腹膜后纤维化致肾积水52例诊治分析

目的探讨腹膜后纤维化致肾积水的诊疗方法,以提高本病早期诊断率。方法回顾性分析天津医大第二医院泌尿外科10年来收治的52例腹膜后纤维化致肾积水患者的临床资料。结果 52例中7例行膀胱镜或输尿管镜下置入双J管并口服激素＋他莫昔芬治疗;45例行输尿管置管＋输尿管松解术,其中11例一期输尿管置管,待肾功能改善后二期输尿管松解术。行输尿管松解术患者中,输尿管移入腹腔35例,带蒂大网膜包裹10例。术后病理检查诊断均为纤维脂肪组织伴炎性细胞浸润。随访1月～10年,52例术后临床症状均减轻或完全消失,肾功能均明显改善。结论对于B超检查提示肾积水患者,在排除输尿管占位、结石、肾盂输尿管连接部狭窄等常见疾病后要考虑到腹膜后纤维化的可能,并进一步行IVU、CT、输尿管镜等检查,以在术前明确诊断。治疗以解除输尿管梗阻,尽可能保护肾功能,减少复发为主要目的。     

Renal autotransplantation for idiopathic retroperitoneal fibrosis

Extensive loss of the ureter is a potential complication of surgery performed to relieve ureteral obstruction caused by retroperitoneal fibrosis. The authors describe the twelfth case managed successfully by renal autotransplantation and review the literature.     

Correction of congenital hydronephrosis in utero III. Early mid-trimester ureteral obstruction produces renal dysplasia

Is the renal dysplasia (RD) commonly seen in babies with urinary tract obstruction a developmental consequence of the obstruction or is it an associated embryologic malformation? We produced complete unilateral ureteral obstruction in six 58- to 66-day old lamb fetuses by clipping a silastic ring on the ureter. Three fetuses survived to term. All obstructed kidneys were not only grossly hydronephrotic but dysplastic by histologic criteria; ie, parenchymal disorganization, primitive epithelial structures, and marked fibrosis. The contralateral unobstructed control kidneys were normal. The changes were similar to those seen in the human neonate with obstruction and RD, suggesting that in this model RD was caused by obstruction to the flow of urine early in fetal development.     

移植肾输尿管并发症的防治

总结１９９０－１９９３年４年间的临床肾移植４１１例，重点探讨移植肾输尿管３种并发症的发生原因，预防及治疗方法。认为尿漏的发生与取肾，修肾过程中输尿管系膜的保护不够以及输尿管膀胱吻合的技巧有直接关系。输尿管狭窄多为粘膜下隧道缝合过紧。急性输尿管梗阻为异物所致。尿漏，输尿管狭窄应早期手术治疗，而急性梗阻则可先行局部按压或颠簸治疗，不能通畅者也应手术解除。     

Surgical treatment of isolated iliac artery aneurysm with ureteral obstruction and/or renal failure

Three patients with isolated iliac artery aneurysm with ureteral obstruction and/or renal failure are presented. One patient had a stenotic lesion of the right ureter caused by direct compression of common and internal iliac artery aneurysms. Resection of the aneurysms and graft replacement were successfully performed. The other patients, who had hydroureteronephrosis and renal failure caused by entrapment of the ureters in perianeurysmal fibrosis, were treated surgically by ureterolysis, resection with graft replacement of the common iliac artery aneurysms, and endoaneurysmorraphy of the internal iliac artery aneurysms. One has had a good postoperative course, whereas the other died from a rare complication of rectosigmoid colon perforation caused by direct compression by the graft.     

Reimplantation of the ureter after unilateral ureteral obstruction provides a model that allows functional evaluation

Experimental unilateral ureteral obstruction (UUO) is widely used to study renal fibrosis; however, renal injury can only be scored semiobjectively by histology. We sought to improve the UUO model by reimplanting the obstructed ureter followed by removal of the contralateral kidney, thus allowing longitudinal measurements of renal function. Mice underwent UUO for different lengths of time before ureteral reimplantation and contralateral nephrectomy. Measurement of blood urea nitrogen (BUN) allows objective evaluation of residual renal function. Seven weeks after reimplantation and contralateral nephrectomy, mean BUN levels were increased with longer duration of UUO. Interstitial expansion, fibrosis, and T-cell and macrophage infiltration were similar in kidneys harvested after 10 days of UUO or following 10 weeks of ureter reimplantation, suggesting that the inflammatory process persisted despite relief of obstruction. Urinary protein excretion after reimplantation was significantly increased compared to control animals. Our study shows that functional assessment of the formerly obstructed kidney can be made after reimplantation and may provide a useful model to test therapeutic strategies for reversing renal fibrosis and preserving or restoring renal function.     

