腹腔镜全膀胱切除回肠膀胱术中输尿管引流的策略

目的探讨腹腔镜全膀胱切除回肠膀胱术(Bricker)中不同输尿管引流方法的临床效果。方法采用Bricker术治疗膀胱癌患者126例。输尿管支架引流管的应用包括双J管引流(A组)37例,F8吸痰管引流(B组)47例,单J管引流(C组)42例。对输尿管支架引流管相关资料进行比较。结果 A组5例输尿管代膀胱吻合口漏尿,4例充分引流后好转,1例引流后仍无好转,局部探查重新吻合后恢复。输尿管代膀胱吻合口不全狭窄A组和B组各1例。术后A组普通留置的双J管于膀胱镜下拔除,2例出现一侧双J管回缩的患者采用经皮肾通道拔除,尾部留有丝线的患者直接在丝线的牵拉下拔除双J管,其中8侧出现丝线断裂或撕脱,改由膀胱镜拔管。B组将固定在代膀胱引流管上的输尿管支架管同代膀胱引流管一并拔除。C组拔除情况同B组,拔管过程均顺利。结论不同的输尿管支架管引流策略对术后的恢复和后期处理具有显著的影响,代膀胱外引流较膀胱内引流具有明显的优势。     

漏斗形生物降解材料输尿管支架的动物实验研究

目的 设计漏斗形生物降解材料输尿管内支架，探讨该支架在上段输尿管梗阻治疗中应用的可行性。方法 制备己内酯丙交酯乙交酯三元共聚材料（PCLGA20：60：20），并加工成漏斗形支架管。雄性家犬4只，体重12～15kg，通过手术方法建立输尿管上段不完全梗阻动物模型；在此基础上行输尿管狭窄段切除吻合术，术中留置漏斗形PCLGA支架管支撑引流；术后定期行IVU检查，并于术后12周行术侧输尿管组织病理学分析。结果 4只犬成功建立输尿管上段梗阻动物模型。漏斗形PCLGA支架管内引流效果良好，肾盂及输尿管扩张积水逐渐缓解；6～8周支架管密度减低，陆续发生断裂，断裂的支架管并未造成输尿管梗阻；术后12周支架管完全降解并排出体外，吻合段输尿管无狭窄，造影剂通过顺畅，局部组织病理学改变轻微，仅见移行上皮细胞增生和固有层增厚。结论 漏斗形PCLGA支架管生物相容性良好，降解时间适宜，在上段输尿管手术中具有良好的内引流效果。     

经皮顺行球囊扩张治疗输尿管-肠吻合口狭窄

目的：评价经皮肾穿刺顺行球囊扩张治疗尿流改道术或原位膀胱术后输尿管-肠吻合口狭窄治疗效果。方法：对15例尿流改道术或原位膀胱术后患者，共25处输尿管-肠吻合口狭窄，采用经皮肾穿刺顺行球囊扩张，并置入输尿管支架管6周进行引流治疗。结果：本组15例中，2例双侧和1例单侧狭窄患者因导丝不能通过狭窄处，扩张失败。其余8例双侧狭窄、4例单侧狭窄患者均成功完成扩张，其中9例拔除支架管后症状好转，血肌酐下降及肾积水保持稳定，随访时间3～29个月（平均13个月），有效率60％；另3例拔除支架管后1～3个月，血肌酐进行性上升，予以再次留置输尿管内支架管并定期更换。结论：经皮肾穿刺顺行球囊扩张治疗输尿管-肠吻合口狭窄，创伤小，操作简单，可替代开放手术作为首选治疗方案。     

自制肾盂输尿管支架造瘘管的临床应用

在52例开放性手术中，采用国产输尿管导管和肾蕈形造瘘管按病情需要组合置于肾盂输尿管内，起引流，冲洗，支架等作用，术后残余小结石掉入肾盂输尿管交界处2处，继发性出血1例，未出现管腔堵塞，继发感染，吻合口狭窄及伤口漏尿等其他并发症，自制肾盂输尿管支架造瘘造制作简单，使用简便，应用效果良好。     

