输尿管切开取石术后并发尿瘘的防治

报告输尿管切开取石术后并发尿痿12例,结合文献,讨论发生尿瘘的原因和防治方法,指出:施行输尿管切开取石术时,对有漏尿和狭窄倾向者放置肾盂输尿管支架引流管是预防并发尿瘘的重要措施。术后并发尿瘘时,首先要充分引流伤口和抗感染,等待2～3周后作进一步处理;先作膀胱镜逆行插入输尿管导管;失败者作输尿管镜逆行插管,以加速尿瘘愈合,预防继发性狭窄;对合并肾脏严重感染者则作经皮肾穿刺造瘘和顺行输尿管插管。     

肾盂恒压灌注下灌注时间对兔肾脏损伤的实验研究

目的探讨肾盂恒压灌注下灌注时间与兔肾脏损伤的关系。方法采用新西兰大白兔64只,随机建立肾盂灌注30min、60min、90min及假手术组动物模型,每组16只。灌注压力维持在100cmH2O,灌注液为生理盐水。分别于术后1d、5d留取灌注侧尿液,行24h尿蛋白测定,留取尿液后于术后1d、5d分批处死各组兔子,取灌注侧肾脏标本,行HE染色及透射电镜检查。结果各灌注组与假手术组相比均出现尿蛋白增高（P〈0.05）,且尿蛋白随灌注时间的延长而增加（P〈0.05）;各灌注组术后5d尿蛋白含量与术后1d相比降低（P〈0.05）;HE染色显示：术后第1天灌注30min组少数肾小球增大,囊腔及肾小管扩张,上皮细胞轻度水肿;随着灌注时间延长,扩张的肾小球增多且在灌注90min组时肾小管内出现大量蛋白管型。术后5d与术后1d各组比较,肾小球及肾小囊基本恢复正常,肾小管蛋白管型明显减少或消失。透射电镜下观察显示：术后第1天灌注30min组肾小球毛细血管管腔、肾小囊囊腔轻度扩张,随着灌注时间的延长,毛细血管腔及肾小囊腔扩张更加明显,灌注90min后可见部分细胞及细胞内线粒体出现空泡化。术后5d各组肾小球毛细血管管腔及肾小囊基本恢复正常或管腔扩张程度明显减轻。结论肾盂恒压灌注下灌注时间对肾脏损伤明显,且灌注时间越长肾脏损伤越严重,但在100cmH2O灌注压力下灌注时间在90min以内造成的肾脏损伤为可逆损伤。     

双侧巨输尿管症的临床分析(附9例报告)

目的:探讨双侧巨输尿管症的诊疗方法.方法:回顾性分析9例双侧巨输尿管症患者的临床资料:主要症状为腰痛、血尿、尿路感染等,均经B超、KUB加IVU、逆行造影、膀胱镜、尿动力学检查等予以诊断.3例肾功能尚正常者行I期双侧输尿管裁减修整、膀胱再植术;2例先行双肾造瘘术,其中1例肾功能明显改善后行双侧输尿管裁减修整、膀胱再植术,另1例肾功能及一般情况仍较差,继续保守治疗;2例一侧行肾造瘘术,另一侧行输尿管裁减修整、膀胱再植术,1年后,1例行输尿管裁减修整、膀胱再植术,另1例行一侧肾输尿管切除术;1例行一侧I期输尿管裁减修整、膀胱再植术,另一侧行肾输尿管切除术;1例肾功能正常、肾脏轻度积水,给予保守治疗.结果:术后随访1～2年,7例手术者和2例保守治疗者肾功能、肾积水均有不同程度的改善.结论:双侧巨输尿管症病因复杂,不易诊断,需综合判断.治疗时应根据病因、肾功能、年龄、肾积水及输尿管扩张程度等综合决定.输尿管裁减修整、膀胱再植术是最佳治疗方法,宜早期选用.肾脏造瘘对保护肾功能有积极作用,适用于肾功能差的患者.     

经皮肾穿刺造瘘后输尿管镜钬激光碎石肾盂内压力变化及临床意义

目的 探讨经皮肾穿刺造瘘后输尿管镜钬激光碎石术术中肾盂内压力变化及对术后并发症的影响.方法 回顾性分析输尿管镜碎石术治疗上尿路结石64例的临床资料,其中术前行肾脏穿刺造瘘28例(实验组);术前未行肾脏穿刺造瘘36例(对照组).采用压力传感器实时测量行输尿管镜碎石术的患者肾盂内压力,统计术后发热、疼痛指数及肾功能等相关临床指标.结果实验组术中平均肾盂压力(17.4±3.5)mm Hg(1mm Hg=0.133kPa),对照组为(22.3±5.7)mm Hg.实验组术后发热、早期一过性肾功能减退发生率及肾区疼痛均明显低于对照组,差异有统计学意义.结论 术前肾造瘘能够降低输尿管镜钬激光碎石术中的肾盂压力及术后的并发症.     

