盆腔器官肿瘤浸润或术后放疗致输尿管梗阻的处理

目的探讨盆腔器官肿瘤浸润或术后放疗致输尿管梗阻的诊治方法。方法回顾性分析1990年6月至2000年5月经临床处理的15例本病的临床资料,其中双J管内引流或输尿管导管引流术6例,经皮肾穿刺造瘘术4例。行开放性肾造瘘术3例,输尿管皮肤造瘘术2例。结果本组15例经尿流改道或内引流后全身状况及尿毒症症状很快好转,其中7例肾功能恢复正常,8例肾功能改善。结论B超、输尿管逆行插管和／或磁共振尿路水成像(MRU)检查是较好的诊断手段。输尿管插管引流或双J管内引流和经皮肾穿刺造瘘术。具有损伤小、对患影响轻的优点,是解除梗阻的首选方法。     

晚期膀胱癌致梗阻性肾功能衰竭的诊疗体会

目的探讨晚期膀胱癌侵犯输尿管所致梗阻性肾功能衰竭的诊疗方法与临床疗效。方法对21例晚期膀胱癌导致肾后性肾功能衰竭患者的临床资料进行回顾性分析。结果采用B超、CT、MRU等检查确定输尿管梗阻的部位,明确梗阻与膀胱癌的关系。采用尿流改道术治疗该类患者21例,其中肾造瘘术5例,输尿管皮肤造口术12例,回肠膀胱术4例。术后17例患者肾功能完全恢复正常,4例肾功能明显改善。结论 CT扫描和MRU对输尿管梗阻部位的确定较准确;对并发梗阻性肾功能衰竭的晚期膀胱癌,应尽早行尿流改道术,以保护肾功能、提高生活质量、延长生命。     

上尿路梗阻性急性肾功能不全内、外引流的选择

目的探讨内、外引流在上尿路梗阻急性肾功能不全时的选择和效果。方法25例各种原因引起的上尿路梗阻（15例肿瘤性梗阻,10例非肿瘤性梗阻）合并急性肾功能不全,分别或先后对12例行输尿管内置双J管（doub le J,D J）内引流15次,对19例行经皮肾穿刺造瘘（percutaneous nephrectomy,PCN）外引流23次。结果引流成功23例,PCN外引流成功率86.9%（20/23）,双J管内引流成功率60.0%（9/15）,PCN术后继发出血1例。结论对于盆腹腔进展期或广泛转移肿瘤导致的梗阻,PCN解除梗阻优于输尿管支架内引流;非肿瘤性梗阻宜先尝试D J内引流。     

膀胱镜下双J管置入术治疗肿瘤转移与浸润相关性输尿管梗阻的疗效探讨

目的探讨盆腔肿瘤转移与浸润所出现的相关性输尿管梗阻、肾功能不全的处理方法及疗效。方法对10例盆腔肿瘤转移与浸润所出现的相关性输尿管梗阻、肾功能不全的患者,采用膀胱镜下逆行放置双J管内引流,观察双J管内引流及肾功能改善的情况。结果本组10例,均经膀胱镜下置入双J管内引流,其中一次性置管成功8例,二次置管成功2例,均引流通畅,肾功能均明显好转。随访期间1例死于转移或多器官功能衰竭,无一例死于肾功能衰竭。结论膀胱镜下放置双J管内引流,是处理盆腔肿瘤后转移与浸润所出现的相关性输尿管梗阻、肾功能不全较为理想的办法,麻醉方便、手术操作简便、安全性高、引流可靠等,值得在临床中推广应用。     

恶性输尿管梗阻的腔内微创治疗(附85例报告)

目的探讨盆腔肿瘤或盆腔转移性肿瘤及放疗等引起的恶性输尿管梗阻的腔内微创治疗方法和效果。方法2004年1月-2007年1月收治恶性输尿管梗阻病人85例,采用腔内泌尿外科微创治疗,其中72例经尿道膀胱镜下（25例）或输尿管镜下（47例）留置双J管,单侧42例,双侧30例,13例经皮肾穿刺微造瘘顺行放置2根双J管。结果所有病例均获随访,平均9（6-24）个月。术后下腹不适15例,排尿时腰部胀痛22例,肉眼血尿3例,均自行缓解。腹平片未发现双J管移位。术后3个月更换双J管时,未发现导管周围结石形成。71例患者留置双J管后引流通畅,尿量明显增加,肾功能复查,肌酐5-7 d恢复正常或接近正常,B超示置管侧肾积水减轻。14例患者术后B超示肾积水无明显改变,肾功能改善不明显,改行经皮肾穿刺微造瘘术后肾功能恢复正常。8例术后9-15月再发梗阻,经皮肾穿刺微造瘘术后肾功能恢复正常。结论恶性输尿管梗阻的腔内治疗创伤小,疗效确切,可以为患者解除痛苦,提高生活质量。     