多孔支架双向引流管在回肠代输尿管术中的应用

1979～1998年我们共作回肠代输尿管术17例,其中10例采用我们设计的多孔支架双向引流管,临床效果满意。1.临床资料:本组17例,男11例,女6例,年龄22～63岁。肾结石及肾盂整形术后肾盂闭锁并狭窄13例、输尿管镜及肾移植术后长段输尿管狭窄2例、输尿管癌及转移癌2例。17例均行单侧替代,其中全长替代15例、部分替代2例。10例全长替代者采用多孔支架双向引流管,7例采用由回肠、膀胱或肾造瘘口引出的单向引流管。置管方法及术后处理;选用Ｆ1618硅胶管,由肾造瘘引入,通过回肠代输尿管,再由膀胱造瘘口引出。在引流管两端腰、腹部外露处,以胶管垫固定。…     

膀胱全切除后施行回肠代膀胱尿道吻合术的体会

自1973～1986年对14例膀胱全切除的患者施行了回肠代膀胱尿道(或前列腺被膜)吻合术。术后病人均能从尿道排尿,无尿失禁。未发生输尿管回肠吻合口瘘,吻合口狭窄及肠梗阻等手术并发症。经3～13年随访的8例,回肠代膀胱及尿道内无肿瘤复发。部分病例作了静脉肾盂造影,显示肾功能良好,输尿管不扩张,无肾积水。     

肾盏造瘘技术在小婴儿重度肾积水腹腔镜肾盂成形术中的应用

目的探讨小婴儿重度肾积水行腹腔镜肾盂成形术中输尿管双J管置入失败,应用肾盏造瘘替代输尿管双J管引流的效果。方法 2016年4月～2017年6月6例小婴儿重度肾积水肾盂成形术中放置输尿管双J管失败,经肾盏留置吻合口支架管和肾盂造瘘管,替代输尿管双J管的引流作用。术后2～3周拔除吻合口支架管,夹闭肾盂造瘘管行亚甲蓝排泄试验阴性后拔除肾盂造瘘管。结果 6例患儿术中行肾盏造瘘,顺利留置吻合口支架管和肾盂造瘘管,术后肾盂造瘘管引流通畅。拔除吻合口支架管,夹闭肾盂造瘘管和拔管后患儿均无发热、呕吐及哭闹不适。4例术后1、3、6、12个月随访,超声或CT示肾积水明显减轻(肾盂前后径1 cm,肾盏扩张0. 5 cm),肾皮质逐渐增厚至0. 5～1. 0 cm(术前肾皮质最薄处仅1mm),肾脏形态接近正常; 2例患儿术后6个月复查肾核素扫描示分肾功能接近正常,分别为47. 3%、48. 2%(分肾功能50%为正常)。结论肾盏造瘘技术在小婴儿重度肾积水腹腔镜肾盂成形术中的辅助作用确切,效果良好。     

膀胱软镜下逆行留置单J管治疗回肠膀胱术后输尿管回肠膀胱吻合口狭窄

输尿管-回肠膀胱吻合口狭窄是回肠膀胱术(Bricker术)后常见并发症之一.2008年1月至2010年9月我们采用膀胱软镜下经造口逆行留置单J管治疗Bricker术后输尿管回肠膀胱吻合口狭窄患者7例,现报告如下.     