肾移植术后输尿管并发症17例临床分析

目的 总结肾移植术后输尿管并发症的诊治经验.方法 回顾分析济南军区总医院诊治的17例肾移植术后输尿管并发症患者的临床资料.结果 17例患者伴有不同程度的少尿和局部肿胀不适等症状,实验室检查血清肌酐（Scr）升高,彩色多普勒超声（彩超）检查示移植肾积水、移植肾输尿管扩张,经磁共振水成像或计算机断层摄影术（CT）尿路成像明确诊断.其中输尿管膀胱吻合口狭窄15例,输尿管坏死2例.治疗经过：14例行开放性手术,包括行移植肾输尿管膀胱重新吻合术12例,移植肾输尿管-自体输尿管吻合1例,移植肾输尿管游离、重新放置输尿管支架管1例.3例行非开放性手术治疗,包括输尿管皮肤造瘘1例、腔内球囊导管扩张术1例、软膀胱镜下逆行输尿管支架管插管治疗1例.疗效：14例开放手术治疗患者与1例输尿管皮肤造瘘患者的移植肾肾盂与膀胱的连接部恢复通畅,移植肾功能均明显改善.另2例非开放手术治疗患者,包括1例腔内球囊导管扩张术及1例行软膀胱镜下逆行输尿管支架管插管术患者术后复发,行开放手术治疗.结论 彩超及磁共振成像水成像或CT尿路成像等影像学检查是确诊移植肾输尿管并发症的主要方法.肾移植术后输尿管并发症应以预防为主,确诊后视具体情况行开放性手术或非开放性手术治疗,开放手术治疗的疗效较佳.     

不同引流术急诊处理输尿管结石梗阻合并尿脓毒血症的比较

目的比较2种不同引流术急诊处理输尿管结石梗阻合并脓毒血症的有效性及安全性。方法 2003年3月～2011年3月52例输尿管结石梗阻合并尿脓毒血症,27例采用输尿管镜直视下逆行置入双J管引流术(输尿管镜组),25例采用B超引导下经皮肾穿刺造瘘术治疗(经皮肾组)。结果输尿管镜组由6名不同级别术者完成,经皮肾组由2名高级别术者完成。输尿管镜组置管引流成功率(100%)明显高于经皮肾组(21/25,84.0%)(Fisher’s检验,P=0.047);2组术后尿脓毒血症控制时间无统计学差异[(6.5±1.2)d vs.(6.4±1.2)d,t=0.300,P=0.765];2组无输尿管穿孔、大出血及死亡等严重并发症。结论输尿管镜直视下逆行置入双J管引流术和经皮肾穿刺造瘘术均为急诊处理输尿管结石梗阻合并尿脓毒血症安全有效的方法;输尿管镜直视下逆行置入双J管引流术置管成功率更高;对于超声技术不熟练的术者和患肾轻度积水的患者,推荐首选输尿管镜手术。     

经瘘道插管造影联合输尿管内顺行置管诊治复杂尿瘘

目的:总结复杂尿瘘的治疗经验,探讨一种可以应用于复杂尿瘘的新的诊治方法。方法:对同时行膀胱癌Bricker术和直肠癌Hartmann术且术后出现漏尿的患者,在常规输尿管镜检查无法进行且B超、IVU、CT、MRU等手段无法明确瘘口位置的情况下,尝试在DSA机透视下经瘘道插管造影,明确瘘口位于输尿管下段,然后行患侧肾脏穿刺造瘘并经造瘘处顺行置入双J管,以期治愈尿瘘、保护患侧肾脏功能。结果:治疗后瘘口愈合,随访半年,查肾功能正常,B超示患肾无明显积水。结论:经瘘道插管造影联合输尿管内顺行置管法避免了再次手术且保留了患侧的肾脏功能,适用于复杂尿瘘的诊断和治疗,尤其适用于无法明确瘘口位置的患者。     

