistent reflux.     

The modern endoscopic approach to ureterocele

PURPOSE: During the last 20 years the surgical approach to ureterocele has evolved from major open surgery to minimally invasive endoscopic puncture. We believe that the endoscopic approach decreases the need for open surgical procedures. We identified specific factors that predict the need for repeat surgery. MATERIALS AND METHODS: We reviewed the charts of 60 new patients with ureterocele treated with primary endoscopic incision between 1991 and 1995. Followup ranged from 4 to 62 months (mean 20). Mode of presentation, ureterocele location, associated vesicoureteral reflux and association of the ureterocele with a duplex system were evaluated. Ureterocele wall thickness was assessed subjectively via radiographic and cystoscopic methods, and categorized as thin, intermediate and thick. RESULTS: All 9 patients with a single system ureterocele had an intravesical ureterocele. No patient had associated reflux nor did any require a secondary open procedure. In 3 cases new onset ipsilateral reflux into the ureterocele spontaneously resolved. Of the 51 patients with a duplex system and associated ureterocele 19 (37%) required a secondary open procedure. The ureterocele was intravesical and ectopic in 22 (43%) and 29 (57%) cases, respectively. Reflux was associated with the ureterocele in 27 patients (53%), and 12 (44%) required a secondary open procedure. A total of 11 patients underwent ureteral reimplantation of 15 refluxing renal units and only 2 renal units required ureteral tapering. Reflux is no longer present in 14 of the 15 renal units (93%). Patients with a thick walled ureterocele required repeat puncture more frequently than those with a nonthick ureterocele. CONCLUSIONS: With the use of modern endoscopic techniques children with intravesical and single system ureteroceles require secondary open surgery less frequently than those with ectopic and duplex system ureteroceles. The mode of presentation does not predict the need for a repeat open procedure. Thick walled ureteroceles require repeat endoscopic puncture more frequently than thin and intermediate walled ureteroceles.     

Laser incision of ureterocele in the pediatric patient.

PURPOSE: We evaluated the effectiveness of initial laser transurethral incision of ureterocele for relieving obstruction, prevention of infection and need for subsequent surgery. MATERIALS AND METHODS: We reviewed the medical records and imaging studies of 30 children with ureterocele treated between 1995 and 2000. Of 30 children 14 underwent initial transurethral laser incision of the ureterocele. Records and images were evaluated for mode of presentation, ureterocele location, thickness, and decompression, and relief of obstruction. The incidence of urinary tract infection, new onset vesicoureteral reflux, upper segment renal function and need for subsequent surgery after incision was investigated. RESULTS: There were 5 boys and 9 girls in our series. Mean patient age at presentation was 17.5 months. There were 12 patients who had ectopic and 2 orthotopic ureteroceles. Ureterocele was defined as thick if ultrasound measurement was 4 mm. or greater. Thick ureterocele was present in 4 (28%) patients. All patients had ultrasound evidence of decompression of the ureterocele and upper tract with 1 treatment. Urinary infection risk was 0.015 per month of followup after incision. Vesicoureteral reflux was present in 8 of 12 (67%) ectopic systems before incision and 9 of 10 (90%) after. None had resolved reflux during followup. Upper pole renal function was assessed by renal scan and/or renal ultrasound. Upper pole function or increased cortical thickness was documented in 9 of 11 (82%) patients. Endoscopic laser incision was the only treatment required in 4 of 14 (28%) patients, including 2 with orthotopic and 2 ectopic ureteroceles. Of 14 patients 5 (36%) had undergone definitive surgery and 5 were followed. CONCLUSIONS: Endoscopic laser incision of ureterocele allows a precise incision and decompression of the ureterocele with 1 treatment. Laser incision of ureterocele should be considered as the initial treatment in most patients.     

Surgical correction of ureteroceles in childhood

Ureteroceles can present complex problems, but appropriate reconstructive surgery can abolish urinary infection in nearly all cases. It does not suffice to resect or unroof a ureterocele, for this creates vesicoureteral reflux. Instead, for small ureteroceles, total resection by open technique should be carried out, together with reimplantation of the ureter. In large ureteroceles, usually with duplex kidney, removal of the ureterocele and its associated ureter, reimplantation of the ipsilateral ureter, and sometimes the contralateral ureter, should be performed. The associated upper pole renal segment should be removed in most instances; occasionally it can be saved, anastomosing it to the adjacent lower pole renal pelvis. Although management of an individual case must vary with anatomy, age of the patient, etc., the fundamental goals remain identical in all cases: relief of obstruction, removal of destroyed renal segments, and surgical correction of vesicoureteral reflux.     