经皮肾通道顺行输尿管软镜技术处理回肠输出道术后输尿管回肠吻合处狭窄的临床应用

目的 探讨经皮肾通道顺行输尿管软镜技术处理回肠输出道术后输尿管回肠吻合处狭窄的有效性及安全性。方法 回顾性总结2017年1月至2019年12月,同济医院泌尿外科收治的16例膀胱根治性切除结合回肠输出道术后发生输尿管回肠吻合处狭窄梗阻的患者,采用经皮肾通道顺行输尿管软镜联合输尿管硬镜的术式行腔内手术治疗。术后3d复查腹部平片及泌尿系CT以检查输尿管支架管位置及肾积水情况,术后7d复查血肌酐以检查肾功能恢复情况。术后2～3个月后经回肠输出道造口拔除输尿管支架管,每3个月复查1次,随访12个月。结果 共进行18侧手术,17侧顺利完成,1侧因输尿管迂曲角度过大而未能完成手术;所有手术患者未出现严重并发症,有3例出现发热,9例患者术后出现短暂持续性血尿;手术时间为35～130min,平均(53.7±16.5)min。术后3d复查腹部平片及泌尿系CT,患侧肾积水均有不同程度缓解。术后随访12个月,13侧在随访期内患侧肾积水无明显加重,肾功能持续稳定。术后随访中有4侧出现狭窄复发,复发时间在术后4～6个月。结论 经皮肾通道顺行输尿管软镜联合输尿管硬镜处理回肠输出道术后输尿管回肠吻合处狭窄具有较好的临床应用价值。     

输尿管镜下双 J管置入术治疗输尿管损伤的疗效分析（附36例报告）

目的：探讨输尿管镜手术治疗输尿管损伤的临床疗效。方法回顾性分析2006年1月～2013年12月采用输尿管镜下置入双J管内引流治疗36例输尿管损伤患者的临床资料。结果33例顺利经输尿管镜置入双J管引流，术后1～3周停止漏尿，其中13例术后1～3个月拔除双J管，20例盆腔肿瘤放疗者术后5～11个月拔除或更换进口巴德（ BADE）内支架管，术后随访3个月～6年，泌尿系CT成像（ CTU）检查证实患侧输尿管通畅，6例肾积水及输尿管扩张较前明显减轻，其余正常。1例腹腔镜下全子宫切除术中发现右侧输尿管损伤，术后40天拔出双J管后输尿管阴道瘘，因局部瘢痕及漏口较大，再次置管失败，改行输尿管膀胱再植术。2例因前列腺癌或宫颈癌放疗后严重输尿管狭窄，行永久性双肾造瘘术。结论输尿管镜下置入双J管内引流术治疗输尿管损伤的疗效可靠，微创，患者易于接受。     

Negative Pressure Wound Therapy Used to Heal Complex Urinary Fistula Wounds Following Renal Transplantation into an Ileal Conduit

Transplantation into an ileal conduit is an established option for patients with end‐stage renal failure and a nonfunctioning urinary tract. Urinary fistulae are more common following these complex transplants. Urinary fistula in this scenario can cause substantial morbidity and even result in graft loss. The management options depend on the viability of the transplant ureter, the level of local sepsis and the overall condition of the patient. Urinary diversion with a nephrostomy and ureteric stents has been described in aiding the healing of urinary leaks in renal transplants into a functioning urinary tract. We describe the successful use of negative wound pressure therapy to eradicate the local sepsis and help the healing of a recurrent urinary fistula following kidney transplantation into an ileal conduit. To our knowledge these are the first such cases reported in the literature.     

肾移植术后尿瘘的治疗策略研究(附72例报告)

目的探讨肾移植术后尿瘘并发症的治疗策略。方法回顾性分析2008年6月至2012年12月在解放军第309医院全军器官移植研究所接受同种异体肾移植术的1 228例患者中,术后发生尿瘘的72例患者的临床资料。结果本组尿瘘发生率为5.86%。患者确诊后,首先保持输尿管支架管留置状态,并采取留置Foley导尿管的方法,在确认无效后在原创口或引流口置入普通导尿管或乳胶管引流,最后采取手术治疗,均采用无张力吻合。72例尿瘘患者中,46例经保守治疗后治愈,26例保守治疗无效后采用手术治疗,其中12例行瘘口修补术+留置膀胱Foley导尿管、10例行输尿管-膀胱重新吻合术+置入输尿管支架治愈,4例行输尿管-膀胱肌瓣吻合术无效后,行自体输尿管-移植肾输尿管吻合术后治愈。2例出现局部伤口感染,经加强引流及抗感染治疗后治愈。结论肾移植术后尿瘘预防胜于治疗,早期诊断、正确选择治疗措施是成功救治的关键。患者确诊后,首先采用保守治疗,确认无效后采取手术治疗,遵循无张力吻合原则。     