微创经皮肾输尿管镜气压弹道碎石术在尿路上段应用

目的:探讨经皮肾输尿管镜气压弹道碎石术治疗肾、输尿管结石的临床疗效。方法:在C臂机引导下,经皮肾穿刺造瘘,并将穿刺通道扩张自F8～F16,从通道插入输尿管镜到结石处,用气压弹道碎石机将结石击碎,用灌注泵和输尿管导管逆行脉冲注水,冲洗出细小的碎石;较大碎石用取石钳取出。结果:35例患者,32例一次性取净结石治愈;3例患者一周后2次取净结石治愈。结论:经皮肾输尿管镜气压弹道碎石术具有疗效好,创伤小,患者恢复快等特点,可作为治疗肾、输尿管上段结石的重要方法。     

上尿路结石合并尿脓毒血症的治疗

目的探讨上尿路结石合并尿脓毒血症的治疗方案。方法回顾2014年7月~2018年5月在我院确诊收治的43例上尿路结石合并尿脓毒血症患者的临床资料,43例患者均行积极抗感染治疗,同时,一期行经输尿管镜下逆行插管术或经皮肾穿刺造瘘术,以解除梗阻,待患者感染控制后,二期行经输尿管镜或经皮肾镜碎石术。结果一期行经输尿管镜下逆行插管术29例,单侧结石23例,双侧结石6例,均成功置入导管。不宜行经输尿管镜下逆行插管术或逆行插管术失败者,在B超定位下行经皮肾穿刺造瘘术,共14例。待感染控制、病情稳定后出院,出院1个月后,再二期行腔内微创手术处理结石,碎石成功41例,碎石率95.35%(41/43),2例患者术后行体外冲击波碎石治疗,出院后3个月随访,42例患者结石排净,结石排净率为97.67%(42/43),肾功能及肾积水程度明显改善,43例患者在整个治疗过程中未出现严重并发症。结论经输尿管镜下逆行插管术或经皮肾穿刺造瘘术联合腔内微创手术是治疗上尿路结石合并尿脓毒血症的一种安全、有效的方法。     

有无负压吸引装置输尿管镜钬激光碎石术治疗输尿管上段结石疗效比较

目的 探讨有无负压吸引装置输尿管镜钬激光碎石术治疗输尿管上段结石的疗效.方法 分析本院2009年1月～2012年8月治疗的62例输尿管上段结石行钬激光碎石术患者的临床资料,所有患者入院前均留置肾造瘘管,其中20例为一期经皮肾取石术后输尿管残留结石的患者,35例为严重肾积水一期行经皮肾造瘘引流术的患者,7例为输尿管上端结石引起一侧肾感染留置肾造瘘管引流择期手术治疗的患者,根据入院顺序先后,随机分为两组,实验组为有负压吸引装置的输尿管镜下钬激光碎石术患者30例,对照组为无负压吸引装置的输尿管镜下钬激光碎石术患者32例,术中通过肾造瘘管测定肾盂压力的变化,术前及术后检测钠、钾的变化,记录手术时间及术后一周X片检查结石清除情况.结果 术中实验组肾盂压力为(93.46±3.56) cmH2O,对照组肾盂压力为(201.13±4.69) cmH2O,两组术中肾盂压力有显著性差异(P＜0.05).实验组手术时间(30±4.39)min,对照组为(50±5.28) min,术后第三天复查平片,实验组和对照组一次结石清除率分别为98.72％、90.25％,随访6个月,结石排净时间分别为(3±2.5)d、(15.3±9.8)d,术前术后两组患者电解质未见明显变化.结论 有、无负压吸引装置输尿管镜下钬激光碎石术对电解质无明显影响,但前者可明显降低术中肾盂压力,使视野清晰,减少结石上移,缩短手术时间,结石清除率高,减少因肾盂压力高而带来的并发症.     

微创经皮肾镜取石术中肾盂压力对肾功能的影响

目的：探讨微创经皮肾镜取石（MPCNL）术中肾盂内压力变化对肾功能的影响。方法：通过逆行所置输尿管导管连接尿动力学仪监测肾盂内压力，术后即刻及术后每天测定尿蛋白：尿微量白蛋白（尿Alb）及B2微球蛋白（尿β2-M）。结果：肾盂内压力≥3．92kPa的总时间≥5min为高压组，高压组肾盂压力平均为2．59kPa（1．27～14．60kPa），低压组平均为2．19kPa（1．08～12．25kPa）；术后即刻尿蛋白明显增高，与术前相比差异有统计学意义（P〈0．05），此后尿蛋白逐渐下降，高压组与低压组同一天所测尿蛋白相比差异有统计学意义（P〈0．05）。结论：MPCNL大部分时间其肾盂压力是相对安全的，MPCNL术后出现了短暂肾功能损害，且肾盂压力越高，肾功能损害越严重。     

