肾迷走血管致肾盂输尿管连接部梗阻20例报告

目的：探讨肾迷走血管的起源、致病机制及其所致的肾盂输尿管连接部梗阻的诊断与治疗方法。方法：对20例手术证实为肾迷走血管压迫致肾盂输尿管连接部梗阻的患者的临床资料及预后情况进行回顾性分析。结果：本病多以肾区间歇性或持续性胀痛、隐痛为首发症状,肾盂输尿管连接部带状压迫截断征和输尿管扭转征是本病的较典型影像学征象,均伴有不同程度的患侧肾积水,手术以选择性保留迷走血管的肾盂输尿管成形术为主,术后2～6个月随访,1例术后1个月出现急性肾盂肾炎,其余肾脏及输尿管积水均减轻;术后1～10年随访(平均6．2年),除1例行肾切除术,19例患侧肾脏积水均明显减轻,肾功能良好。结论：肾迷走血管经肾盂肾尿管连接部前方或后方进人肾下极者均可造成该处梗阻,临床表现无特异性,静脉尿路造影、逆行尿路造影及彩色多普勒超声对诊断有较大价值,选择性保留迷走血管的肾盂输尿管成形术仍是治疗的首选方法。     

64层螺旋CT在肾盂输尿管连接部狭窄中的应用

目的 研究利用64层CT在血管造影(CTA)、尿路造影(CIU)对肾盂输尿管连接部狭窄诊断的应用价值.方法 对15例肾盂输尿管连接部狭窄进行64层螺旋CT平扫及多时相期CT增强扫描.CTA、CTU影像检查.术前评估结果与手术探查结果进行对比.结果 通过CTA及CTO检查包括平扫和增强扫描.15例肾盂输尿管连接部狭窄获得确诊.其中3例平扫发现肾内伴发结石,CTA发现2例异位血管压迫.CTU很好的显示了狭窄的位置和狭窄长度,所有患者行开放或微创手术,影像结果和手术探查一致.结论 64层CT尿路和血管三维重建,可作为肾盂输尿管连接部狭窄术前评估的常规方法.其应用价值值得进一步的研究和分析.     

左肾动静脉血管畸形致左肾积水1例报告

动静脉血管畸形致肾盂输尿管连接处狭窄、肾积水临床上少见。2008年6月本院收治1例,现报告如下。 1临床资料 患者,女,70岁。以左侧腰部胀痛不适1月来本院就诊。B超检查示：左肾积水。CT报告：左肾输尿管上段肿瘤可能、左肾积水。MRI示：左肾盂肾盏积水扩张,考虑输尿管起始部狭窄梗阻。查体示：左肾叩击痛可疑,余无特殊。2008年6月25日行左肾探查术,术中见输尿管走行正常,未见输尿管扩张。左肾蒂见数个隆起的血管瘤压迫肾盂输尿管连接处,     

后腹腔镜下离断式肾盂成形术治疗肾迷走血管压迫导致输尿管肾盂连接部狭窄

目的探讨后腹腔镜下离断式肾盂成形术治疗肾迷走血管压迫导致输尿管肾盂连接部狭窄（UPJO）的疗效。方法回顾性分析15例因肾脏迷走血管压迫导致的UPJO患者的诊断及治疗经过,其中男性11例,女性4例,所有患者均存在患侧腰部胀痛症状,经B超、静脉肾盂造影（IVU）和（或）磁共振水成像（MRU）,和（或）逆行肾盂输尿管造影检查明确诊断为UPJO并肾积水,所有患者均行后腹腔镜下离断式肾盂成形术。结果所有患者均顺利完成手术,无1例中转开放手术,术后1例患者出现发热,1例患者出现漏尿,经治疗后均好转,其余患者均无明显并发症出现。术后1月拔除双J管,所有患者均恢复良好。平均随访18月,显示患肾积水显著减少,患者腰痛症状完全消失。结论对包括肾脏迷走血管压迫在内的各种导致UPJO的病因,均可开展后腹腔镜离断式肾盂成形术,该手术创伤小、恢复快,长期随访效果满意。     