球囊扩张术联合双根D-J管在治疗良性输尿管狭窄中的疗效分析

目的 探讨双根D-J管联合球囊扩张术在治疗良性输尿管狭窄的疗效,分析其安全性及有效性.方法 通过回顾分析本单位12例良性输尿管狭窄围手术期患者及随访相关资料.所有患者诊断为良性输尿管狭窄,患侧输尿管接受了巴德球囊扩张术,放置两根4.8F输尿管内支架管,留置时间为3个月.取出支架后行输尿管镜检术评估输尿管狭窄情况及此后第...     

移植肾输尿管膀胱的吻合口瘘

目的：有效地减少或避免同种异体肾移植术后移植肾输尿管膀胱吻合口瘘,延长移植肾的存活期。方法：从病因,诊断和处理方面回顾性分析30例肾移植患者术后移植肾输尿管膀胱吻合口瘘的临床资料。结果：4例采用保守治疗,2例做单纯瘘口修补。11例切除血供差,水肿严重的移植肾输尿管远端,或调整移植肾的位置,做移植肾输尿管膀胱再吻合。13例膀胱翻瓣后,用20－24Foley尿管连接供肾的肾盂和受者膀胱瓣,其中9例无法实现残留的移植肾输尿管与膀胱瓣无张力的间断缝合,只能待移植肾肾盂或上段输尿管沿Foley尿管爬行,形成隧道。受者1年存活率96.7%(29/30),移植肾1年存活率为86.7%(26/30)。结论：肾移植的任何步骤处理不当都可以引起移植肾输尿管膀胱吻合口瘘;术后应根据输尿管血液供应,水肿情况,瘘口大小和输尿管的长度来选择不同的术式,以确保无张力的可靠吻合。     

The effect of length of ureteral resection on benign ureterointestinal stricture rate in ileal conduit or ileal neobladder urinary diversion following radical cystectomy

ObjectivesTo assess the effect of the length of the ureter resected and other clinical variables on ureterointestinal anastomotic (UIA) stricture rate following radical cystectomy and ileal segment urinary diversion.Methods and materialsWe identified 519 consecutive patients who underwent cystectomy and ileal conduit or ileal orthotopic neobladder diversion from January 2007 to August 2012. The length of the ureter resected was defined as the length of the ureter in the cystectomy specimen plus the length of the distal ureter submitted for pathologic analysis. The primary end point was the risk of UIA stricture formation, assessed by Cox proportional hazards analysis.ResultsA total of 463 patients met the inclusion criteria with complete data. Median follow-up was 459 days (interquartile range [IQR]: 211–927). Median time to stricture formation was 235 (IQR: 134–352) and 232 days (IQR: 132–351) on the right and the left ureter, respectively. Overall stricture rate per ureter was 5.9% on the right vs. 10.0% on the left (P = 0.03). There was no difference in demographic, operative, or perioperative variables between patients with and without UIA strictures. On multivariate analysis adjusted for age, sex, anastomosis technique (running vs. interrupted), and length of ureter resected, only a Clavien complication≥III (hazard ratio = 2.11, 1.01–4.40) and urine leak (hazard ratio = 3.37, 1.08–10.46) significantly predicted for left- and right-sided stricture formation, respectively. The length of the ureter resected did not predict UIA stricture formation on either side.ConclusionsThe etiology of benign UIA strictures following ileal urinary diversion is likely multifactorial. Our data suggest that a complicated postoperative course and urine leak are risk factors for UIA stricture formation. The length of the distal ureter resected did not significantly affect stricture rate.     