125I-hippuran absorption from the human renal pelvis

The absorption of 125I-hippuran from human renal pelvis was studied peroperatively in 18 patients with obstruction at the pelviureteric junction. Three types of experiment were included: absorption during induced diuresis, absorption at a constant intrapelvic pressure of 30 cm. H2O, and excretion of the indicator by the contralateral kidney. Total and separate glomerular filtration rate were measured using 51Cr-EDTA clearance technique and isotope renography. Distal tubular function was evaluated as maximum concentration ability. During induced diuresis the intrapelvic pressure increased to an average maximum value of 31.6 cm. H2O. The excretion of isotope from the contralateral kidney varied from one to 44% of the given dose. A significant correlation (r = 0.87) between the maximum intrapelvic pressure obtained and the amount of isotope excreted from the contralateral kidney was demonstrated. At a constant intrapelvic pressure of 30 cm. H2O the excretion of isotope from the contralateral kidney varied from two to 26% of the dosage given. The low value probably depended on the impaired function of the obstructed kidney. Our results show the existence of a significant reflux from the renal pelvis of small molecules, which was affected by renal function, intrapelvic pressure and volume.     

Pressure-flow study after percutaneous nephrolithotripsy

In 46 patients treated with PNL in our hospital, the intervals from PNL to removal of a catheter indwelled in the nephrostomy were studied. The intervals were longer in the cases with ureteral stones than those with renal stones probably because of the different degrees of obstruction. To investigate the degree and the interval of upper urinary tract obstruction after PNL, Pressure-flow Studies were performed every or every other day after PNL in 5 cases with renal stones and 5 cases with ureteral stones, selected from 46 cases. In Pressure-flow Studies, intrapelvic pressures were measured while saline mixed with pigment was being dripping at a rate of 5 ml/min into the renal pelvis through the nephrostomy catheter. Saline initially reached into the urinary bladder at an average of 4.8 days after PNL (range 3 to 7 days) with a mean intrapelvic pressure of 37.6 cmH2O (range 28 to 52 cmH2O) in the cases with renal stones and at an average of 9.2 days (range 7 to 12 days) with a mean intrapelvic pressure of 27.0 cmH2O (range 9 to 43 cmH2O) in the cases with ureteral stones. Pressure-flow Studies were performed again a few days after the initial passage of saline into the urinary bladder in 2 of 10 cases. The intrapelvic pressures, 16 cmH2O and 13 cmH2O, respectively, several days after the initial passage of saline were lower than those, 35 cmH2O and 43 cmH2O, respectively, at the initial passage of saline. Therefore, it was likely that the proper interval of indwelling catheter after PNL was about 7 to 8 days, in the cases with renal stones and about 11 to 12 days in the cases with ureteral stones.     

Characteristics and mechanism of pyelorenal backflow correlated to renal pelvic pressure

The present study was conducted to examine the characteristics of pyelo-renal backflow related with the changes in renal pelvic pressure. Forty rabbits weighting approximately 3.0 kg were used in this experiment. The renal pelvis was continuously perfused with PSP solution through the double lumen catheter placed above the ureteropelvic junction. The renal pelvic pressure was also recorded during the intrapelvic perfusion. Simultaneously, PSP concentrations in blood and urine excreted from the contralateral kidney were measured. During the intrapelvic perfusion with PSP solution, PSP blood concentration began to increase immediately and reached maximum within 1 or 2 minutes after a start of perfusion. Then, its concentration gradually decreased toward the constant, low levels. The urinary concentration of PSP showed the same change as the blood concentration with a time lag of 1 or 2 minutes. A compartment analysis showed that this backflow curve composed of an early phase and a late phase. The early phase was characterized by a rapid increase and following decrease (exponentially declining) in PSP concentration. The late phase was a portion of constant PSP concentration in the backflow curve. A maximum PSP concentration in the early phase was elevated with an increase in the increment rate of renal pelvic pressure. There was a significant, positive correlation between the maximum PSP urinary concentration and the increment rate of renal pelvic pressure (dp/dt). The constant values of PSP concentration in the late phase could be correlated with neither increment rate nor absolute values of renal pelvic pressure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Influence of intrapelvic pressure on excretion of sodium from human hydronephrotic kidneys

The influence on urinary excretion of sodium (NNa . V) of intrapelvic pressure, urinary flow, and mean arterial blood pressure during forced diuresis was evaluated in 12 patients with unilateral hydronephrosis. Total and divided renal functions were measured using 51Cr-EDTA clearance and isotope renography. The amount of sodium, excreted by the obstructed kidney, decreased with higher maximum intrapelvic pressure and increased with higher differences between the mean arterial blood pressure and maximum intrapelvic pressure. The higher the concentrating ability, the lower the amount of sodium excreted by the obstructed kidney. There was a highly significant negative correlation between maximum intrapelvic pressure and urinary flow, but no correlation between mean arterial blood pressure and maximum intrapelvic pressure. Thus, obstructed kidneys with normal concentrating ability have the same excretion of sodium as the nonobstructed contralateral kidney during forced diuresis. Obstructed kidneys with decreased concentrating ability on the other hand excrete comparatively more sodium. This is probably due to a defect in sodium resorption.     