腹腔镜辅助腰部小切口肾盂成形术治疗小儿肾盂输尿管连接部梗阻

目的：探讨腹腔镜在辅助手术治疗小儿肾孟输尿管连接部梗阻（UPJO）的疗效。方法：回顾性分析2008-2011年收治的24例UPJO患儿的临床资料。24例患儿均采用腹腔镜辅助腰部小切口离断式肾盂成形术。其中肾盂输尿管连接部狭窄18例;肾孟输尿管高位连接1例,迷走血管压迫3例,输尿管息肉2例。结果：24例手术顺利完成,手术切口长9,5≈4,5cm,平均3．0cm,术后梗阻症状解除。1例患儿术后出现吻合口漏,术后延长切口引流管留置时间盾愈合。术后随访6-36个月,复查B超及IVU显示患肾形态基本正常。结论：腹腔镜辅助小切口离断式肾盂成形术治疗小儿肾盂输尿管连接处梗阻创伤小,手术简便快捷、疗效可靠。     

儿童原发性肾积水的影像学诊断和治疗

目的：探讨儿童味发性肾积水的影像学诊断和治疗方法。方法：收集1999年4月～2006年9月收治的原发性肾积水患儿80例．临床主诉以腹痛或腰痛为主。80例均经过B超筛查．再行静脉肾盂造影（IVP）检查31例次．排泄性尿路造影检查3例次．逆行上尿路造影2例次．肾脏同位素检查（ECT）70例次．核磁共振尿路成像（MRU）38例次．并有1例同时进行了动态增强核磁共振尿路成像（Gd—MRU）检查。69例72侧进行了离断式肾盂整形术．其中5例在B超引导下行经皮穿刺肾造瘘术,4例行肾盂输尿管内引流术,3例因重度积水且肾发育不良行肾切除术．7例暂且随访观察。结果：手术及病理检查诊断52侧为肾盂输尿管连接处狭窄．8侧为高位输尿管．3侧为迷走血管压迫．6侧为肾盂输尿管连接处息肉或黏膜乳头样增生．3侧为肾血管或下腔静脉压迫肾盂输尿管交界处。结论：原发性肾积水临床病因以肾盂输尿管连接处梗阻（UPJO）最为多见,影像学以B超为最初筛杏方法．IVP和ECT为公认的诊断UPJO时评价病肾形态功能的必需检查方法．但MRU有望替代B超和IVP而成为泌尿系影像学诊断的新“金标准”。在MRU基础上提出Gd—MRU技术可同时评定肾形态及功能,有很好的应用前景。Anderson—Hynes离断式肾盂整形术为UPJO手术“金标准”。     

多层螺旋CT血管造影在血管压迫所致肾盂输尿管连接部梗阻中的诊断价值

目的探讨多层螺旋CT血管造影（CTA）对血管压迫所致肾盂输尿管连接部梗阻（UPJO）中的诊断价值。方法分析手术证实的16例血管压迫所致UPJO患者的CT血管造影图像,观察有无肾脏血管变异,肾盂输尿管连接部周围有无骑跨血管、血管的起源、大小及其与UPJO间的关系。结果16例UPJO中,肾动脉解剖变异12例,肾静脉解剖变异3例。CTA16例见19支血管压迫,其中动脉血管15支,静脉血管4支。单支血管压迫13例,双支血管压迫3例,包括副。肾动脉12例,迷走动脉3例,性腺静脉2例,副肾静脉2例。均与手术病理相吻合。结论多层螺旋CTA不但能够了解肾脏血管解剖及变异,并且在血管压迫所致UPJO的诊断及手术治疗方面具有重要价值。     

经皮肾镜气压弹道碎石术后患者重度肾功能损害11例临床分析

目的:分析经皮肾镜气压弹道碎石术对患者肾功能影响的原因和机制,寻求预防方法。方法:回顾分析11例经皮肾镜气压弹道碎石患者资料,包括手术前后肾脏影像学(超声,MRU,IVP)及肾功能检查(ECT)的临床资料。结果:11例严重肾功能损害的患者,患肾滤过率均低于正常20%,ECT呈低平曲张,IVP不显像,9例重度肾积水,1例无明显积水,1例肾脏萎缩,其中7例术前存在肾盂输尿管交界部狭窄,4例术前无明显狭窄;8例再行肾盂输尿管交界部狭窄手术,3例切除肾脏。结论:经皮肾镜气压弹道碎石取石术后患者肾功能损害最重要的原因仍为肾盂输尿管交界部狭窄,需在取石术时同时手术解除输尿管梗阻,并密切定期术后随访。     

