小儿先天性肾盂输尿管连接部梗阻126例

目的 探讨小儿先天性肾盂输尿管连接部梗阻的诊断及治疗方法。方法 回顾总结126例先天性肾盂输尿管连接部梗阻患儿的病例资料,分析其诊断、治疗方法及疗效。结果126例均行离断性肾盂成形术,一期治愈124例,2例术后10d试行夹管后感腰部胀痛、发热,予带管持续引流．延期3周拔除肾造瘘管,痊愈出院。全部病例术后随访6个月,临床症状消失．复查B超及IVP．均提示患肾形态缩小,肾实质厚度增加,造影剂显影和排泄状况好转。结论小儿先天性肾盂输尿管连接部梗阻可通过B超、IVP等检查,结合临床症状明确诊断。离断性肾盂成形术设计合理,成功率高。     

小儿先天性肾盂输尿管连接部梗阻诊治265例

目的探讨离断性肾盂成形术在小儿先天性。肾盂输尿管连接部梗阻中的治疗效果。方法总结2006年至2007年收治的265例小儿先天性肾盂输尿管连接部梗阻患儿的临床资料。男226例，女39例。左侧183例，右侧65例，双侧17例。平均年龄4．5岁，其中年龄小于1岁34例。根据症状、超声、静脉尿路造影（IVU）或核磁水成像明确诊断，对重度肾积水患儿行肾核素扫描了解分肾功能。均行腹部横行小切口离断性肾盂成形术（Anderson—Hynes术式）。结果术后随访6个月，以梗阻症状消失、。肾盂变窄或肾实质增厚为治愈标准。病理诊断：肾盂输尿管连接部狭窄并高位输尿管最多见，占93．2％。265例（282侧）一次手术成功率为98．5％。结论新生儿肾积水多为生理性，有白行改善的可能，绝大多数不需要手术治疗。小儿先天性肾盂输尿管连接部梗阻的首要病因是。肾盂输尿管连接部狭窄。有明显梗阻症状、肾盂进行性扩张或。肾功能损害进行性加重者需手术治疗，首选离断性。肾盂成形术。     

小儿膀胱镜输尿管插管逆行造影检查术在肾输尿管先天畸形诊断中的价值

目的 评价小儿膀胱镜输尿管捕管逆行造影检查术在肾输尿管先天畸形诊断中的价值.方法 总结分析2806年8月-2008年11月本院收治的经小儿膀胱镜输尿管插管逆行造影检查术诊断为肾输尿管先天畸形的患儿病例资料.71例患儿中肾盂输尿管连接部梗阻(UPJO)43例(60.56%),其中狭窄35例,息肉5例,高位输尿管2例,下腔静脉后输尿管1例,并肾结石9例;输尿管末端狭窄17例(23.94%),并输尿管末端结石5例;输尿管中段狭窄6例(8.45%);肾发育不良3例(4.23%);重复肾重复输尿管畸形2例(2.82%).所有病例依据小儿膀胱镜逆行造影检查的术前诊断进行相应手术,术后随访49例,其中11例行逆行造影检查.结果 71例肾输尿管畸形术前均行小儿膀胱镜输尿管插管逆行造影检查术,术前诊断在术中均得到证实,符合率为100%.其中43例UPJO者均行Anderson-Hynes肾盂输尿管成形术,并肾结石9例,同期取净结石;3例肾发育不良和2例重复肾重复输尿管畸形行发育不良肾、重复肾及输尿管切除术;6例输尿管中段狭窄者行狭窄段输尿管切除、输尿管斜形吻合术;17例输尿管末端狭窄者行输尿管膀胱吻合术,并结石者同期取出.出院时疗效均满意.术后随访期间11例再次经小儿膀胱镜输尿管插管逆行造影检查,输尿管均通畅,全程显影,未见狭窄及扩张.结论 随着小儿膀胱镜输尿管插管逆行造影检查术的开展,使得肾输尿管先天畸形的术前正确诊断得到明显的提高,有利于手术方法 的正确选择,从而防止了术中的盲目探查;同时还可进行术后的有效随访.     