输尿管梗阻致急性肾衰的治疗

目的探讨输尿管梗阻致急性肾衰时的急诊处理方法，以保护和恢复肾功能。方法输尿管梗阻致急性肾衰患者43例，均以少尿或无尿1～6d来诊。经生化检查均存在肾功能不全，经B超、CT、X线摄片及（或）急诊经膀胱输尿管插管均诊断为输尿管梗阻，分别急诊行输尿管插管、输尿管镜或输尿管切开取石、肾造瘘、血液透析，并在1～12d内根据病情进行了后期病因治疗。结果7例保留永久肾造瘘或输尿管皮肤造口，2例进入永久血液透析，其余34例均解除梗阻恢复生理排尿通道，梗阻症状均消失；共有37例患者出现多尿期，持续1～2周。血尿素氮、肌酐随访，3d～5个月内可恢复，恢复程度80％～100％。结论经膀胱镜输尿管插管是输尿管梗阻致急性。肾衰时的首选处理；肾造瘘术则是插管失败的急诊补救措施及病因不能解除时永久引流尿液的措施；双“J”管的应用代替了部分肾造瘘。     

先天性巨输尿管症的诊治体会（附9例报告）

目的：探讨先天性巨输尿管症的诊治特点。方法：9例先天性巨输尿管症,其中左侧4例,右侧2例,双侧3例。主诉症状不典型,最终经B超、KUB＋IVP、膀胱镜逆行插管造影、CT、MRU等检查确诊。采用输尿管中、下段裁剪、坑逆流输尿管膀胱再植术5例。1例先行肾盂穿刺造瘘术,3个月后行输尿管膀胱再植术。因肾重度积水,功能严重受损而行。肾、输尿管切除术1例。1例行输尿管末端切开术。1例行保守治疗,定期更换双J管。结果：输尿管膀胱再植术6例（包括先行肾盂穿刺造瘘术,3个月后再行输尿管膀胱再植术的患者）,均于6-12周后拔除支架管或双J管（幼儿患者约6周拔除支架管导尿管,成人患者约2-3个月拔除双J管）。术后随访经B超及静脉肾盂造影检查,显示患侧输尿管扩张度和肾积水均明显减轻。1例行输尿管末端内切开术的患者在术后3个月拔除并更换双J管1次,复查B超亦提示恢复良好。保守治疗的1例患者到目前为止,病情尚无恶化征象。结论：B超和KUB＋IVP检查是诊断先天性巨输尿管症的首选检查方法,但MRU近年体现出更多的诊断优势。治疗本症的原则是解除梗阻,尽量保留肾功能。手术方式以输尿管剪裁或折叠加输尿管膀胱吻合术为主,但腹腔镜和内镜手术也逐渐受到重视。肾功能尚好者也可行扩张或放置内支架等保守治疗。     

恶性肿瘤引起输尿管梗阻的处理

我院1993年1月～2002年6月收治15例恶性肿瘤引起的输尿管梗阻，并导致肾功能不全的患者，经采用留置输尿管双J支架管或肾造瘘术引流处置后，肾功能恢复良好。现报告如下。     

上尿路结石合并脓肾的诊断与治疗

目的提高上尿路结石合并脓肾的早期诊断和治疗水平，保护肾功能，减少肾切除率。方法上尿路结石合并脓肾24例，15例行输尿管镜碎石留置双J管引流后二期手术，8例行经皮肾穿刺造瘘引流后二期手术，1例开放手术术中发现脓肾行肾切除术。结果临床表现结合影像学明确诊断脓肾15例，经皮肾穿刺发现3例，输尿管镜术中发现5例，开放手术中发现1例。行保肾手术21例，肾切除3例。随防3个月-2年，保肾手术21例未因肾功能恶化而切肾，3例肾切除者血肌酐正常。结论早期诊断、及时引流、解除梗阻是上尿路结石合并脓肾保肾治疗的关键。B超和CT检查对脓肾的诊断有重要作用。输尿管镜碎石并留置双J管及经皮肾穿刺造瘘引流是较好的解除梗阻的方法。     

恶性肿瘤致输尿管梗阻性肾功能衰竭的处理

<正>恶性肿瘤致输尿管梗阻引起肾积水、肾后性肾功能不全在临床上时有所见[1],尤其在恶性肿瘤晚期患者中,其发生率更高。本院2003年1月～2008年12月,应用双J管内引流方法或经皮肾穿刺造瘘术外引流方法治疗恶性肿瘤并发输尿管梗阻所致急性肾功能衰竭患者15例,现报告如下。     

