医源性输尿管损伤并发上尿路梗阻的外科治疗策略

目的：研究医源性输尿管损伤后并发上尿路梗阻的病理基础。探讨处理医源性输尿管损伤后梗阻的外科治疗策略。方法：回顾性分析自2007年2月～2009年4月，上海交通大学医学院附属仁济医院泌尿外科诊治的16例输尿管腔内操作致医源性输尿管损伤并发上尿路梗阻的患者。患者平均年龄49岁。所有患者输尿管损伤后均曾成功留置D-J管4～6周。就诊时平均术后时间9．8个月（3～18个月）。通过磁共振水成像（MRU）评价输尿管梗阻累及部位、梗阻段长度及输尿管瘢痕组织厚度。以STORZF7.9。输尿管镜检查患侧输尿管。对于患侧输尿管管腔通畅者行开放输尿管梗阻段切除术，并对该段输尿管行病理检查。对于输尿管镜证实受累输尿管存在机械性梗阻，狭窄段长度〈2cm的患者行输尿管镜下钬激光输尿管内切开术。所有患者术后留置D-J管6周。术后6个月以静脉尿路造影（IVu）评价手术效果。结果：在4例患者中，STORZF7.9。输尿管硬镜成功进镜至肾盂，未发现患侧输尿管机械性梗阻。予切除瘢痕增生段输尿管，病理检查提示输尿管全层增厚伴慢性炎症，纤维组织增生，平滑肌细胞排列杂乱，但黏膜层尿路上皮完整且无明显增生。另12例患者经输尿管硬镜检查证实机械性梗阻存在，行钬激光输尿管内切开术。术后6个月随访显示，4例行开放手术患者均未出现输尿管再狭窄。12例行输尿管钬激光内切开患者中3例上尿路梗阻复发。行狭窄段切除，6个月后随访见上尿路积水消失。结论：在部分输尿管损伤后上尿路梗阻的患者，其输尿管管腔通畅，动力性梗阻可能占主导地位。对于这些患者外科手术切除输尿管狭窄段可能是最佳选择。输尿管腔内钬激光内切开术适用于狭窄段较短（〈2cm）且不伴严重输尿管增厚的患者，但远期复发率较高。尿外渗是加重输尿管损伤后纤维瘢痕形成的重要因素，在合并严重尿外渗的患者中，经皮肾穿刺（PCN）引流可能减轻局部纤维瘢痕反应，改善患者预后。

The Surgical Strategy for the Iatrogenic Ureteral Trauma Complicating Upper Tract Obstruction

Objective： To study the pathological basis of the iatrogenic ureteric lesion complicating upper tract obstruction. To evaluate the efficacy of different surgical strategies in these cases. Methods： From February 2007 to April 2009, 16 cases with iatrogenic ureteric lesion complicating upper tract obstruction were enrolled in this retro-spective study. The average age of the patients was 49 years old. After the endourologic trauma, a D-J stent had been set in place for 4-6 weeks in all the cases. The length of the obstructive portion and the thickness of the ureteric scar were evaluated by MRU. The STORZ F7.9 semi-rigid ureteroscope was used to observe the altered ureter. For the patients with no obstruction found by the ureteroscopy, an open surgery was carried out to remove the stricture part and the specimen was examined by a pathologist. For the rest of the cases, we tried the internal ure terotomy with holium laser under the ureteroscope. After all the procedure, a F7 D-J stent was indwelled for 6 weeks. An intravenous urography was done 6 months after the procedure to evaluate the results. Results ： The semi- rigid ureteroscope could advance without any difficulty in 4 patients, in whom the involved mucosa were flat and the lumen were unobstructed. The surgical specimen showed a thickening of the whole ureteric wall with chronic inflammation and interlace of smooth muscle cell while the mucosa was intact. In the other 12 patients, we gave up the ureteroscopy for the tight stenosis with the guide wire set in place and a holium laser endoureterotomy was car ried out. In all the 4 patients with open surgery, 6 month after the surgery, the IVU showed there was no more obstruction in the altered ureter while in 3 cases treated by internal incision had a recurrence of ureteric stricture and hydronephrosis. We have removed the obstructive part in these 3 patients and the follow-up at 6 months after the second surgery demonstrated the ureter intact. Conclusions： In some of the patients with iatrogenic ureter lesion, the ureterie mucosa could be intact while there is a thickening of the sub-mucosa, the rnucueularis and the peri-ureteric tissue. For the patients the ureteral kinetic obstruction was probably the main cause and the surgical removal of the altered segment might be the reasonable choice. For the patients with a tight and relatively short stricture （〈2 cm）confirmed by the ureteroscopy, the holium laser endoureterotomy or the ballon dilation could be proposed with a relatively high late recurrence rate. The urine extravasation might enhance the fibrosis of the ureter and for the cases with an important urinoma, the PCN drainage might be a good solution.