小儿肾积水的手术治疗及其疗效观察
摘要
研究背景及目的
小儿肾积水在泌尿系统疾病中是最常见的一种先天性畸形。小儿肾积水多由肾盂输尿管连接部狭窄、输尿管膀胱连接部狭窄及膀胱输尿管返流等先天性疾病引起。目前对小儿肾积水是否需要手术干预治疗及何时治疗仍存在较大争议,其手术干预治疗及疗效仍是目前研究的主要方向之一。自2008年“三聚氰胺奶粉事件”发生后,我院收治体检意外发现的肾积水患儿50余例,治疗效果满意。我们对其病历资料进行了分析整理并随访其术后恢复情况,旨在总结小儿肾积水的临床治疗经验,评价小儿肾积水术后效果。
临床资料与方法
回顾性分析52例肾积水患儿病例资料。36例肾盂输尿管连接部狭窄患儿行Anderson-Hynes术(其中4例为双侧发病),12例行膀胱输尿管再植术,1例输尿管下段息肉行息肉段切除输尿管断端吻合术,3例行患肾及输尿管切除术。肾盂输尿管成形术患儿10个肾术中放置经吻合口的肾造瘘管外引流,30个肾放置双J管内引流。术后随访复查B超及ECT。
结果
52例患儿一期治愈48例,治愈率达92.3%。1例二期治愈,3例失肾。肾盂输尿管成形术患儿术中放置双J管内引流组并发症明显少于放置经吻合口的肾造瘘管外引流组(3.3% VS 40%,P<0.01)。患儿随访B超显示术后肾积水程度明显减轻甚至消失,分肾功能受损严重的26个患肾GFR术前为(23.58±9.28)ml/min,术后半年增加至(33.25±10.63)ml/min,P<0.01,分肾功能明显恢复,有症状的患儿症状全部消失。
结论
1、小儿肾积水术中应尽量安放双J管内支架引流。
2、小儿肾积水需早期手术治疗,解除梗阻或返流,使肾功能得到更大程度地恢复。
Background and objective of research
Hydronephrosis in children is the most common congenital abnormality of the uropathy. Ureteropelvic junction obstruction, ureterovesical junction stenosis and vesicoureteral reflux are implicated in the majority of cases of hydronephrosis in children. Whether and when the postnatal hydronephrosis need to surgical intervention is still on the controversy. Nowadays the necessity and effect in the surgical intervention is still one of the focus in the research of the hydronephrosis. More than 50 cases of hydronephrosis in children were examinated and accepted surgical intervention since the melamine milk powder incident occurred in 2008. We analyzed and discussed the 52 cases of hydronephrosis and followed the patients and aimed to summarize the clinical treatment experience of pediatric hydronephrosis and evaluated the effect of postoperation.
Clinic data and methods
The clinical data of 52 cases of hydronephrosis in children were analyzed retrospectively. 36 cases were treated by Anderson-Hynes pyeloplasty(4 cases were bilateral hydronephrosis), 12 cases by ureteric reimplantation, 3 cases by nephroureterectomy and 1 cases were treated by ureteric polyp resect and an end-to-end anastomosis of the ureter were performed. Among the cases underwent dismembered pyeloplasty, 10 cases were placed external drainage fistula through the anastomotic mouth, and 30 cases were placed double J tube internal drainage. The stenosis of UPJ were sent to pathological examination. Ultrasound and ECT were reviewed periodically after operation.
Results
48 cases were cured in the first surgery, and one was cured after a second surgery, and 3 cases lost kidney. The complications in the group placed double J tube significantly lower than the group placed external drainage fistula (3.3% VS 40%,P<0.01). Symptoms were disappeared and the degree of hydronephrosis was alleviated obviously through ultrasound examination. The mean preoperative and postoperative renal function of 26 cases was(23.58±9.28)ml/min and (33.25±10.63)ml/min respectively (p<0.01).
Conclusions
1、Double J tube internal drainage should be the best choice in the Anderson-Hynes pyeloplasty.
2、Hydronephrosis in children must be early treated by surgery. To resect obstruction or resist vesico-ureteric reflux can recover renal function greatly.