肿瘤转移和浸润致输尿管梗阻性肾功能衰竭的临床处理

为提高肿瘤转移和浸润引起的上尿路梗阻性肾功能衰竭的临床诊断和治疗水平，总结了１９８９年８月￣１９９７年７月临床处理３４例的结果。其中原发灶为胃肠道肿瘤１０例，膀胱癌７例，前列腺癌６例，宫颈癌４例，卵巢癌３例，其他肿瘤４例。梗阻部位在输尿管上段９例，经皮尿管下段２５例（７３．５％），其中输尿管膀胱交界处７例（２０．６％）。治疗采用双Ｊ管内引流９例，经皮尿管下段２５例（７３．５％），其中输尿管膀胱交界     

螺旋CT在输尿管结石诊断中的应用价值

目的:探讨螺旋CT在输尿管结石诊断中的应用价值。方法:对51例临床可疑输尿管结石而常规B超、KUB、IVU等检查未确诊者,均未口服造影剂直接螺旋CT平扫,5例平扫后静注76%泛影葡胺60ml,延迟10～15s增强扫描,11例将获得的容积图像行输尿管多平面重建。结果:平扫确诊45例,可疑结石6例,其中5例经增强CT延迟扫描确诊,另1例经输尿管重建确诊。11例输尿管多平面重建成像均清楚地显示输尿管全程,同时显示结石大小、形态、位置和输尿管梗阻扩张程度及范围。结论:螺旋CT除直接显示高密度结石及其部位和大小外,还可显示输尿管梗阻扩张程度等继发征象,增强CT延迟扫描有助于鉴别腹膜后其他高密度影,输尿管多平面重建可获得良好的输尿管成像,弥补轴位图像不足,对输尿管结石诊断、鉴别诊断及治疗均有重要的临床应用价值。     

金属内支架介入治疗恶性输尿管狭窄的临床应用

目的探讨经皮顺行植入输尿管金属内支架治疗恶性输尿管狭窄的效果。方法对14例恶性肿瘤伴输尿管狭窄的患者行经皮顺行植入输尿管金属内支架治疗。术后观察尿量及性状,超声及腹部平片随访。结果14例患者植入输尿管内支架均获成功,输尿管梗阻解除,患者临床症状改善,肾功能好转。结论对恶性输尿管狭窄的患者行顺行植入输尿管金属内支架治疗输尿管狭窄,是一种简便、有效、创伤小的治疗方法。     

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.     

Ureteral obstruction during pregnancy

We report on a woman with recurrent renal failure due to bilateral ureteral obstruction during the mid trimester of pregnancy. The first pregnancy was terminated due to obstructive renal failure. In the second pregnancy renal function again deteriorated due to bilateral ureteral obstruction. After successful placement of a right ureteral catheter and a left percutaneous nephrostomy, renal function normalized and the gestation was continued through 37 weeks. Recurrent ureteral obstruction during pregnancy was attributed to changes following bilateral ureteral reimplantation. Patients with a history of urologic surgery warrant surveillance for renal failure secondary to mechanical obstruction. Those with a history of proved obstruction during pregnancy might benefit from the prophylactic placement of ureteral catheters and chronic antimicrobial therapy during subsequent gestations.     

先天性双侧输尿管末端狭窄性梗阻致尿闭的临床处理

目的探讨双侧输尿管末段狭窄性梗阻致尿闭的临床特点、诊断及治疗。方法先天性双侧输尿管末段狭窄患儿7例,男2例,女5例,年龄35～57d。临床表现为突发性尿闭或少尿,均行B超、膀胱造影及肾盂穿刺造影,3例行磁共振尿路水显像,诊断明确后行输尿管狭窄段切除、输尿管再植术。结果7例患儿均经肾盂穿刺造影确诊,一期手术后6例治愈,随诊2—4年未发现输尿管狭窄及返流发生,肾功能恢复良好;1例症状复发,二次手术后治愈。结论对生后突发尿闭患儿应考虑先天性双侧输尿管末段狭窄的可能,肾盂穿刺造影及磁共振尿路水显像可明确诊断,输尿管狭窄段切除、输尿管再植术是有效的治疗方法。     