先天性肾盂输尿管连接部梗阻的临床病理学分析

目的采用病例对照研究的方法来探讨肾盂输尿管连接部Cajal间质细胞(interstitial cell of cajal,ICC)以及代表信息传递的神经组织的改变与先天性肾积水发病机制的关系及其临床意义。方法收集2013年01月至2014年12月由本院确诊的30例非管腔压迫或新生物所致先天性肾盂输尿管连接部梗阻(Ureteropelvic junction obstruction,UPJO)患儿为病例组;选择同期11例无肿瘤细胞浸润肾盂输尿管连接部的肾肿瘤患儿作为对照组。所有标本观察组织学改变、神经纤维和ICC标记物的变化。结果病例组肌层肥厚,排列紊乱、稀疏,其间可见大量增粗胶原纤维。与对照组相比,管腔明显狭窄;与对照组比较,病例组平滑肌神经纤维丝蛋白大部分标本呈阴性表达,仅少部分标本呈弱阳性表达,且神经纤维异常增粗。病例组神经纤维分布密度为(1.51±0.39),对照组为(3.79±0.48),差异有统计学意义(t=15.36,P0.01);病例组UPJ肌层仅见少量ICC呈C-kit阳性表达,甚至部分标本C-kit免疫反应呈阴性表达。病例组ICC标记物分布密度为(1.70±1.24),对照组为(9.09±1.76),差异有统计学意义(t=15.099,P0.01)。结论神经纤维与Cajal间质细胞减少在先天性肾盂输尿管连接部梗阻的病因和发病机制中起重要作用,术中应彻底切除肾盂输尿管连接部病变段,以减少术后复发。     

利尿性肾图在小儿肾盂输尿管连接部梗阻致肾积水诊断中的作用

目的探讨以利尿性肾图替代静脉尿路造影对小儿肾盂输尿管连接部梗阻引起的肾积水进行诊断的可能性.方法对1995年8月至2001年10月间的52例同时行静脉尿路造影和利尿性肾图检查并进行了肾盂成形术的病例进行回顾性分析,男47例,女5例,年龄0.2～13岁(平均6.5岁).结果本组52例静脉尿路造影对梗阻部位判断有52例(100%)正确;利尿性肾图检查后,52例患儿梗阻部位的判断也都(100%)正确.静脉尿路造影和利尿性肾图在梗阻部位诊断上差异没有显著性意义(P＞0.05).结论在诊断小儿肾盂输尿管连接部梗阻上,以利尿性肾图来替代静脉尿路造影是可行的.     

非钳夹式吻合口缝合法在腹腔镜离断式肾盂成形术中的应用

目的 探讨“非钳夹”式吻合口缝合法在腹腔镜肾盂输尿管成形术治疗小儿肾盂输尿管连接部梗阻(UPJO)的手术技巧、疗效及临床应用价值.方法 2015年1月至2015年4月对我院收治的81例肾盂输尿管连接部梗阻小儿肾积水患儿行“非钳夹”式吻合口缝合法经脐单部位腹腔镜肾盂输尿管成形术,其中男68例,女13例,左侧57例,右侧24例,平均年龄3.5岁(11d至15岁),所有患儿术前均行泌尿系B型超声、MRU及MAG3肾核素扫描等检查明确诊断.采用经脐单部位建立手术操作通道,吻合肾盂输尿管前后壁时,离肾盂输尿管吻合口最低点1.0～1.5 cm处于肾盂瓣及输尿管前后壁分别用4-0慕斯线牵引用于缝合吻合口时钳夹与牵拉用,其余方法基本同普通腹腔镜肾盂输尿管成形术.结果 81例患儿手术均获得成功,无中转开放手术,无术中并发症,有2例大龄右侧病变患儿术中在上腹部增加一5 mmTrocar后完成手术.平均手术时间94(80～150)min、术中平均出血量15(10～50)ml、平均引流管拔除时间5(3～10)d、术后平均住院时间7(5～10)d.术后行超声、放射性核素扫描随访3～6个月,术侧肾实质不同程度增厚,肾盂前后径明显减小或消失,62例形态接近正常,患肾分肾功能不同程度恢复.结论 腹腔镜肾盂输尿管成形术治疗小儿肾积水时采用“非钳夹”式吻合口缝合法安全可行,具有损伤小、恢复快、成功率高等优点,值得临床推广应用.     

腹部小切口手术治疗小儿肾盂输尿管连接部梗阻

目的探讨腹部小切口离断式肾盂成形术治疗小儿肾盂输尿管连接部梗阻的临床疗效。方法2010年12月至2011年12月作者采用腹部小切口腹膜外入路行离断式肾盂成形术,治疗小儿肾盂输尿管连接部梗阻患儿33例,分析其手术入路、临床效果及并发症情况。结果33例均手术成功,平均手术时间（89±37）min,平均出血量（16±12）mL,伤口愈合良好。术后随访3~12个月,无吻合口狭窄、尿瘘、泌尿系感染等并发症,患儿肾盂均不同程度缩小,肾实质增厚。结论腹部小切口离断式肾盂成形术治疗小儿肾盂输尿管连接部梗阻,操作简单,损伤少,并发症少,疗效好,值得临床推广。 Abstract：     