左肾静脉压迫综合征的手术治疗(附四例报告)

目的　探讨左肾静脉压迫综合征 (胡桃夹现象 )的临床特点及诊治方法。　方法　左肾静脉压迫综合征男性患者 4例 ,年龄 16～ 2 2岁。临床主要表现为反复发作肉眼血尿 ,1例合并左侧精索静脉曲张。膀胱镜下均可发现左侧输尿管口喷血尿 ,B超及CT三维重建示腹主动脉与肠系膜上动脉夹角处左肾静脉明显受压 ,肾静脉近端扩张。结合文献讨论其发病特点 ,影像学特征和治疗。　结果　 4例患者术前均明确诊断 ,均行左肾静脉重建手术 ,术后血尿消失 ,痊愈出院。术后 6个月及 9个月分别复查B超、CT三维血管重建 ,4例患者肾脏大小正常 ,重建肾静脉通畅 ,受压现象消失 ,尿常规正常。　结论　左肾静脉压迫综合征临床特点为肾静脉高压 ,肉眼或镜下血尿 ,精索静脉曲张。左肾静脉重建手术是治疗血尿的有效方法。     

肾盂输尿管连接部梗阻的开放手术治疗

目的 探讨肾盂输尿管连接部梗阻(UPJO)的临床特点和诊治方法.方法 UPJO患者222例.男155例,女67例.平均年龄29(13～75)岁.病程6个月～4.5年,平均27个月.临床表现为腰腹部胀痛173例、尿路感染19例、腹部包块12例、肉眼血尿7例,体检B超检查发现11例.其中肾盂输尿管连接部狭窄185例、肾盂输尿管高位连接18例、纤维条索或迷走血管压迫19例.患者均行B超检查,提示不同程度肾积水;IVU检查215例,其中肾积水轻度29例、中度115例、重度61例,患肾不显影10例;逆行肾盂造影检查37例及CT尿路造影检查19例,均提示肾盂输尿管连接部狭窄.222例均手术,其中离断性肾盂成形术191例、纤维条索或迷走血管切断19例、患肾无功能行肾切除12例.结果 191例行离断性肾盂成形术者随访6个月～8年,平均38个月,B超及IVU检查提示患侧肾实质明显增厚,尿路通畅.肾积水完全消失127例,轻度肾积水58例、中度积水6例;患者腰腹胀痛,腹部包块,尿路感染及肉眼血尿症状消失;7例术前SCr为146～203μmol/L者术后复查均<133μmol/L.结论 离断性肾盂成形术为UPJO病例的标准术式,疗效确切.     

MISSED ANTERIOR CROSSING VESSELS DURING OPEN RETROPERITONEAL PYELOPLASTY: LAPAROSCOPIC TRANSPERITONEAL DISCOVERY AND REPAIR

PURPOSE: Extrinsic ureteropelvic junction obstruction due to anterior crossing segmental renal vessels is present in more than 50% of patients in adulthood. In this situation the ureter must usually be dismembered and transposed anterior to the crossing vascular structures, where it is anastomosed to the renal pelvis. Via the open retroperitoneal approach there may be a limited view of the anterior surface of the ureteropelvic junction and, hence, anterior crossing vessels may possibly be missed. We describe 2 patients with ureteropelvic junction obstruction in whom anterior vessels were missed during open retroperitoneal repair. Laparoscopic transperitoneal secondary pyeloplasty with posterior displacement of the crossing renal vessel was performed in each case. MATERIALS AND METHODS: Two patients presented with symptomatic congenital ureteropelvic junction obstruction after failed endopyelotomy in 1 and failed open retroperitoneal procedures in both. Preoperatively spiral computerized tomography angiography with a ureteropelvic junction protocol revealed crossing vessels in the 2 cases. This finding was confirmed at transperitoneal laparoscopic pyeloplasty. The ureter and renal pelvis were transposed anterior to the crossing vessels and 2 rows of running sutures were placed to complete the anastomosis. RESULTS: The 2 laparoscopic procedures were completed successfully. The anterior crossing vessels were preserved in each case. Currently the patients are asymptomatic and furosemide washout renal scan was normal. CONCLUSIONS: Spiral CT angiography reliably delineates the renal vascular anatomy in patients with ureteropelvic junction obstruction. This study may be valuable before planned open retroperitoneal ureteropelvic junction obstruction repair. Laparoscopic pyeloplasty may successfully manage anterior crossing vessels associated with secondary ureteropelvic junction obstruction.     

Retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels for ureteropelvic junction obstruction

PURPOSE: We developed a new approach of retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels for ureteropelvic junction obstruction as an alternative to conventional antegrade or retrograde endopyelotomy. MATERIALS AND METHODS: From February 1997 to August 1999 we treated 5 cases of ureteropelvic junction obstruction due to crossing vessels that were diagnosed by helical computerized tomography. Ureterovascular hydronephrosis characterized by a malrotated renal pelvis with anterior crossing vessels was observed in 4 cases and ureteropelvic junction obstruction with a posterior crossing artery was present in 1. After endoureterotomy stent insertion under cystoscopic guidance we performed retroperitoneoscopic endopyelotomy with the kidney in standard position. Crossing vessels were transposed to a higher position to remove obstruction and fixed with peripelvic tissue via retroperitoneoscopy. In all cases a longitudinal incision approximately 1.5 cm. long was made with a potassium titanyl phosphate laser. RESULTS: Convalescence was uneventful in all patients and the endoureterotomy stent was removed 4 to 8 weeks after surgery. Postoperatively helical computerized tomography showed the successful transposition of crossing vessels and significant hydronephrosis resolution in all cases. All patients were asymptomatic during followup of 17 to 28 months. CONCLUSIONS: Despite our small number of patients our results are sufficient to conclude that retroperitoneoscopic pyelotomy combined with the transposition of crossing vessels is a simple and reliable method for treating ureterovascular hydronephrosis and associated conditions.     

A prospective study of endoluminal ultrasound versus computerized tomography angiography for detecting crossing vessels at the ureteropelvic junction

PURPOSE: Crossing vessels at the ureteropelvic junction are associated with bleeding complications and a higher risk of failure after endopyelotomy. We compared computerized tomography (CT) angiography and endoluminal ultrasound for detecting crossing vessels before planned endopyelotomy. MATERIALS AND METHODS: Preoperatively patients underwent CT angiography. Intraoperative evaluation included retrograde ureteropyelography, endoluminal ultrasound and ureteroscopy. Intraoperative findings were used to direct treatment. RESULTS: Endoluminal ultrasound detected 19 crossing vessels in 14 of 20 patients (70%), while CT detected 9 crossing vessels in 7 (35%). Endoluminal ultrasound identified a septum between the ureter and renal pelvis in 7 patients (35%) but CT demonstrated none. On the basis of imaging findings we selected 5 patients for pyeloplasty, and endoluminal ultrasound accurately predicted the absence or presence of crossing vessels in all 5. CT angiography was accurate in 3 patients. However, in 2 patients a total of 4 vessels were missed by CT. A total of 15 patients underwent endopyelotomy with no bleeding complications. The presence or absence of a septum on endoluminal ultrasound was confirmed in all patients. Imaging findings altered the treatment chosen in 4 patients and changed the direction of the incision at the ureteropelvic junction in another 4. Clinical and radiographic success was achieved in all 13 patients (100%) with adequate followup. CONCLUSIONS: Endoluminal ultrasound was more sensitive than CT angiography for identifying crossing vessels and septa. Treatment based on endoluminal ultrasound findings may decrease complications and improve the results of minimally invasive treatment for ureteropelvic junction obstruction.     