Congenital bladder diverticula causing ureteral obstruction

Two boys with congenital periureteral bladder diverticula without vesicoureteral reflux but with severe hydronephrosis and ureteral obstruction are described. No bladder outflow obstruction was present. Urinary tract infection was the presenting symptom in both boys, and this is the most common presenting symptom of bladder diverticula. Diverticulectomy, ureteral tailoring, and reimplantation were performed. Three different mechanisms are proposed for the association of bladder diverticula and ureteral obstruction: compression of the extravesical ureter against the detrusor by the full, tense diverticulum, fibrosis resulting from peridiverticulitis, or primary hypomuscularity of the ureterovesical junction and distal ureter.     

An unusual cause of complete distal ureteral obstruction: giant fibroepithelial polyp

Fibroepithelial polyp of the ureter is a rare benign neoplasm of mesodermal origin. It is an extremely rare cause of hydronephrosis in children. It usually causes partial ureteral obstruction without loss of renal function. The preferred treatment is endoscopic or surgical resection of the polyp with preservation of the renal unit. The authors present an adolescent patient with a nonfunctioning left hydronephrotic kidney caused by complete ureteral obstruction caused by a giant fibroepithelial polyp of the distal ureter. This is an extremely rare presentation and outcome of this benign ureteral neoplasm with resultant loss of renal unit.     

Ureteral obstruction caused by a duplicated anomaly of inferior vena cava

Developmental anomalies of inferior vena cava are a rare cause of ureteral obstruction. We report a case that presented with right upper ureteral obstruction that radiologically simulated a retrocaval ureter. An aberrant vessel, which caused obstruction of the right ureter was identified at operation and surgical relief of ureteral obstruction was performed. Inferior venocavography was performed postoperatively and disclosed an unusual incomplete duplication of inferior vena cava. Our findings suggested that ureteral obstruction by incompletely duplicated anomaly of the inferior vena cava should be included in the differential diagnosis of extrinsic ureteral obstruction.     

Abdominal aortic aneurysms and ureteric obstruction.

Ureteric obstruction is rarely encountered in abdominal aortic aneurysms and is due to perianeurysmal fibrosis. 3 cases are described in which aortic aneurysm and retroperitoneal fibrosis are found. Excision of the aneurysm and ureterolysis with intraperitonization of the ureter is the most appropriate surgical procedure but treatment must be individualized according to the patient's condition and the operative discoveries.     

Laparoscopic ureterocalicostomy: a feasibility study

PURPOSE: Ureterocalicostomy is occasionally indicated for reconstruction of recurrent, recalcitrant ureteropelvic junction obstruction associated with postoperative fibrosis and a relatively inaccessible renal pelvis. We investigated the feasibility of performing laparoscopic ureterocalicostomy in a survival porcine model. Anatomical, histological and chronic functional outcomes were evaluated. MATERIALS AND METHODS: Laparoscopic ureterocalicostomy was performed in 10 survival female swine. A ureteropelvic junction obstruction model was created by laparoscopic ligation of a 2 to 3 cm. segment of upper ureter. After an interval of complete ureteropelvic junction obstruction laparoscopic ureterocalicostomy was performed in a manner duplicating the steps of conventional open surgery. After transverse amputation of the lower renal pole end-to-end anastomosis of the proximal ureter to the inferior calix was formed by laparoscopic freehand suturing and knot-tying techniques. RESULTS: Mean ureter stricture length was 2.2 cm. (range 1.7 to 3.1). Mean duration of obstruction before laparoscopic ureterocalicostomy was 6.3 days (range 2 to 18). Mean operative time for laparoscopic ureterocalicostomy was 165.3 minutes (range 105 to 240). Mean estimated blood loss was 145 cc (range 25 to 400). Mean stent duration in 6 pigs was 8.7 days (range 7 to 11). Excretory urograms demonstrated immediate function with symmetrical and unobstructed drainage in all operated renal units. At 4 to 8 weeks of followup no urine leaks were noted and histological examination documented complete urothelial healing without fibrosis or scar formation. CONCLUSIONS: Laparoscopic ureterocalicostomy is technically feasible in the porcine model and it effectively duplicates the established principles of open surgery. Our technique further extends the application of laparoscopic surgery for difficult ureteropelvic junction obstruction.     

Lower ureteral compression through external vascular elongation in a cyclist: A case report

Introduction and importanceThere is sparse literature about lower ureteric obstruction due to aberrant blood vessels. We report a case of a patient who was referred to our hospital due to left sided flank pain caused by external compression of the distal ureter.Case presentationA 47-year-old male patient presented with left sided flank pain. A computed tomography scan revealed external compression of the lower ureter. Hypertrophy of the psoas muscle due to extensive cycling for 20 years lead to concomitant kinking and elongation of the iliacal vessels which caused the distal ureteric obstruction. Robotic-assisted laparoscopic ureterocystoneostomy with psoas hitch technique was performed.Clinical discussionLower ureteric obstruction, mostly seen in children, is mostly caused by vascular anomalies such as a persistent umbilical artery. After literature review, we presume it to be the first reported case of distal ureteric obstruction caused by external vascular elongation.ConclusionThe external elongation of pelvic vessels due to excessive cycling and the concomitant extrinsic compression of the distal ureter should be considered as rare but possible cause of lower uretic obstructions.     