“输尿管拖出法”在腹腔镜离断式肾盂成形术中的应用研究

目的探讨"输尿管拖出法"在腹腔镜离断式肾盂成形术治疗小儿肾盂输尿管连接部梗阻中的手术技巧,总结该方法的临床应用价值。方法回顾性分析2015年11月至2016年5月本院收治的15例肾盂输尿管连接部梗阻患儿临床资料,其中男性8例,女性7例,年龄2个月至8岁。因胎儿期发现肾积水出生后随访积水进行性加重8例,因腹痛就诊行超声检查发现肾积水7例。患儿均接受腹腔镜下离断式肾盂成形术,术中采用输尿管拖出法处理病变段。收集手术情况、手术时间、出血量及并发症情况。术后定期门诊超声随访。结果 15例均手术成功,无中转开放手术病例,无留置J管相关并发症。平均手术时间143(116~244)min。平均术中出血量5(2~15)mL。术中留置双J管耗时平均6(3~10)min。术中留置双J管困难,发现输尿管远端狭窄1例。术后平均住院时间7(5~10)d。术后1个月复查超声,提示肾盂积水较术前明显减轻,肾实质厚度稳定。结论在腹腔镜治疗肾盂输尿管连接部梗阻中采用"输尿管拖出法"处理输尿管,并留置双J管安全可行,有精确触觉反馈,能够提高肾盂输尿管连接部梗阻合并输尿管中、远段病变的检出率,降低手术初学者难度,值得临床推广。     

先天性肾盂输尿管连接部梗阻的诊断治疗

目的 探讨小儿先天性肾盂输尿管连接部梗阻（UPJO）致肾积水诊断和治疗的最佳方法。方法 对26例小儿UPJO致重度肾积水，采用B超与静脉尿路造影（IVU）相结合的诊断方法和离断式肾盂输尿管成形术（Anderson—Hynes手术）治疗，总结其效果。结果 所有病例经手术和病理检查证实诊断正确，手术经过顺利，术后恢复好。24例获随访6个月～2年，无血尿、尿频、腹部包块、腹胀等症状，尿常规正常，临床治愈。B超示扩张的肾较术前缩小、肾实质厚度增加；IVU示手术侧肾显影时间提前、杯口形态改善，其中20例输尿管显示良好。结论 B超和IVU相结合是诊断小儿UPJO极有效的方法；Anderson—Hynes手术是治疗UPJO的最佳术式。     

输尿管支架管和肾盂造瘘管在小儿Anderson—Hynes术中的应用

目的 评估小儿肾盂输尿管连接部狭窄（UPJO）采用离断式肾盂成形术（Anderson-Hynes）后,放置输尿管支架管和肾盂造瘘管对术后疗效的影响.方法 回顾性分析139例因肾盂输尿管连接部狭窄在本院行Anderson-Hynes术,术后放置输尿管支架管和肾盂造瘘管的患儿临床资料,对住院时间、术后并发症及拔管时间等进行分析. 结果 139例患儿行144侧Anderson-Hynes术,其中5例为双侧.术后23例出现并发症：12例（8.3%）血尿、2例尿路感染（1.4%）、1例尿性囊肿（0.7%）、2例（1.4%）暂时性吻合口梗阻、2例（1.4%）尿漏.拔除肾周引流管平均时间4.2d.拔除输尿管支架管平均时间9.6d.拔除肾盂造瘘管平均时间13.3 d.平均住院天数14.8 d.术后随访0.5～24个月,没有发现因吻合口再次梗阻等原因需再次手术的病例.结论 小儿肾盂成形术后使用输尿管支架管和肾盂造瘘管引流,减少了尿漏和吻合口狭窄的可能,也未增加术后尿路及切口感染的机会.     

核医学肾脏显像对儿童肾积水患者分肾功能的评估价值

核医学肾脏显像包括肾动态显像和肾静态显像.利尿肾动态显像如应用于儿童肾积水患者,在评估分肾功能的同时,可协助判断尿路梗阻的性质.由于婴儿肾脏肾小球发育不成熟,建议行肾动态显像时,＜2岁患者使用肾小管分泌型显像剂99mTc-双半胱氨酸(99mTc-EC),＞2岁者使用肾小球滤过型显像剂99mTc-喷替酸(99mTc-DT...     

