开放手术治疗肾移植术后输尿管梗阻的技术探讨

目的探讨肾移植术后移植肾输尿管狭窄的开放手术技巧与效果。方法首都医科大学附属北京友谊医院泌尿外科于2019年1月—2020年1月共行166例单肾移植,共发生5例肾移植术后输尿管狭窄,根据梗阻部位的不同采用了不同的开放手术术式进行治疗,回顾性分析这组患者的临床资料及预后。结果5例患者中,男性3例,女性2例,平均年龄42.6岁。其中2例患者原发病为Ⅱ型糖尿病,3例患者为肾小球肾炎。输尿管梗阻确诊的平均时间为肾移植术后143.8 d,行开放手术平均时间为肾移植术后209.8 d,确诊梗阻时平均血肌酐水平为271.94μmol/L。所有患者均因出现移植肾积水合并血肌酐进行性升高经影像学检查确诊,首先采取内支架或经皮肾造瘘紧急挽救肾功能。待肾功能恢复稳定后,根据梗阻段位置,3例患者行移植输尿管-膀胱再吻合术,1例患者行原输尿管-移植肾输尿管端端吻合术,1例患者行膀胱皮瓣翻转代输尿管术。5例患者开放手术平均时间为2.6 h,术中平均出血量为32 ml。开放手术后,5例患者均预后良好,开放手术后平均血清肌酐恢复至111.5μmol/L,尿量正常,无外科并发症发生。随访半年后,5例患者均未再发生输尿管梗阻。结论移植肾输尿管梗阻是肾移植术后常见外科并发症之一,腔内治疗中远期效果有限,根据不同梗阻部位选择不同术式进行开放手术,是治疗移植肾输尿管狭窄的有效方案。

Technical discussion of open surgical treatment for ureteral obstruction after renal transplantation

Objective To investigate the open surgical technique and its effect on ureteral stricture after renal transplantation.Methods A total of 166 cases who underwent single renal transplantations in department of urology,Beijing Friendship Hospital,Capital Medical University from January 2019 to January 2020 were enrolled.The clinical data of 5 cases of ureteral stricture who received open operative treatment after renal transplantation were retrospectively analyzed.Baseline and surgical data were collected and shown.Results Among the 5 patients,there were 3 males and 2 females,with a mean age of 42.6 years.Two had diabetic nephropathy and three had glomerulonephritis.The mean diagnostic time of ureteral obstruction after renal transplantation was 143.8 d,the mean time of open surgery was 209.8 d after renal transplantation,and the mean serum creatinine level at the time of the diagnosis of obstruction was 271.94μmol/L.All the patients were confirmed by imaging examination due to the presence of hydronephrosis and progressive increase of serum creatinine,the renal function was first rescued by internal stents or percutaneous nephrostomy.After the renal function was stabilized,and according to the location of the stenosis segment,3 patients underwent ureterovesical reanastomosis,1 patient underwent ureteral end-to-end anastomosis between primary ureter and the ureter from graft.One patient underwent ureteroneocystostomy with a boari flap.The average operation time was 2.6 h,and the average intraoperative blood loss was 32 ml.All the 5 patients had a good prognosis.The average serum creatinine recovered to 111.5μmol/L after the open surgery,with normal urine volume and no surgical complications.After a follow-up for 6 months,none of the 5 patients had ureteral obstruction.Conclusion Ureteral obstruction is one of the common complications after renal transplantation.The medium and long-term effects of endourologic surgery are limited.Open surgery according to different obstruction sites is an effective plan for the treatment of ureteral stricture of transplanted kidney.