Ureteral obstruction owing to over pressure of a normal right common iliac artery: a case report

We report a case in which a normal right common iliac artery in a normal anatomical relationship to the right ureter at the crossing point caused partial urinary tract obstruction apparently by an over pressure effect. The ureter was attached to the promontorium periosteum following ureterolysis to relieve the obstruction. To our knowledge, such a condition has not been reported previously. We believe that over pressure of the common iliac artery should be considered in the differential diagnosis of extrinsic ureteral obstruction, particularly in muscular subjects.     

Application of percutaneous nephrolithotomy combined with da Vinci Xi robot in complicated upper urinary tract repair surgery: A case report

Duplex kidney and ureter is a congenital malformation. Few patients present with hydronephrosis caused by obstruction of the ureteropelvic junction of the duplex kidney, but lower kidney calculi caused by a duplex kidney abnormality is rare. This study reports a case of a duplex kidney and ureter complicated by multiple calculi in the duplex lower kidney. Percutaneous nephrolithotomy combined with a da Vinci robot-assisted laparoscopic upper urinary tract reconstruction was performed. The lower ureter was resected, and the lower kidney was preserved. One year after the surgery, a follow-up examination reported satisfactory renal function without hydronephrosis or calculi.     

Initial experience with full-length metal stent to relieve malignant ureteral obstruction

Ureteral obstruction caused by extrinsic compression by a malignancy generally can be overcome initially with a ureteral stent. However, the long-term failure rate is high, usually necessitating placement of a nephrostomy tube. Herein, we present the initial case, in this country, of intractable ureteral obstruction managed successfully with the newly developed all-metal Resonance stent (Cook Ireland Ltd., Limerick, Ireland) constructed of MP35N alloy, a composite of nonmagnetic nickel-cobalt-chromium-molybdenum. The patient is a 64-year-old woman with metastatic breast cancer causing retroperitoneal fibrosis and ureteral obstruction diagnosed laparoscopically. The obstruction failed to respond to placement of a single 7F double-J stent and then of two 6F double-J stents in the left ureter. As a last resort, in order to avoid nephrostomy-tube placement, the 6F metal stent was placed; this provided unobstructed flow of urine, as documented on a subsequent Whitaker test and, most recently, on a renal scan, 4 months after initial stent placement.     

Idiopathic retroperitoneal fibrosis infiltrating ureteral wall.

We describe the eight case of idiopathic retroperitoneal fibrosis infiltrating the ureter to cause intrinsic obstruction. Discovery of this situation intraoperatively necessitates a change in treatment plan, as ureterolysis is not sufficient.     

Management of ureteral stenoses and urinary fistulas following kidney transplantation]

The treatment of strictures and fistulas at the lower ureter after kidney transplantation was simple and could be achieved by reimplantation into the bladder. Proximal urinary fistulas caused early abdominal symptoms. The i.v. urogram showed a dilated renal pelvis without drainage into the ureter. The anatomical findings were in all cases strictures or total obstruction of the ureter beneath the pelvic junction and a rupture of the renal pelvis or calix. Adequate therapy consisted of ureteroureterostomy with the recipient ureter and nephrostomy splintage.     

Obstruction of the ileal ureter by mesenteric vessels occurring 5 years after total ureteral substitution for bilateral ureteral stenosis due to systemic lupus erythematosus

We previously reported a case of bilateral ureteral stenosis accompanied by systemic lupus erythematosus, which was successfully managed by total ureteral reconstruction using a segment of the ileum. Herein, we describe an unusual complication in the same patient, which we experienced 5 years after the ileal-ureteral substitution. Left-sided back pain repeated together with transient obstruction of the ileal ureter interposed between the right and left renal pelvis. Consequently, exploratory laparotomy revealed that left colic vessels oppressed and caused obstruction, and the obstructed ileal ureter was released by reconstitution of these vessels instead of re-anastomosis of the ileal ureter. Left hydronephrosis and related back pain disappeared postoperatively. The number of patients with an indication of ileal-ureteral substitution is increasing for various disorders, and thus, the present report gives additional suggestions for the follow up of patients with ileal ureter.     

Intrinsic endometriosis of ureter and bladder in young women without gynecological symptoms

Urological endometriosis as the primary and sole form of presentation is rare. With ultrasound being available at routine examinations by the urologist and gynecologist, asymptomatic and incidental hydronephrosis is picked up far more than before. The behavior of endometriosis may be very aggressive in terms of ingrowth and fibrosis of the ureter, the periureteral structures and the bladder. It is important to get to an accurate and timely diagnosis to prevent loss of renal function. We report 2 cases who presented with asymptomatic hydronephrosis. Because of severe ureteric obstruction and infiltration of the ureters and/or bladder, surgery was selected as treatment option. Ureteric stenting was not possible because of severe fibrosis and stricture formation of the distal ureter. Primary surgery gave satisfactory results at more than 1 year of follow-up.     

Sarcoidosis of the ureter

We present a case of sarcoidosis of the ureter which caused obstruction. This 'one-organ' localization is very rare and raises diagnostic problems.