Long-term outcome of children with malformative uropathies

125 cases of severe malformative uropathies, 42 urethral valves (V), 52 degree III vesicoureteral refluxes (VUR), 18 ureterovesical junction stenoses (UVJ), 13 pyeloureteral junction stenoses (PUJ), were studied for a period of 12 years. Based on the hypothesis that prognosis depends on the number of residual nephrons, we used the glomerular filtration rate (GFR) as our basic reference. 62% of our cases had an initial GFR below 50 ml/min/1.73 m2 and 30% had GFR's below 25. Early diagnosis and intervention are important for improvement of GFR. Of the 32% who improved, most were diagnosed in the first year of life, and the exceptional few after 2 years. The extent of initial renal damage is also a limiting factor. Improvement was rarely seen when the initial GFR was below 30 ml/min/1.73 m2. There was a correlation between the initial and final GFR levels. Renal degradation (28% of cases) is most influenced by follow up time. The average age of end stage renal failure (ESRF) onset was 11 years 4 months, but is earlier for V than for VUR. Onset is even earlier when initial damage is more severe. As normal GFR does not exclude later degradation of renal function, another indicator of the risk of this type of evolution should be adopted.     

The relationship between serum creatinine,serum cystatin C and glomerular filtration rate in pediatric renal transplant recipients: a pilot study

Serum cystatin C more accurately reflects glomerular filtration rate (GFR) in pediatric renal transplant recipients than serum creatinine. Nineteen pediatric renal transplant recipients, 15 male and 4 female, ranging in age from 8.35 yr to 19.06 yr (median 13.52 yr), were enrolled in the study over an 18-month period. Twenty-eight measurements of 99mTc-DTPA GFR were compared with simultaneous measurements of serum cystatin C and Cr. Linear regression analysis, Pearson correlation coefficients and analysis of variance (anova) were used to determine the relationship between creatinine, cystatin C and GFR. The correlation coefficients (R2) for the relationship of 1/Cr to DTPA-GFR and for 1/cystatin C to DTPA-GFR were 0.63 and 0.58, respectively. There was no significant difference between serum cystatin C and serum creatinine as markers of GFR. Serum cystatin C, which costs more to measure than serum creatinine, offers no advantage in monitoring the renal function of pediatric renal transplant recipients.     

Comparison of Tc-99 measurement of glomerular filtration rate vs. calculated creatinine clearance to assess renal function pretransplant in pediatric patients undergoing hematopoietic stem cell transplantation

We compared the results of Tc-99 evaluation of glomerular filtration rate (GFR) vs. the calculation of the creatinine clearance (CCrC) as a predictor for the development of renal insufficiency in pediatric patients following hematopoietic stem cell transplantation (HSCT). We reviewed 95 consecutive patients receiving autologous (n = 37) or allogeneic (n = 58) HSCT at Children's Memorial Hospital between January, 1995 and February, 1998. Diagnoses included leukemia (n = 43), solid tumor (n = 27), bone marrow failure syndrome (n = 12), non-malignant disease (n = 8), CNS tumors (n = 5) and immunodeficiency (n = 3). Tc-99 GFR was compared with a calculated creatinine clearance derived from the Schwartz formula (CCrC) prior to HSCT. These measures of renal function were compared with the patient's subsequent clinical course to determine if patients who developed renal insufficiency of sufficient magnitude as to require continuous veno-venous hemofiltration (CVVH) or dialysis, could have been identified. Overall comparison of the two methods of evaluation of renal function showed low correlation with values obtained by CCrC, which were consistently higher in most patients (r-value 0.01 in the regression analysis and a p = 0.08 95% CI -24.15 to 1.48). When stratified for age, correlation between the two methods was excellent only in children younger than 5 yr of age p = 0.02 95%, CI 0.032-0.49). Eleven patients required therapy with CVVH or dialysis but neither CCrC nor Tc-99 GFR prior to transplant predicted this event. Patients who received TBI were statistically more prone to develop renal insufficiency than those without TBI (p < 0.0001, 95% CI 0.25-0.008). Neither the Tc-99 GFR nor the CCrC was predictive of the development of renal insufficiency in HSCT patients as the majority of patients who required dialysis had normal Tc-99 GFR prior to transplant. The characteristics found in the patients who developed renal insufficiency and required dialysis include: the use of total body irradiation as part of the transplant-conditioning regimen (p < 0.0001) and the use of continuous infusion CSA (p = 0.04).     

