小儿先天性前尿道瓣膜症的诊治(附4例报告)

目的 总结小儿先天性前尿道瓣膜症的诊治经验.方法 回顾性总结4例小儿先天性前尿道瓣膜症并结合国内外该病的临床资料进行分析.结果 该组资料2例通过尿道镜检查确诊,1例通过磁共振尿路造影及排尿性膀胱尿道造影确诊,1例单纯通过排尿性膀胱尿道造影确诊.2例行尿道镜前尿道瓣膜内切开术,另2例行前尿道瓣膜切除,尿道成形术,效果满意.结论 通过临床症状,排尿性膀胱尿道造影和尿道镜检查,该病的诊断并不困难.手术是治疗该病的唯一方法.     

先天性男性前尿道憩室的临床诊治

目的总结先天性男性前尿道憩室的临床诊断和治疗特点。方法回顾性分析1996年1月1日至2009年9月1日收治的4例先天性男性前尿道憩室的临床资料,包括临床表现、影像学检查、手术方法、术后随访等。结果 4例患者年龄3个月～3岁,均为出生后即有尿路梗阻症状,包括排尿困难,尿后滴沥等,排尿时阴茎根部至阴囊可见包块鼓起,均行了排泄性膀胱尿路造影、超声及尿道镜检,1例行MRI检查,均可于术前明确诊断。4例患者都行了开放性前尿道憩室切除和尿道整形术。术后随访15～99个月,患者均恢复好,排尿通畅,未见尿道狭窄和尿道憩室复发病例。结论对出生后出现尿路梗阻的男性患者要考虑到先天性前尿道憩室的可能性而进一步做检查明确诊断,同时要注意与尿道憩室并存的泌尿系统畸形。对先天性前尿道憩室建议开放手术,即憩室切除同时行尿道整形,手术效果好。     

后尿道瓣膜切除术后膀胱及上尿路功能损害的影响因素

目的 探讨后尿道瓣膜切除术后膀胱及上尿路功能损害的尿动力学危险因素.方法 1999年至2005年收治后尿道瓣膜切除术后患儿32例,年龄1.2～9.0岁,平均3.5岁.瓣膜切除术后6个月～6年,平均3.2年行尿动力学检查,其中5例行影像尿动力学检查.手术前后行IVU、B超及排尿性膀胱尿道造影等,11例行肾核素检查.比较手术前后膀胱及上尿路功能变化,分析引起上尿路损害的危险因素.结果 术后影像学检查有肾及输尿管扩张、积水加重19例31侧,肾输尿管积水减轻13例19侧,包括积水消失2例4侧及膀胱输尿管反流消失2例3侧.上尿路损害加重占59%.19例上尿路损害加重者膀胱顺应性(6.53±4.34)ml/cm H2O,最大膀胱测压容积(75.60±15.30)ml,13例上尿路损害减轻者膀胱顺应性(45.23±8.17)ml/cm H2O,最大膀胱测压容积(120.80±19.60)ml,2组比较差异有统计学意义(P＜0.01).结论 膀胱顺应性和膀胱容积是决定后尿道瓣膜切除术后上尿路损害是否加重的关键因素,可以作为后尿道瓣膜患者术后主要的随访监测指标.良好的膀胱顺应性和大的膀胱容量预示患者预后良好.     

损伤性后尿道闭锁尿道膀胱假道的诊治

目的 :探讨损伤性后尿道闭锁、尿道膀胱假道的诊治方法。方法 :报告 1例骨盆骨折致尿道断裂患者 ,因早期处理不当形成假道 ,再次行尿道修补仍不能恢复排尿通畅。经直肠指检、膀胱尿道造影、膀胱尿道镜检及前列腺部位的 MRI检查明确诊断 ,并进行尿道假道横断及前后尿道吻合术。结果 :术后 14d行膀胱尿道造影证实原假道消失 ,吻合口通畅 ,拔除导尿管后排尿通畅 ,尿线粗 ,无尿失禁。结论 :前列腺部位的 MRI检查有利于损伤性后尿道闭锁及尿道膀胱假道的诊断 ,尿道假道横断、前后尿道吻合术是治疗本症的有效方法     