小儿肾积水在泌尿系统疾病中是最常见的一种先天性畸形。小儿肾积水多由肾盂输尿管连接部狭窄、输尿管膀胱连接部狭窄及膀胱输尿管返流等先天性疾病引起。目前对小儿肾积水是否需要手术干预治疗及何时治疗仍存在较大争议,其手术干预治疗及疗效仍是目前研究的主要方向之一。自2008年“三聚氰胺奶粉事件”发生后,我院收治体检意外发现的肾积水患儿50余例,治疗效果满意。我们对其病历资料进行了分析整理并随访其术后恢复情况,旨在总结小儿肾积水的临床治疗经验,评价小儿肾积水术后效果。
临床资料与方法
回顾性分析52例肾积水患儿病例资料。36例肾盂输尿管连接部狭窄患儿行Anderson-Hynes术(其中4例为双侧发病),12例行膀胱输尿管再植术,1例输尿管下段息肉行息肉段切除输尿管断端吻合术,3例行患肾及输尿管切除术。肾盂输尿管成形术患儿10个肾术中放置经吻合口的肾造瘘管外引流,30个肾放置双J管内引流。术后随访复查B超及ECT。
结果
52例患儿一期治愈48例,治愈率达92.3%。1例二期治愈,3例失肾。肾盂输尿管成形术患儿术中放置双J管内引流组并发症明显少于放置经吻合口的肾造瘘管外引流组(3.3% VS 40%,P<0.01)。患儿随访B超显示术后肾积水程度明显减轻甚至消失,分肾功能受损严重的26个患肾GFR术前为(23.58±9.28)ml/min,术后半年增加至(33.25±10.63)ml/min,P<0.01,分肾功能明显恢复,有症状的患儿症状全部消失。
结论
1、小儿肾积水术中应尽量安放双J管内支架引流。
2、小儿肾积水需早期手术治疗,解除梗阻或返流,使肾功能得到更大程度地恢复。
Background and objective of research
Hydronephrosis in children is the most common congenital abnormality of the uropathy. Ureteropelvic junction obstruction, ureterovesical junction stenosis and vesicoureteral reflux are implicated in the majority of cases of hydronephrosis in children. Whether and when the postnatal hydronephrosis need to surgical intervention is still on the controversy. Nowadays the necessity and effect in the surgical intervention is still one of the focus in the research of the hydronephrosis. More than 50 cases of hydronephrosis in children were examinated and accepted surgical intervention since the melamine milk powder incident occurred in 2008. We analyzed and discussed the 52 cases of hydronephrosis and followed the patients and aimed to summarize the clinical treatment experience of pediatric hydronephrosis and evaluated the effect of postoperation.
Clinic data and methods
The clinical data of 52 cases of hydronephrosis in children were analyzed retrospectively. 36 cases were treated by Anderson-Hynes pyeloplasty(4 cases were bilateral hydronephrosis), 12 cases by ureteric reimplantation, 3 cases by nephroureterectomy and 1 cases were treated by ureteric polyp resect and an end-to-end anastomosis of the ureter were performed. Among the cases underwent dismembered pyeloplasty, 10 cases were placed external drainage fistula through the anastomotic mouth, and 30 cases were placed double J tube internal drainage. The stenosis of UPJ were sent to pathological examination. Ultrasound and ECT were reviewed periodically after operation.
Results
48 cases were cured in the first surgery, and one was cured after a second surgery, and 3 cases lost kidney. The complications in the group placed double J tube significantly lower than the group placed external drainage fistula (3.3% VS 40%,P<0.01). Symptoms were disappeared and the degree of hydronephrosis was alleviated obviously through ultrasound examination. The mean preoperative and postoperative renal function of 26 cases was(23.58±9.28)ml/min and (33.25±10.63)ml/min respectively (p<0.01).
Conclusions
1、Double J tube internal drainage should be the best choice in the Anderson-Hynes pyeloplasty.
2、Hydronephrosis in children must be early treated by surgery. To resect obstruction or resist vesico-ureteric reflux can recover renal function greatly.
引文
[1]. Sairam S, Al-Habib A, Sasson S, et al. Natural history of fetal hydronephrosis diagnosed on mid-trimester ultrasound. Ultrasound Obstet Gynecol. 2001;17:191-196.