Outcome of patients with prenatally detected duplex system ureterocele; natural history of those managed expectantly

PURPOSE: We assessed the outcome of patients treated for prenatally detected duplex system ureterocele with particular reference to those treated expectantly. MATERIALS AND METHODS: We reviewed the records of 52 consecutive patients treated between 1984 and 1999 with a median followup of 8 years (range 1 to 16.2). RESULTS: Of the 38 patients who underwent surgical treatment 13 subsequently required unplanned secondary procedures. A total of 14 cases satisfying currently defined criteria, including less than 10% upper renal pole function, an unobstructed lower pole (absent nonrefluxing hydroureteronephrosis), lower pole vesicoureteral reflux not exceeding grade III and unobstructed bladder outflow, were managed expectantly with a median followup of 8 years (range 1.6 to 12.8). In this group of patients prophylactic antibiotics were routinely prescribed until the completion of toilet training or age 5 years in those with persistent reflux on repeat cystography. None has required surgery or had symptoms or urinary infection. In 6 cases followup ultrasonography showed substantial resolution of upper pole hydronephrosis with a collapsed ureterocele. Furthermore, 7 of the 38 patients who underwent surgical treatment early in our series would have been treated expectantly had the current criteria been applied. CONCLUSIONS: In 14 of the 52 patients (approximately 27%) with prenatally detected duplex system ureterocele the natural history of the complaint is essentially benign within the currently available followup.     

Reflux nephropathy in infancy: a comparison of infants presenting with and without urinary tract infection.

PURPOSE: We compared the incidence of renal scarring in infants with high grade vesicoureteral reflux in those presenting with and without urinary tract infection. METHODS AND METHODS: We reviewed the medical records of 81 male and 46 female infants (194 renal refluxing units) with a mean age of 4 months who had grade IV or V primary vesicoureteral reflux and underwent an anti-reflux procedure between 1984 and 1997. Dimercapto-succinic acid (DMSA) scans and voiding cystourethrography were performed in all cases. Patients were followed for 2 to 16 years, including 90% for greater than 3 years. Renal ultrasound and DMSA scan were done at followup. RESULTS: A total of 97 patients (76%) (148 refluxing renal units) presented clinically with urinary tract infection. The initial DMSA scan demonstrated renal scarring in 40 of the 106 grade IV (38%) and 28 of the 42 grade V (67%) refluxing renal units. There was no scarring on followup in previously normal refluxing renal units. Of the patients 30 (24%) (46 refluxing renal units) were diagnosed before a urinary tract infection developed, 16 underwent screening due to vesicoureteral reflux in a sibling and in 10 reflux was initially suspected due to hydronephrosis on prenatal ultrasound. In the remaining 4 patients vesicoureteral reflux was suspected during abdominal ultrasound to investigate abdominal pain, jaundice, associated hypospadias and fetal alcohol syndrome, respectively. DMSA scan showed evidence of scarring in 6 of 21 grade IV (29%) and 9 of 25 grade V (36%) refluxing renal units in this group. Followup revealed scarring in only 1 previously normal refluxing renal unit. CONCLUSIONS: The incidence of reflux nephropathy in primary grade V vesicoureteral reflux is lower in cases detected by screening and with treatment it remained lower than in cases of urinary tract infection that presented clinically. Early treatment of grade V vesicoureteral reflux made possible by screening may prevent renal damage.     

Ipsilateral ureteroureterostomy for the treatment of vesicoureteral reflux or obstruction associated with complete ureteral duplication

PURPOSE: We reviewed our experience with ureteroureterostomy as definitive treatment for vesicoureteral reflux or obstruction associated with ureteral duplication to determine the efficacy and morbidity of this procedure and identify factors that affect outcome. MATERIALS AND METHODS: We performed a total of 100 ureteroureterostomies in 94 children with an average age of 28 months during the 23-year period ending May 1999. Four patients (4 kidneys) failed to return for postoperative evaluation. Followup was 2.5 to 206 months (mean 33). Indications for surgery were vesicoureteral reflux in 53 cases, obstructing ureterocele in 19, ureterocele with upper pole reflux in 4, an ectopic obstructed upper pole ureter in 18 and other in 2. In 23 kidneys ureteroureterostomy was combined with reimplantation of the recipient ureter. Surgery was considered successful when postoperative imaging revealed no reflux or obstruction and a patent ureteroureterostomy anastomosis. RESULTS: Ureteroureterostomy with or without ureteroneocystostomy was successful for treating 94% of kidneys, including 51 of 53 with reflux, 21 of 23 (91%) with ureterocele and 17 of 18 (94%) with an ectopic obstructed upper pole ureter. Significant ureteral size disparity, defined as a donor ureter diameter greater than 2-fold that of the recipient ureter, was noted in 69 kidneys. The most common complication (13 patients) was prolonged output from the Penrose drain. However, this complication did not result in a failed procedure in any case. CONCLUSIONS: Ipsilateral ureteroureterostomy is safe and efficacious for treating abnormalities associated with ureteral duplication. A significant discrepancy in ureteral size does not preclude ureteroureterostomy.