肾盂输尿管连接部再狭窄的介入扩张治疗与肾盂成形术的疗效评价
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摘要
目的：比较肾盂输尿管连接部再狭窄的介入扩张治疗与离断式肾盂成形术的疗效。
方法：收集2006年1月至2009年10月郑州大学第一附属医院泌尿外科肾盂输尿管连接部再狭窄的病人30例,均经过彩超、静脉肾盂造影等明确诊断。介入扩张治疗组10例,男5例,女5例,平均年龄42.1岁,8例是开放式肾盂成形术后再狭窄,1例是腹腔镜下肾盂成形术后吻合口狭窄,再行肾下盏输尿管吻合术后仍有吻合口处狭窄,1例为双肾多发结石行多次体外冲击波碎石及左输尿管切开取石术后双侧肾盂输尿管连接部狭窄及双侧输尿管中段狭窄；再次行离断式肾盂成形术组20例,男12例,女8例,平均年龄23.3岁,均是肾盂成形术后吻合口再狭窄。介入扩张治疗在局部麻醉或全麻下进行,首先经膀胱镜将5F导丝及5FH1导管置入输尿管内,转移至DSA手术室,取仰卧位,拔除5F导丝,沿导管造影见远端通过狭窄段,沿导管置入加强导丝,退出导管,经加强导丝引入10.2F或12F引流管,狭窄严重者沿加强导丝行球囊扩张术,扩开狭窄段再置入引流管,使引流管远端盘曲于肾盂内,下段位于膀胱内。离断式肾盂成形术在全麻下进行,取健侧卧位,腰部垫高,12肋下斜形口,充分暴露肾盂输尿管连接部,距肾实质1.5cm处环形剪裁肾盂壁,并切除狭窄段输尿管,输尿管断端成形且与肾盂残端最低位呈斜形对应,后用5-0可吸收线间断吻合肾盂输尿管并留置5-6F号双J管,使吻合口呈漏斗状。对两种术式的手术时间、术中出血量、术后住院天数、术后胃肠道恢复时间、术后镇痛药物用量、手术效果等指标进行对比分析。
结果：介入扩张治疗组手术时间(66.5±16.5)min、术后住院时间(8.4±2.4)d、术中平均出血量7.5ml明显优于开放肾盂成形组的(188.0±26.1)min、(16.5±3.8)d、252.3ml(p<0.05；p<0.05；p<0.05)；但是拔管时间(78.4±14.2)d与开放肾盂成形组(61.5±5.0)d相比较晚(P<0.05)。介入治疗组术后胃肠道平均恢复时间4.8h、术后镇痛药物平均应用量5.0mg明显小于开放手术组的37.4h、80.Omg,比较均有统计学意义(p<0.05,p<0.05)。介入治疗组与开放手术组肾积水改善情况比较无统计学意义(p=0.066)。介入治疗组血尿1例,膀胱刺激征1例。开放手术组切口愈合不良3例,血尿5例,尿漏4例,保守治疗后好转；术后并发术侧下腹钝痛者5例。两组患者术后每3月复查彩超及每6月复查静脉肾盂造影,随访3-24个月,平均随访时间12个月,介入治疗组4例(40%)治愈,6例(60%)好转；开放手术组5例(25%)治愈,7例(35%)好转,8例(40%)无效。
结论：肾盂输尿管连接部再狭窄的部分选择病例介入扩张治疗的手术效果可达到开放手术水平,在手术时间、术中出血量、术后住院天数、胃肠道恢复时间等方面优于开放手术组,但支架管拔除较晚。介入扩张治疗是一种安全、有效、操作简单、恢复快、损伤小的治疗方法,对于肾盂成形术后吻合口再狭窄的病人可作为首选的治疗方式。
Objective
To compare the clinical efficacy of interventional therapy with dismembered pyeloplasty for recurrent ureteropelvic junction obstruction.
Methods
We retrospectively analysed the records of 30 patients with recurrent ureteropelvic junction obstruction after dismembered pyeloplasty from the urology department of the First Affiliated Hospital of Zhengzhou University during January 2006 to October 2009.Of these patients,10 cases (5 males and 5 females;mean age 42.1 years) underwent interventional treatment and 20 cases (12 males and 8 females; mean age 23.3 years) underwent the secondary dismembered pyeloplasty. Interventional treatment(10 cases):Local anesthesia or general anesthesia was administered.First,the patient was placed with the lithotomy position,and the 5F guide wire and 5FH1 catheter were inserted into the ureteral orifice under the cystoscopy.Then the patient was transferred to the DSA operating room.The patient was placed with the supine position, and the ureteropelvic junction obstruction was confirmed and the tip of catheter was in the renal pelvis under fluoroscopic imaging. Two patients underwent retrograde catheter dilation, and 10.2F or 12F stent catheter was placed in all patients.The second dismembered pyeloplasty(20 cases):the patient was placed with a lateral position under general anesthesia. The subcostal incision was made, and the dilated renal pelvis was mobilized in the retroperitoneal space.The pelvis was cut 15mm away from the edge of renal sinus and the pyeloplasty was made.The pelvi-ureteric anastomosis was sutured with absorbable suture and a 5-6F D-J catheter was inserted.The operative time, average intraoperative blood loss and postoperative length of hospital stay of the 2 groups were analyzed.