Die Duplex-Doppel-J-Schiene bei intrinsischen und extrinsischen Harnleiterengen

Background

Duplex or twin ureteral stenting has previously been described as a viable option for patients where single double-J ureteral stenting has failed in order to avoid nephrostomies or further surgical intervention. We assessed a series of 20 patients at our institution after unsuccessful primary single ureteral stenting where parallel ureteral stents were inserted.

Methods

Between 2003 and 2009, 20 patients underwent double-J ureteral stenting for ureteral compression or ureteral strictures. After failure of single stenting two ureteral stents were consecutively inserted into the ureter in a parallel fashion after dilating the ureter up to 14 F. The second stent was passed over a hydrophilic guidewire while holding the first stent secure to prevent dislocation.

Results

In all patients the insertion of two parallel stents was technically possible. In 8 of 12 patients with extrinsic tumor compression the stents provided sufficient drainage (67%). When the stricture was due to surgery or radiation two of three patients were successfully diverted with twin stents. In five patients with a ureteral stricture due to malignant disease the stenting did not provide sufficient drainage and a nephrostomy had to be placed after a mean duration of 19 days. Two of those patients were later managed with a pyelovesical bypass. Three patients were later managed with a ureterocystoneostomy (psoas hitch). In four of five patients with benign disease a long-term management was feasible. The patient with retroperitoneal fibrosis developed immediate hydronephrosis and severe flank pain and ultimately underwent an ileal ureter replacement. In three patients with a benign ureteral stenosis after stone therapy, hysterectomy, or colon ureter replacement, a temporary duplex stenting sufficiently resolved the hydronephrosis for spontaneous urine passage. In one patient the duplex stenting prevented a kidney stone from dislocating into the ureter during lithotripsy.

Conclusions

Duplex or twin (double) ureteral stenting is a valid option in selected patients to avoid the placement of a nephrostomy. Severe stenosis may however demand a nephrostomy insertion or more invasive procedures in the later course. For certain benign ureteral strictures a therapeutic dilating effect of the two ureteral stents that makes further intervention unnecessary can be discussed.     

Management of malignant extrinsic compression of the ureter by simultaneous placement of two ipsilateral ureteral stents.

BACKGROUND AND PURPOSE: Extrinsic ureteral obstruction caused by various malignancies often necessitates urinary diversion. The use of single ureteral stents as a form of urinary diversion results in a high failure rate, while the use of two ipsilateral stents has shown promising results. We report our experience using the latter technique. PATIENTS AND METHODS: Between 1996 and 2001, four male and three female patients with a mean age of 65 years (range 37-95 years) who had extrinsic compression of the ureters underwent single stent management to relieve obstruction. Ureteral obstruction was secondary to prostate cancer (N = 3), cervical cancer (2), non-Hodgkin's lymphoma (1), and transitional-cell cancer of the bladder and ureter (1). After failure of such management, two 7F stents or a combination of 8F/6F double-J ureteral stents were placed. The stents were changed every 4 to 6 months. Follow-up included serial renal ultrasound scans and serum creatinine measurements. RESULTS: Ureteral stricture length ranged from 2 to 4 cm. Insertion of two double-J ureteral stents in a single ureter was successful in all cases. During the mean follow-up of 16 months (range 1-38 months), the ureteral stents were tolerated by all patients, without significant discomfort. Marked improvement of hydronephrosis and alleviation of flank pain was noted in all patients. Three patients have died at 1 to 3 months. Renal function improved, with a mean decline in the serum creatinine concentration from 3.2 mg/dL to 1.48 mg/dL in the five patients tested. CONCLUSION: Simultaneous placement of two double-J ureteral stents for the management of ureteral obstruction secondary to a malignancy is a safe and effective technique.     