Pressure volume relationships in human hydronephrosis

Pressure volume curves were obtained in 8 children with ureteropelvic junction obstruction prior to pyeloplasty after totally obstructing the ureteropelvic junction. All human renal pelves displayed a similar shape pressure volume curve. The human renal pelvis is able to accommodate to increasing volumes by maintaining a relatively low intrapelvic pressure Once its capacity is reached, pressures rise to pathologically high levels at a much faster rate. These findings suggest that hydronephrosis can be viewed as a compensatory mechanism which protects some kidneys from further overdistention, high intrapelvic pressures, and progressive renal deterioration by virtue of acquired changes in compliance, pelvic size, and renal function which limit the rate of pressure rise within the hydronephrotic kidney.     

Urinothorax as a manifestation of nondilated obstructive uropathy following renal transplantation

A 12-year-old patient developed prolonged nondilated urinary obstruction and pleural effusion shortly after undergoing renal transplantation. Renal sonography, angiography, and isotope renography failed to identify an obstructive process. On the 18th postoperative day, pleural effusion was noted in the right hemithorax, and by day 24, increased perinephric fluid was observed on renal scan. Following a nephrostomy, the pleural effusion resolved and renal function improved remarkably. A ureterovesical junction obstruction and renal pelvis tear that were later discovered were repaired. Whenever a ureteral obstruction is suspected the diagnosis should be pursued vigorously, despite normal radiologic findings, especially in the presence of pleural effusion. Consideration of the possibility of urinothorax in such cases may obviate the need for lung biopsy.     

Determinants of progression and equilibrium in hydronephrosis

Upper urinary tract urodynamic parameters were measured serially in 12 dogs subjected to partial ureteropelvic junction obstruction. Measurements of pressure-volume relationships (pelvimetrics) and the physiologic capacity of the renal pelvis were important predictors of hydronephrotic equilibrium which occurred only in kidneys whose pelvic urine volume remained lower than the renal pelvic capacity. Because of acquired changes in compliance and renal function, the same degree of obstruction caused progressive hydronephrosis at low pelvic volumes but not at high volumes in some kidneys. Hydronephrosis can thus be viewed as a compensatory mechanism which protects the kidney against further dilation and elevated intrapelvic pressure.     

Impaired renal sensory responses after renal ischemia in the rat

Renal sensory responses and reflex function were examined in rats 24 h after 45 min of ischemic injury caused by unilateral renal arterial occlusion (RAO). The integrity of renal pelvic mechanoreceptor (MRu)-mediated renorenal reflex was examined. An increase in ipsilateral afferent renal nerve activity (ARNA) and a reflex decrease in efferent renal nerve activity (ERNA) and contralateral diuresis and natriuresis produced by increasing the intrapelvic pressure were seen in sham-operated (Sham) rats, but it was largely attenuated in RAO rats. Using single-fiber recordings of the renal MRu discharge, graded increases in intrapelvic pressure or renal pelvic administration of substance P (SP) resulted in pressure- or concentration-dependent increases in ARNA in the control kidney of Sham rats, whereas attenuated responses were seen in the postischemic kidney of RAO rats. The unresponsiveness of renal MRus in RAO rats was accompanied by an insufficient release of SP. However, the baseline SP release is higher in RAO kidneys due to a reduced neutral endopeptidase (NEP) activity in the renal pelvis of the postischemic kidney. No changes in NK-1 receptor mRNA levels were demonstrated; however, the expression of NK-1 receptors in the plasma membrane of RAO pelvis were decreased, possibly resulting from the internalization of the receptors associated with beta-arrestin trafficking. Renal excretory responses after saline loading were significantly lower in the postischemic kidney of RAO rats than in Sham rats. Responses of ARNA and ERNA were also lower. It is concluded that the defective activation of renal sensory mechanoreceptors in the postischemic kidney results from an inadequate release of SP after mechanostimulation and the reduced functional NK-1 receptors.