[2]. Peters CA. Urinary tract obstruction in children. J urol. 1995;154(5):1874-83.
[3]. Chevalier RL, Thornhill BA, Chang AY. Unilateral ureteral obstruction in neonatal rats leads to renal insufficiency in adulthood. Kindney Int. 2000;58(5):1987-95.
[4]. Palmer L, Maizels M, Cartwright P, et al. Surgery versus observation for managing obstructive grade 3 to 4 unilateral hydronephrosis: a report from the Society for Fetal Urology. J urol. 1998;159(1):222-8.
[5]. Chertin B, Pollack A, Koulikov D, et al. Does renal function remain stable after puberty in children with prenatal hydronephrosis and improved renal function after pyeloplasty? J urol. 2009;10(4):1845-8.
[6].Fernbach SK, Maizels M, Conway JJ. Ultrasound grading of hydronephrosis: introduction to the system used by the Society for Fetal Urology. Pediatr Radiol 1993;23(6):478–480.
[7].Tatlisen A, Ekmekcioglu O. Direct nipple ureteroneocystostomy in adults with primary obstructed megaureter. J Urol. 2005;173(3):877-880.
[8].王小宁,岳婧,王德杭等.磁共振尿路造影在尿路梗阻中的诊断价值.南京医科大学学报.2001;21(2):142-145.
[9].Gonzales R, Schimke CM. Ureteropelvic junction obstruction in infants and children. Pediatr Clin North Am 2001;48(6):1505–1517.
[10].Chandrasekharam VV, Srinivas M, Bal CS, et al. Functional outcome after pyeloplasty for unilateral symptomatic hydronephrosis. Pediatr Surg Int. 2001;17(7):524–527.
[11].Koff SA, Campbell KD. Ureteropelvic junction obstruction: the nonoperative management of unilateral neonatal hydronephrosis—naturalhistory of poorly functioning kidneys. J Urol. 1994;152(2):593–595.
[12]. Fefer S, Ellsworth P. Prenatal hydronephrosis. Pediatr Clin North Am. 2006;53(3):429-447.
[13].Castillejos-Molina RA, Rodriguez-Covarrubias F, Feria-Bernal G, et al. [Surgical treatment of ureteropelvic junction obstruction]. Gac Med Mex. 2006;142(3):205-208.
[14].谢向辉,黄澄如,孙宁等.小儿先天性肾盂输尿管连接部梗阻的临床和病理特点.首都医科大学学报. 2007; 28(1):121-123.
[15].Koff SA. Estimating bladder capacity in children. Urology. 1983;21(3):248-52.
[16].杨屹,吉士俊,赵国贵等.小儿重度肾积水术后肾功能的评价.中华小儿外科杂志.2000;21(4):226-228.
[17]. Chertin B, Fridmans A, Knizhnik M, et al. Does early detection of ureteropelvic junction obstruction improve surgical outcome in terms of renal function? J urol. 1999;162(3):1037-40.
[18].黄澄如,梁若馨,白继武等.小儿原发性膀胱输尿管返流的诊断与手术治疗.中华泌尿外科杂志. 2001;11(22):674-676.
[19].王永禄,王淑芹,贾均等.肾动态显像方法观察先天肾积水肾功能恢复情况.中华小儿外科杂志. 1993 ,14(2):196-198.
[20]. Wagner M, Mayr J, Hacker FM. Improvement of renal split function in hydronephrosis with less than 10% function. Eur J Pediatr Surg. 2008;18(3):156-9.
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[3] Livera LN, Brookfield DS, Egginton JA, et al. Antenatal ultrasonography to detect fetal renal abnormalities: a prospective screening programme. BMJ. 1989;298(6685):1421-3.
[4]Brown T, Mandell J, Lebowitz RL. Neonatal hydronephrosis in the era of sonography. AJR Am J Roentgenol. 1987;148(5):959-63.
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[2]. Peters CA. Urinary tract obstruction in children. J urol. 1995;154(5):1874-83.