膀胱全切及双"拖入式"改良Bricker术治疗结核性膀胱挛缩和炎性尿道狭窄

目的探讨膀胱全切并双"拖入式"改良Bricker术治疗结核性膀胱挛缩和尿道狭窄的安全性及可行性。 方法回顾性分析2020年4月至2020年9月喀什地区第一人民医院诊治的4例结核性挛缩膀胱患者临床资料特征，总结该手术要点及步骤。4例男性患者（36~76岁），术前影像学及T-SPOT诊断为泌尿系结核，膀胱容量<40 ml，合并后尿道炎性狭窄。4例患者均施行挛缩膀胱切除并双"拖入式"改良Bricker术。术中取中下腹正中切口，先切除挛缩膀胱，术中膀胱颈部多点活检后最大限度保留膀胱颈口组织并封闭。双"拖入式"改良Bricker术步骤：游离输尿管并保护其血运，置入7 F尿流改道支架管并固定；距离回盲部20 cm以上，寻找血管分支适合的回肠段（15~18 cm），近端3-0可吸收线缝合封闭；直线切割闭合器回肠侧侧吻合；将取出的回肠段清洁；拖入右侧造口腹壁，回肠末端浆肌层与皮下组织缝合两次固定，形成自然乳头3 cm突出于皮肤；将输尿管"拖入式"错位植入回肠对侧系膜腔内。 结果手术时间131~178 min，术中出血为50~400 ml。术后5~7 d拔除尿流改道支架管，术后住院时间5~7 d，无严重并发症。术后随访3~8个月肾功能恢复良好，Bricker造口乳头满意。3例患者恢复正常性生活。 结论膀胱全切并双"拖入式"改良Bricker术可作为难治性结核性膀胱挛缩和尿道狭窄的手术选择方式，其远期安全性尚需进一步验证。     

De-serosalized muscle layer covering method for antireflux ureteroileostomy: a new operative technique and pressure study with ureterometry at the ureteroileal anastomotic site in dogs

PURPOSE: In pursuit of a more effective antireflux ureteroileostomy with a lower postoperative complication rate we performed a new operative technique and evaluated intraureteral pressure with ureterometry to examine the mechanism of antireflux function. MATERIALS AND METHODS: A total of 11 beagle dogs were used in this study. A 3 x 2 cm. section of the ileal serosa was removed, the severed ureter was directly anastomosed to the de-serosalized area and 1 cm. of terminal ureter and the direct anastomotic site were covered with the de-serosalized ileal wall. The bladder was augmented with the ileum containing the ureter. Postoperative evaluations were performed monthly and ureterometry of the reimplanted ureter was done 6 months postoperatively. RESULTS: Complete reflux prevention and a low stricture rate were achieved with this procedure. Direct ureteroileal anastomosis caused stricture in 1 of the 11 ureters but the covering procedure to prevent ureteral reflux caused no ureteral strictures. When the bladder was empty, ureteral closure pressure at the intramural portion of the ureter was low. At the phase of high intravesical pressure ureteral closure pressure at the intramural ureter was as high as intravesical pressure. CONCLUSIONS: The de-serosalized muscle layer covering method prevented ureteral reflux completely with a low stricture rate. The antireflux function of this method seems to depend on the flexibility of the terminal ureter covered with the de-serosalized ileal wall. Reflux prevention in the low intravesical pressure phase seems to be due to extension of the ileal wall.     

胆肠吻合术后良性吻合口狭窄的影像学诊断与介入治疗

目的评价经皮胆管穿刺引流术(PTCD)+球囊扩张术治疗胆肠吻合术后良性吻合口狭窄的疗效。方法回顾性分析采用PTCD+球囊扩张术治疗胆肠吻合术后吻合口良性狭窄的患者13例,评估胆管通畅情况、黄疸指数、肝功能及引流管放置时间。结果对所有患者均成功完成PTCD+球囊扩张术,对其中2例植入金属支架;术后未发生再狭窄,吻合口近期、远期均通畅(13/13,100%);术后黄疸指数、肝功能均明显改善;引流管放置时间为7～98天,平均(57.3±29.9)天。胆管出血3例,无严重并发症发生。结论 PTCD+球囊扩张术可有效治疗胆肠吻合术后吻合口良性狭窄;应根据具体情况选择不同治疗方式。