Estimation of Glomerular Filtration Rate in Children Using 99m-Technetium DTPA

ABSTRACT. The usefulness of radionuclide imaging studies with 99m-technetium diethylenetriaminepen-taacetic acid (Tc-DTPA) for quantitating the glomerular filtration rate (GFR) in children was studied. This was compared to the conventional methods for measuring GFR using 51-chromium-EDTA clearance (Cr-EDTA), creatinine clearance and a height/plasma creatinine formula. In the 22 children studied, the correlation coefficient between renal uptake of DTPA and Cr-EDTA was 0.90 ( p <0.001). In contrast, there was a poorer correlation between Cr-EDTA and creatinine clearance ( r =0.69) or the derived GFR using height/creatinine formula ( r =0.83). The regression line between Tc-DTPA uptake and Cr-EDTA clearance was used to derive a formula for calculating the predicted GFR. This was tested in 10 additional children, and the correlation between the predicted GFR and measured GFR (using Cr-EDTA clearance studies) was 0.92 ( p <0.001). Quantitative estimation of the GFR during renal imaging studies is a feasible and convenient method of assessing renal function.     

Estimation of glomerular filtration rate in children using 99m-technetium DTPA. A comparison with 51-chromium EDTA clearance

The usefulness of radionuclide imaging studies with 99m-technetium diethylenetriaminepentaacetic acid (Tc-DTPA) for quantitating the glomerular filtration rate (GFR) in children was studied. This was compared to the conventional methods for measuring GFR using 51-chromium-EDTA clearance (Cr-EDTA), creatinine clearance and a height/plasma creatinine formula. In the 22 children studied, the correlation coefficient between renal uptake of DTPA and Cr-EDTA was 0.90 (p less than 0.001). In contrast, there was a poorer correlation between Cr-EDTA and creatinine clearance (r = 0.69) or the derived GFR using height/creatinine formula (r = 0.83). The regression line between Tc-DTPA uptake and Cr-EDTA clearance was used to derive a formula for calculating the predicted GFR. This was tested in 10 additional children, and the correlation between the predicted GFR and measured GFR (using Cr-EDTA clearance studies) was 0.92 (p less than 0.001). Quantitative estimation of the GFR during renal imaging studies is a feasible and convenient method of assessing renal function.     

Radioisotopic evaluation of the renal parenchymal function in children with ureteropelvic junction obstruction. A retrospective study

Separate glomerular filtration rates were evaluated in 21 children with uni- or bilateral ureteropelvic junction stenosis, using the Tc-99m DTPA complex and the scintillation camera.The grade of alteration seen on urograms has influenced the surgeon in his decision to use a conservative or a surgical treatment, whereas the type of intervention (pyeloplasty or nephrectomy) was mainly based on the scintigraphic quantitation. The morphological data provided by an excretory urogram could not predict the degree of functional impairment.The scintigraphic evaluation of single kidney clearance was useful in the evaluation of the effects of medical and surgical treatment.Abbreviations PUJ Pelvi-ureteric junction obstruction - SGFR separate glomerular filtration rate - GFR glomerular filtration rate Offprint requests to: St Peter's Hospital, Dept. of Radioisotopes, Rue Haute 322, B-1000 Brussels, Belgium     

Renal function following liver transplantation in children

The literature regarding the etiology and incidence of short and long-term renal functional impairment in pediatric liver allograft recipients was reviewed. Most of the reports include recipients receiving cyclosporine as the primary immunosuppressant. Using calculated glomerular filtration rate (cGFR), creatinine clearance or the serum creatinine level will lead to an overestimation of GFR. In contrast to data in adults, there are a limited number of pediatric recipients whose renal dysfunction has progressed to chronic kidney disease or end-state renal disease. Calcineurin inhibitors minimization has proven effective in reversing or preventing progressive deterioration of GFR; however, rejection episodes and complications have limited efficacy of this approach. Future multicenter studies using optimal GFR measurements are required to delineate the magnitude of renal dysfunction in pediatric recipients.     

Evaluation of glomerular function in individual kidneys using dynamic magnetic resonance imaging

We used the fast field-echo technique of magnetic resonance (MR) imaging with an intravenous bolus injection of paramagnetic contrast agent to evaluate glomerular function. The time-dependent curves of changes in signal intensity observed in the renal cortex and renal medulla brought about by the paramagnetic contrast agent allowed insight into excretory kinetics. The time at which the cortical and medullary curves cross, the cortico-medullary (C-M) junction time, was delayed with a decrease in glomerular function. The mean C-M junction time in both kidneys showed a significant inverse correlation with total creatinine clearance (Ccr), indicating the glomerular filtration rate. The C-M junction time in an individual kidney also showed an inverse correlation with individual Ccr in each kidney. Results suggest that dynamic MR imaging is a useful tool in evaluating renal morphology and in evaluating semi-quantitatively the glomerular function of the kidneys, singly and together, in a manner analogous to radionuclide scintigraphy.