小儿输尿管膨出症的治疗--附91例分析

目的 选用创伤小，疗效好的术式治疗输尿管膨出症，减法二次手术。方法 91例输尿管膨出症，男25例，女66例，其中70例（76.9%)并发于重肾双输尿管畸形，其中左上输尿管膨出症40例，右上27例，双上3例，影像学检查；双上肾积水4例，患侧上肾积水52例，患侧上下肾积水10例，患侧上，下及对侧都有肾积水4例。21例单一系统输尿管膨出症中，左侧5例，右侧11例，双侧5例。影像学检查；患侧肾积水10例，双侧肾积水5例，患肾功能严重受损5例。上尿路正常1例。结果 78例（85.7%)术后平均随访2年。重肾组；（1）上肾部切除48例52侧，治愈36例，失访7例，需加做输尿管残留切除3例，需再经尿道戳穿输尿管膨出2例；（2）切除输尿管膨出及输尿管膀胱再吻合6例，治愈5例。术后加做上肾部切除1例；（3）经尿道戳穿输尿管膨出15例，治愈9例，失访4例。需加做上肾部切除2例；（4）输尿管膨出自行缩小，症状消失1例。单一系统21例中15例经尿道戳穿输尿管膨出，治愈12例，失访2例，需加做输尿管膀胱再植1例，1例经输尿管膨出切除，输尿管膀胱再植治愈，发育不良肾切除5例。治愈2例，有尿失禁症状2例，仍时有尿路感染1例。全组1次手术治愈65例。结论 输尿管膨出症的治疗须根据患肾功能决定，如患肾功能严重受损，首选患肾或肾部切除，反之则经尿道做膨出部下缘戳孔术，对单一系统肾发育不良并发异位输尿管膨出的女性，其位置低至尿道远端，因该处尿道肌肉缺损造成失禁，须进一步治疗。

The management of ureterocele in children: analysis of 91 Cases

Objective To identify factors related to recurrence of ureterocele. Methods Ninety one patients (male 25, female 66) with ureterocele were studied. Seventy patients had duplex kidneys associated ureteroceles. These included 40 left upper, 27 right upper, and 3 bilateral upper ureteroceles. Imaging studies showed hydronephrosis and hydroureter of bilateral upper renal moieties in 4 patients, ipsilateral upper renal moieties in 52, ipsilateral upper and lower renal moieties in 10, bilateral hydronephrosis and hydroureter in 4. Twenty one patients had ureteroceles without duplex kidney, including 5 on the left side, 11 on the right, and 5 bilaterally. Imaging examination showed bilateral hydronephrosis and hydroureter in 5 patients, unilateral in 10, nonfunctioning of the diseased kidney in 5, and normal upper urinary tract in 1. Results Seventy eight patients were followed up for a mean of 2 years. Of 59 patients with duplex system, 5/41(12%), 1/6(17%) and 2/11(18%) respectively required a second operation after the excision of the upper renal moiety, ureterocele excision with ureteral reimplantation, and endoscopic puncture of ureterocele. The secondary operation included resection of the ureteral stump remnant in 3 patients, endoscopic puncture of the ureterocele in 2, and resection of the upper renal moiety in 3. One child had spontaneous resolution of uretrocele and has been free of symptoms. 19 patients with single system required further operations. The secondary management included reimplantation of ureter in one, 2 patients had urinary incontinence and one with urinary infection still waiting for further investigation. Conclusions In patients with ureterocele and nonfunctioning kidney, partial or total nephrectomy should be considered as the treatment of choice. Otherwise endoscopic ureterocele decompression has identical cure rates. Of single system ectopic ureterocele with hypoplastic kidney further management may be needed to achieve urinary continence.