[3]. Chevalier RL, Thornhill BA, Chang AY. Unilateral ureteral obstruction in neonatal rats leads to renal insufficiency in adulthood. Kindney Int. 2000;58(5):1987-95.
[4]. Palmer L, Maizels M, Cartwright P, et al. Surgery versus observation for managing obstructive grade 3 to 4 unilateral hydronephrosis: a report from the Society for Fetal Urology. J urol. 1998;159(1):222-8.
[5]. Chertin B, Pollack A, Koulikov D, et al. Does renal function remain stable after puberty in children with prenatal hydronephrosis and improved renal function after pyeloplasty? J urol. 2009;10(4):1845-8.
[6].Fernbach SK, Maizels M, Conway JJ. Ultrasound grading of hydronephrosis: introduction to the system used by the Society for Fetal Urology. Pediatr Radiol 1993;23(6):478–480.
[7].Tatlisen A, Ekmekcioglu O. Direct nipple ureteroneocystostomy in adults with primary obstructed megaureter. J Urol. 2005;173(3):877-880.
[8].王小宁,岳婧,王德杭等.磁共振尿路造影在尿路梗阻中的诊断价值.南京医科大学学报.2001;21(2):142-145.
[9].Gonzales R, Schimke CM. Ureteropelvic junction obstruction in infants and children. Pediatr Clin North Am 2001;48(6):1505–1517.
[10].Chandrasekharam VV, Srinivas M, Bal CS, et al. Functional outcome after pyeloplasty for unilateral symptomatic hydronephrosis. Pediatr Surg Int. 2001;17(7):524–527.
[11].Koff SA, Campbell KD. Ureteropelvic junction obstruction: the nonoperative management of unilateral neonatal hydronephrosis—naturalhistory of poorly functioning kidneys. J Urol. 1994;152(2):593–595.
[12]. Fefer S, Ellsworth P. Prenatal hydronephrosis. Pediatr Clin North Am. 2006;53(3):429-447.
[13].Castillejos-Molina RA, Rodriguez-Covarrubias F, Feria-Bernal G, et al. [Surgical treatment of ureteropelvic junction obstruction]. Gac Med Mex. 2006;142(3):205-208.
[14].谢向辉,黄澄如,孙宁等.小儿先天性肾盂输尿管连接部梗阻的临床和病理特点.首都医科大学学报. 2007; 28(1):121-123.
[15].Koff SA. Estimating bladder capacity in children. Urology. 1983;21(3):248-52.
[16].杨屹,吉士俊,赵国贵等.小儿重度肾积水术后肾功能的评价.中华小儿外科杂志.2000;21(4):226-228.
[17]. Chertin B, Fridmans A, Knizhnik M, et al. Does early detection of ureteropelvic junction obstruction improve surgical outcome in terms of renal function? J urol. 1999;162(3):1037-40.
[18].黄澄如,梁若馨,白继武等.小儿原发性膀胱输尿管返流的诊断与手术治疗.中华泌尿外科杂志. 2001;11(22):674-676.
[19].王永禄,王淑芹,贾均等.肾动态显像方法观察先天肾积水肾功能恢复情况.中华小儿外科杂志. 1993 ,14(2):196-198.
[20]. Wagner M, Mayr J, Hacker FM. Improvement of renal split function in hydronephrosis with less than 10% function. Eur J Pediatr Surg. 2008;18(3):156-9.
[1] Lee RS, Cendron M, Kinnamon DD, et al. Antenatal Hydronephrosis as a Predictor of Postnatal Outcome: A Meta-analysis. Pediatrics 2006;118(2);586-593.
[2] Lim DJ, Park JY, Kim JH, et al. Clinical characteristics and outcome of hydronephrosis detected by prenatal ultrasonography. J Korean Med Sci 2003;18(6):859–62.
[3] Livera LN, Brookfield DS, Egginton JA, et al. Antenatal ultrasonography to detect fetal renal abnormalities: a prospective screening programme. BMJ. 1989;298(6685):1421-3.
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[5] Zerin JM, Ritchey ML, Chang AC. Incidental vesicoureteral reflux in neonates with antenatally detected hydronephrosis and other renal abnormalities. Radiology. 1993;187(1):157-60.
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