Predicting the success of retrograde stenting for managing ureteral obstruction

PURPOSE: Retrograde ureteral stenting is often considered the first line option for relieving ureteral obstruction when temporary drainage is indicated. Several retrospective studies have implied that in cases of extrinsic obstruction retrograde ureteral stenting may fail and, therefore, percutaneous nephrostomy drainage is required. We examined the efficacy of retrograde ureteral stenting for resolving ureteral obstruction and identified clinical and radiological parameters predicting failure. MATERIALS AND METHODS: Enrolled in our prospective study were 92 consecutive patients with ureteral obstruction, which was bilateral in 8. Retrograde ureteral stenting was attempted in all cases by the urologist on call. When stent insertion failed, drainage was achieved by percutaneous nephrostomy. Patients were followed at 3-week intervals for 3 months. Each followup visit included a medical interview, blood evaluation, urine culture and ultrasound. Stent malfunction was defined as continuous flank pain manifesting as recurrent episodes of acute renal colic, 1 or more episodes of pyelonephritis, persistent hydronephrosis or elevated creatinine. Preoperative data and outcomes were compared in cases of intrinsic and extrinsic obstruction. Univariate and multivariate analysis was done to identify predictors of the failure of ureteral stent insertion and long-term function. RESULTS: The etiology of obstruction was intrinsic in 61% of patients and extrinsic in 39%. Extrinsic obstruction, which was associated with a greater degree of hydronephrosis, was located more distal. Retrograde ureteral stenting was successful in 94% and 73% of patients with intrinsic and extrinsic obstruction, respectively. At the 3-month followup stent function was maintained in all patients with intrinsic obstruction but in only 56.4% with extrinsic obstruction. On multivariate logistic regression the type of obstruction, level of obstruction and degree of hydronephrosis were the only predictors of stent function at 3 months. Stent diameter and preoperative creatinine had no predictive value. CONCLUSIONS: Retrograde ureteral stenting is a good solution for most acutely obstructed ureters. In patients with extrinsic ureteral obstruction a more distal level of obstruction and higher degree of hydronephrosis are associated with a greater likelihood of stent failure. These patients may be better served by percutaneous drainage.     

经皮肾通道顺行输尿管软/硬镜联合输尿管镜治疗恶性输尿管梗阻

目的探讨斜仰卧截石位经皮肾通道顺行输尿管软/硬镜联合输尿管镜置入双J管治疗输尿管支架管置入失败的恶性肿瘤致输尿管梗阻的安全性及临床效果。 方法回顾性收集并分析2016年10月至2019年1月我院收治的25例恶性肿瘤引起的输尿管梗阻患者的资料,上述患者均因常规逆行膀胱镜或输尿管镜置双J管失败,进而以斜仰卧截石位利用经皮肾通道顺行输尿管软/硬镜联合输尿管镜置入双J管。 结果25例患者（32侧输尿管梗阻）中,1例因肿瘤侵犯输尿管造成双侧输尿管管腔完全闭塞,双J管置入失败。其余24例均成功放置双J管（成功率93.7%）。手术时间平均（57.4±22.4）min,平均住院时间（5.5±1.9）d,术中无严重肾出血,无输尿管穿孔及撕脱。术后6~14 d拔除肾造瘘管,拔除肾造瘘管后随访12个月,肾积水缓解。 结论斜仰卧截石位皮肾通道顺行输尿管软/硬镜联合输尿管镜置入双J管治疗输尿管支架管置入失败的恶性肿瘤引起的输尿管梗阻安全、有效,值得临床推广。     

Management of extrinsic malignant ureteral obstruction with urinary diversion

OBJECTIVE: The effectiveness of urinary diversion for patients with renal insufficiency due to extrinsic ureteral obstruction was assessed. METHODS: Between 1990 and 2003, 30 males and 45 females, ranging 36-90 years of age (average, 62.7) who had secondary ureteral obstruction due to either a retroperitoneal or pelvic invasion of malignant disease, underwent nephrostomy or ureteral stenting using a double-J stent without side holes. RESULTS: Ureteral stenting was attempted as an initial procedure in 51 of the 75 cases. The remaining 24 cases had a nephrostomy at the first step. Of 51, 37 cases were successfully stented, while internal stenting was unsuccessful in the remaining 14 cases. These 14 cases were treated with nephrostomy at the second step following the unsuccessful internal stenting. Eight cases of the 37 successfully stented cases were eventually changed to a nephrostomy because of catheter trouble. As a result, 29 cases could be managed by internal ureteral stenting up until the end of their life. The follow-up period for the 75 cases who underwent urinary diversion ranged from 5 days to 19 months, averaging 5.7 months. The average period from diversion to death was 5.6 months in the internally stented group and 5.9 months in the nephrostomy group. CONCLUSION: The high patency rate of the internal ureteral stent in our cases might be due to our use of a stent without shaft vent holes.