小儿下尿路梗阻的球囊扩张治疗

目的探讨球囊导管扩张术治疗小儿下尿路梗阻的临床疗效.方法 1990年4月～2004年8月,收治下尿路梗阻患儿26例,年龄18 d～12岁,其中后尿道瓣膜23例,前尿道瓣膜2例,外伤性后尿道狭窄1例.术前常规行排尿性膀胱尿道造影确诊.双肾均有不同程度的肾盂及输尿管扩张.术前伴尿潴留及肾功能不良者行尿液引流及纠正电解质紊乱后,再行球囊扩张术.术中采用静脉氯胺酮麻醉,30%泛影葡胺作为球囊扩张剂,应用囊径分别为5、8和10 mm,囊长4 cm的球囊导管扩张尿道.术后常规留置双腔气囊导尿管.结果 23例后尿道瓣膜扩张28次,2例前尿道瓣膜扩张2次,1例后尿道狭窄扩张1次后症状好转改用金属探子扩张治疗后3个月治愈,扩张术中均可见球囊被挤压痕迹消失.术后1周拔管,患儿均排尿通畅,尿线增粗.6例术后1～3个月行膀胱输尿管防返流术返流消失.术后25例获随访1～13年,患儿生长发育良好,排尿通畅,双侧肾积水有不同程度的改善.结论球囊扩张术是小儿下尿路梗阻的一种有效的治疗方法,且安全简便.     

窥视下尿道内切开术治疗儿童下尿路梗阻

１９８６年３月至１９９３年１２月应用儿童尿道内窥镜对３０例下尿路梗阻患儿进行了窥视下尿道内切开治疗，其中先天性尿道瓣膜１７例，外伤性尿道狭窄或阻塞１１例，先天性精阜增生和神经源性膀胱各１例，术后均获得满意效果，排尿通畅。     

索利那新治疗小儿下尿路梗阻导致膀胱过度活动症一例报告并文献复习

目的 探讨索利那新治疗小儿下尿路梗阻导致OAB的有效性和安全性. 方法 2010年1月6日我院收治下尿路梗阻致OAB患儿l例,男,4岁.排尿困难、尿频、尿急、尿失禁4年.BUN 4.7 mmol/L,SCr 39.3 μmol/L.B超检查示双肾集合系统分离,肾盂前后径分别为左侧3.3 cm,右侧2.3 cm;肾实质厚度为左侧1.0cm,右侧0.4 cm;双侧输尿管内径左侧1.3 cm,右侧1.6 cm,至膀胱壁段管腔变细.IVU检查示左肾中度积水,输尿管明显增粗,迂曲扩张,输尿管末端似存在狭窄,膀胱呈高张状态.排泄性膀胱尿道造影检查示膀胱壁不光滑,密布憩室;排尿时膀胱颈部存在狭窄征像,尿道膜部似存在狭窄征像.泌尿系CT检查示双肾积水,双输尿管增粗,膀胱壁增厚,内壁不光滑;膀胱呈高张状态.核素肾动态显像检查示GFR左肾86.6 ml/min,右肾18.5 ml/min;左肾盂、肾盏排泄受阻,右肾血流灌注及肾小球功能严重受损.尿动力学检查:尿流率6.7 ml/s,储尿期可见膀胱无抑制性收缩,膀胱顺应性下降,排尿期逼尿肌压力为80 cm H2O(1 cm H2O=0.098 kPa),呈现梗阻曲线(高压低排).入院诊断为后尿道瓣膜.在全麻下行膀胱镜后尿道瓣膜切除术,术中见后尿道自精阜远端发出瓣膜,瓣膜附着于尿道下壁,在尿道球膜部交界处分为2个帆状突起,沿尿道两侧壁走行,用电切襻切除瓣膜.术后患儿排尿通畅,术后3个月复查B超示肾和输尿管积水无改善,于全麻下行膀胱穿刺造瘘术.造瘘术后6个月,复查B超示肾盂前后径为左侧3.2 cm,右侧2.0 cm;输尿管全程扩张,左侧1.3 cm,右侧1.4 cm.加用索利那新(5 mg/片),1/3片,约1.7 mg,每天1次. 结果 服药1个月后复查B超示输尿管由全程扩张改善为上段扩张;服药2个月后复查B超示肾盂前后径为左侧1.1 cm,右侧1.0 cm;双侧输尿管扩张消失.随访至今共服药13个月,无口干、便秘、视物迷糊等不良反应. 结论 外科治疗后加用索利那新,能够安全有效地减轻下尿路梗阻致OAB患儿的上尿路积水,有利于保护肾功能.     

下尿路排尿功能障碍患者的影像尿动力学评估

目的:研究影像尿动力学检查在下尿路排尿功能障碍患者诊断和治疗中的价值。方法:应用影像尿动力学仪检查64例下尿路排尿功能障碍患者的排尿功能情况。结果:神经原性膀胱(Neurogenic bladder,NB)28例(43.75%),女性压力性尿失禁(Stress urinary incontinence,SUI)15例(23.43%),BPH 12例(18.75%),前列腺切除术(TURP)后排尿障碍4例(6.25%),女性排尿困难5例(7.82%)。发现膀胱输尿管反流5例,膀胱小梁或憩室25例,逼尿肌尿道括约肌协同失调8例,尿道远端狭窄1例。结论:影像尿动力学检查通过同时评估膀胱尿道的功能和形态,为复杂性下尿路排尿功能障碍性疾病的临床诊断和治疗提供可靠的依据。     