先天性肾盂输尿管连接处梗阻的诊断与治疗

目的：总结肾盂输尿管连接处理梗阻（PUJO）引起的小儿先天性 肾积水的诊断及治疗经验。方法：回顾性分析22例由PUJO引起的小儿先天性肾积水的临床资料。结果：术前诊断符合率90.9%(20/22),手术治愈率90.0%(18/20)。结论：B超为由PUJO引起的先天性肾积水首选的诊断方法;电视监视IVU为轻度由PUJO 引起的先天性肾积水的主要诊断方法;CT为中重度由PUJO引起的先天性肾积水的主要诊断方法。Anderson-Hynes成形术为其首选的治疗方法。     

Ureteropelvic junction obstruction: does CT angiography allow better selection of therapeutic modalities and better patient outcome?

PURPOSE: To determine whether preoperative helical CT angiography (CTA) with three-dimensional (3D) reconstructed images improves outcome in patients with ureteropelvic junction obstruction (UPJO) by identifying crossing vessels that may lead to surgical failure. PATIENTS AND METHODS: Twenty-five patients with UPJO underwent imaging with CTA to identify crossing vessels. Patients with crossing vessels or severe hydronephrosis underwent laparoscopic dismembered pyeloplasty. In the absence of crossing vessels, and with >25% renal function on MAG-3 scan, the patient underwent an endopyelotomy. Procedures were assessed as successful by resolution of patient symptoms as well as relief of obstruction on renal scintography. RESULTS: Twenty-seven procedures (14 laparoscopic dismembered pyeloplasties [9 in the setting of a crossing vessel], 11 ureteroscopic endopyelotomies, and two antegrade endopyelotomy procedures) were performed. Follow-up ranged from 2.4 to 40 months (mean 21.6 months). Twenty-three of the primary procedures (92.0%) were successful. Primary laparoscopic pyeloplasty was successful in 100% of patients, while primary endopyelotomy had a success rate of 83.3%. Both secondary procedures were successful rendering the patients unobstructed and pain free. No complications occurred. The sensitivity and specificity of CTA in determining crossing vessels was 78% and 40%, respectively. CONCLUSIONS: Helical CT angiography with 3D reconstructed images provides valuable preoperative information in patients with UPJO scheduled for surgical intervention. This study may be used in selecting patients for proper operative intervention according to the anatomy of crossing vessels to attain high treatment success rates.     

Ureteropelvic junction obstruction repair: when, how, what?

PURPOSE OF REVIEW: To review factors that affect the success of ureteropelvic junction obstruction repair and recent developments in minimally invasive procedures for the repair of ureteropelvic junction obstruction. RECENT FINDINGS: Recent reports and studies further confirm earlier findings that the success rate of endopyelotomy is decreased when a crossing vessel is the primary cause of ureteropelvic junction obstruction, poor renal function and significant hydronephrosis. Various minimally invasive procedures have emerged recently for the treatment of ureteropelvic junction obstruction. These include laparoscopic pyeloplasty, robotically assisted laparoscopic procedures, and percutaneous endopyeloplasty. These procedures offer potential advantages over conventional endopyelotomy, including better success rates in the presence of crossing vessels, wider caliber reconstruction of the ureteropelvic junction, and full-thickness healing with primary intent. SUMMARY: With such a large variety of minimally invasive procedures for the treatment of ureteropelvic junction obstruction available, the treatment choice for ureteropelvic junction obstruction must be based on several factors, including the success and morbidity of the procedures, the surgeon's experience, the cost of the procedure, and the patient's choice.     

Prevention and Management of Hemorrhage Associated with Cautery Wire Balloon Incision of Ureteropelvic Junction Obstruction

The functional significance of crossing lower pole vessels in patients with ureteropelvic junction obstruction is controversial. However, there is clear evidence that the incidence of such vessels in patients with ureteropelvic junction obstruction is significantly higher than in the general population. We report on a patient with secondary ureteropelvic junction obstruction treated with retrograde cautery wire balloon incision in whom significant hemorrhage developed as a result of disruption of a lower pole accessory artery crossing the ureteropelvic junction. Angiographic intervention with selective arterial embolization resulted in immediate, complete resolution with salvage of the kidney. Because the incidence of crossing vessels is relatively high in this patient population, steps should be taken to identify and possibly exclude affected patients before the use of blind incisional procedures.