女性膀胱颈纤维化导致膀胱出口梗阻的诊治（附22例报告）

目的报告女性膀胱颈纤维化导致膀胱出口梗阻（BOO）的诊断治疗体会。方法膀胱颈纤维化导致BOO女性病例22例，经尿流动力学及膀胱镜检确诊，均行经尿道膀胱颈部分切除术，并联合药物治疗。结果随访2～15个月，排尿情况均有改善，最大尿流率〉15mL／s，国际前列腺症状评分（IPSS）5．2±1．6。病理报告显示所有病例膀胱颈组织纤维增生，其中合并慢性炎症改变10例。结论根据临床症状、尿流动力学检查及膀胱镜检可以明确诊断膀胱颈纤维化导致的BOO，经尿道膀胱颈部分切除术可以取得良好的治疗效果。     

尿路内翻性乳头状瘤151例临床分析

目的探讨尿路内翻性乳头状瘤的临床表现、病理类型及临床诊治方法。方法回顾性分析1992年3月至2003年9月,我院收治尿路内翻性乳头状瘤151例,其中男134例、女17例,平均年龄54岁。临床表现主要为无痛性肉眼血尿。诊断依据泌尿系B超、尿路造影、膀胱镜检及病理检查。上尿路7例,除1例行肿瘤局部切除外余行患侧肾、输尿管全长切除术。下尿路144例,行经尿道膀胱肿瘤切除(TURBT)124例,其中11例合并良性前列腺增生者同时行经尿道前列腺切除术,前列腺部尿道肿瘤电切3例,膀胱部分切除术15例,膀胱全切术2例。结果118例随访1～12．5年,平均6．3年。5例膀胱内复发,其中2例分别于术后8,30个月发生恶变,行膀胱全切治疗。结论尿路内翻性乳头状瘤是良性肿瘤,多见于男性,好发于膀胱,TURBT是膀胱内翻性乳头状瘤的首选治疗方法。预后良好,但需定期随访。     

Bladder outlet obstruction in women: difficulties in the diagnosis

OBJECTIVE: To identify the difficulties in diagnosing bladder outlet obstruction in women. MATERIAL AND METHODS: 53 women with a mean age of 37.2 (range 16-70) with chronic lower urinary tract symptoms and no neurogenic or organic diseases were examined. The prevalent symptoms were frequency (96%), urgency (92%) and nocturia (75%), and the mean duration of symptoms was 3.8 years. After pressure-flow studies and voiding cystourethrography were conducted, patients either underwent bladder neck or urethral incisions based on their diagnosis. These patients were subsequently subjected to follow-up uroflow studies. RESULTS: Abnormal uroflow curves were observed in 19 of 53 women. In 10 of them (52.6%), bladder outlet obstruction based on pressure-flow results was confirmed. Voiding cystourethrography results from these 19 women confirmed that 17 patients had bladder neck obstruction, while the remaining 2 had urethral obstruction. 16 of 19 were treated endoscopically, with 14 patients undergoing bladder neck incisions through the 5- and 7-o'clock positions and 2 patients having a distal urethral incision through the 12-o'clock position. In all of these 16 cases, there were both a statistical increase in the maximum flow rate (Qmax) as well as an improvement in the flow curves. Symptomatic improvement was observed in 12 of the 16 women subjected to surgical intervention. CONCLUSION: Bladder outlet obstruction exists in women with lower urinary tract symptoms. Pressure-flow studies and voiding cystourethrography are reliable modalities for confirming bladder outlet obstruction. Bladder outlet obstruction can be functionally or structurally caused.     

Neonatal abdominal wall urinoma due to rupture of anterior urethral diverticulum

An anterior urethral valve with diverticulum is an uncommon cause of congenital urethral obstruction and urinary extravasation compared with a posterior urethral valve. We report a neonate presenting with an abdominal wall urinoma caused by rupture of an anterior urethral diverticulum. Urine drainage via urethral catheter was effective to resolve the abdominal urinoma. Voiding cystourethrogram performed 6 months after an endoscopic incision of the distal margin of the diverticulum revealed a normal urethra with smooth voiding. To our knowledge, no similar case has been reported previously.     

Anterior urethral valves resulting from congenital urethral diverticula

Five cases of anterior urethral diverticula with resulting anterior urethral valves are reported. All children presented with a poor stream. Diagnosis was accomplished by voiding cystourethrography, and treatment was by open resection of the diverticulum in four neonates and endoscopic excision of the valve in a four-year-old boy.     

Application of flexible renoureteroscope for antegrade urethroscopy in the treatment of congenital anterior urethral valve.

Antegrade urethroscopy was performed through a cystostomy using a 10.8-fr caliber flexible renoureteroscope in 4 children (aged 2 years and 8 months, 2 months, 14 years and 1 month) with anterior urethral valve. The anatomy of the valves as well as their destruction after transurethral resection (TUR) were well visualized by antegrade urethroscopy. This technique was helpful in performing TUR-valve, after which the findings of voiding cystourethrography in every case and the findings of uroflowmetry in the elder 2 cases showed remarkable improvement. This technique is relatively simple to perform and is thought to be one of the best methods to treat anterior urethral valve. This technique is also applicable to other lower urinary tract lesions in children.     

Holmium laser ablation of anterior urethral valves: case report

PURPOSE: To report a novel method for treating anterior urethral valves in children using the holmium:YAG laser. CASE REPORT: A 2-year-old boy presented with symptoms of urinary-outflow obstruction. A micturating cystourethrogram (MCUG) revealed an abrupt narrowing of the penile urethra. At cystourethroscopy, an anterior urethral valve without a diverticulum was visible. This was ablated endoscopically using the Ho:YAG laser. The child voided successfully and was discharged the next day. Repeat MCUG 6 months later revealed a normal-caliber urethra. CONCLUSION: Holmium:YAG laser ablation of anterior valves is a minimally invasive treatment modality that provided a satisfactory result and appears to be very promising.     

女性尿道旁腺囊肿及尿道憩室的临床特征

目的:探讨女性尿道旁腺囊肿及尿道憩室的临床特征.方法:报告45例女性尿道旁腺囊肿及尿道憩室患者临床资料.全部患者均行经阴道前壁或经囊肿表面完整切除囊肿和憩室.结果:手术经过均顺利完成,随访期间全部患者的尿道旁腺囊肿和憩室无复发.结论:体检结合简单的实验室,影像学和尿道膀胱镜检查可以确诊该项疾病.尽早手术完整切除十分必要且效果良好.     

Endoscopic operation of congenital anterior urethral valve. Application of flexible renoureteroscope for antegrade urethroscopy]

4 children with anterior urethral valve were treated by TUR-Valve. Before TUR, valve anatomy could be easily seen by antegrade urethroscopy through cystostomy using a 10.8Fr caliber flexible renoureteroscope and destruction of the valve could be recognized after TUR. Antegrade urethroscopy with a flexible fiberscope was so helpful to TUR-Valve and the findings of voiding cystourethrography and micturition have remarkably improved. This technique is not so difficult to apply and thought to be one of the best methods to recognize valve anatomy and degree of resection. This technique is also applicable to other lower urinary tract lesions in children.     

CT virtual cystourethroscopy for complex urethral strictures: an investigative,descriptive study

Purpose

To compare the values of CT virtual cystourethroscopy and of conventional cystourethroscopy in diagnosing complex urethral strictures.

Methods

From January 2012 to December 2012, 33 patients, suspected of having complex urethral strictures before operation, were enrolled in this study. After CT scanning, a virtual cystourethroscopic view was software-generated. Conventional cystourethroscopy was also used before operation. The time durations of virtual cystourethroscopy and conventional cystourethroscopy were recorded. The accuracies of both techniques were compared using the actual findings from the operation.

Results

For 16 patients suffering from urethral strictures associated with various fistulas, the duration of examination with virtual cystourethroscopy was statistically significantly shorter than with conventional cystourethroscopy (P < 0.001). The detection rate of fistula by virtual cystourethroscopy was similar to than by conventional cystourethroscopy (P = 0.057). The same results were obtained in eight patients suffering from urethral strictures associated with false passages. Only virtual cystourethroscopy could reveal the details of the urethral lumen in nine patients suffering from long anterior urethral strictures caused by lichen sclerosus. By contrast, conventional cystourethroscopy failed in those same patients.

Conclusion

CT virtual cystourethroscopy is a useful technique for the diagnosis of urethral disease, especially in male patients suffering from complex urethral strictures.     

Pediatric voiding cystourethrography: An essential examination for urologists but a terrible experience for children

Voiding cystourethrography is the most important fluoroscopic examination in pediatric urology for the investigation of lower urogenital tract diseases, such as vesicoureteral reflux or urethral stricture. However, this invasive procedure imposes a significant burden on children and their parents, and recently there has been a paradigm shift in the diagnosis and treatment of vesicoureteral reflux. In the 2011 revision, the American Academy of Pediatrics guidelines on urinary tract infection recommended abandoning routine voiding cystourethrography after the first febrile urinary tract infection. In 2014, the randomized intervention for children with vesicoureteral reflux study recommended discontinuation of routine continuous antibiotic prophylaxis for vesicoureteral reflux. The time is now ripe to radically reconsider indications for voiding cystourethrography and the procedure itself.