Results
The interventional group had fewer operative time(66.5±16.5min vs 188.0±26.1min,P<0.05), shorter postoperative length of hospital stay (8.4±2.4d vs 16.5±3.8d, p<0.05), but longer extubation time(78.4±14.4d vs 61.5±5.0d, P<0.05). The mean intraoperative blood loss was 7.5ml,the mean postoperative analgesic administered was 5.0 mg and the mean gastrointestinal recovery time 4.8h in the interventional group vs 252.3ml,80.0 mg and 37.4h in the open group (p<0.05). The two groups of hydronephrosis has no statistically significant(p=0.066). One patient with hematuria and one with bladder irritation sign were observed in the interventional group. Three patients with wound dehiscence and five patients with hematuria in the open group, were managed conservatively. Radiographic assessment by intravenous urography or ultraphonic showed 40% cure rate and 60% improvement rate in the interventional group and 25% cure rate,35% improvement rate and 40% invalid rate in the open group at a follow up of 3-24 months.
Conclusion
Our study demonstrated that the interventional treatment was an effective therapy in some select patients with recurrent ureteropelvic junction obstruction.
方法：收集2006年1月至2009年10月郑州大学第一附属医院泌尿外科肾盂输尿管连接部再狭窄的病人30例,均经过彩超、静脉肾盂造影等明确诊断。介入扩张治疗组10例,男5例,女5例,平均年龄42.1岁,8例是开放式肾盂成形术后再狭窄,1例是腹腔镜下肾盂成形术后吻合口狭窄,再行肾下盏输尿管吻合术后仍有吻合口处狭窄,1例为双肾多发结石行多次体外冲击波碎石及左输尿管切开取石术后双侧肾盂输尿管连接部狭窄及双侧输尿管中段狭窄；再次行离断式肾盂成形术组20例,男12例,女8例,平均年龄23.3岁,均是肾盂成形术后吻合口再狭窄。介入扩张治疗在局部麻醉或全麻下进行,首先经膀胱镜将5F导丝及5FH1导管置入输尿管内,转移至DSA手术室,取仰卧位,拔除5F导丝,沿导管造影见远端通过狭窄段,沿导管置入加强导丝,退出导管,经加强导丝引入10.2F或12F引流管,狭窄严重者沿加强导丝行球囊扩张术,扩开狭窄段再置入引流管,使引流管远端盘曲于肾盂内,下段位于膀胱内。离断式肾盂成形术在全麻下进行,取健侧卧位,腰部垫高,12肋下斜形口,充分暴露肾盂输尿管连接部,距肾实质1.5cm处环形剪裁肾盂壁,并切除狭窄段输尿管,输尿管断端成形且与肾盂残端最低位呈斜形对应,后用5-0可吸收线间断吻合肾盂输尿管并留置5-6F号双J管,使吻合口呈漏斗状。对两种术式的手术时间、术中出血量、术后住院天数、术后胃肠道恢复时间、术后镇痛药物用量、手术效果等指标进行对比分析。
结果：介入扩张治疗组手术时间(66.5±16.5)min、术后住院时间(8.4±2.4)d、术中平均出血量7.5ml明显优于开放肾盂成形组的(188.0±26.1)min、(16.5±3.8)d、252.3ml(p<0.05；p<0.05；p<0.05)；但是拔管时间(78.4±14.2)d与开放肾盂成形组(61.5±5.0)d相比较晚(P<0.05)。介入治疗组术后胃肠道平均恢复时间4.8h、术后镇痛药物平均应用量5.0mg明显小于开放手术组的37.4h、80.Omg,比较均有统计学意义(p<0.05,p<0.05)。介入治疗组与开放手术组肾积水改善情况比较无统计学意义(p=0.066)。介入治疗组血尿1例,膀胱刺激征1例。开放手术组切口愈合不良3例,血尿5例,尿漏4例,保守治疗后好转；术后并发术侧下腹钝痛者5例。两组患者术后每3月复查彩超及每6月复查静脉肾盂造影,随访3-24个月,平均随访时间12个月,介入治疗组4例(40%)治愈,6例(60%)好转；开放手术组5例(25%)治愈,7例(35%)好转,8例(40%)无效。
结论：肾盂输尿管连接部再狭窄的部分选择病例介入扩张治疗的手术效果可达到开放手术水平,在手术时间、术中出血量、术后住院天数、胃肠道恢复时间等方面优于开放手术组,但支架管拔除较晚。介入扩张治疗是一种安全、有效、操作简单、恢复快、损伤小的治疗方法,对于肾盂成形术后吻合口再狭窄的病人可作为首选的治疗方式。
Objective
To compare the clinical efficacy of interventional therapy with dismembered pyeloplasty for recurrent ureteropelvic junction obstruction.
Methods
We retrospectively analysed the records of 30 patients with recurrent ureteropelvic junction obstruction after dismembered pyeloplasty from the urology department of the First Affiliated Hospital of Zhengzhou University during January 2006 to October 2009.Of these patients,10 cases (5 males and 5 females;mean age 42.1 years) underwent interventional treatment and 20 cases (12 males and 8 females; mean age 23.3 years) underwent the secondary dismembered pyeloplasty. Interventional treatment(10 cases):Local anesthesia or general anesthesia was administered.First,the patient was placed with the lithotomy position,and the 5F guide wire and 5FH1 catheter were inserted into the ureteral orifice under the cystoscopy.Then the patient was transferred to the DSA operating room.The patient was placed with the supine position, and the ureteropelvic junction obstruction was confirmed and the tip of catheter was in the renal pelvis under fluoroscopic imaging. Two patients underwent retrograde catheter dilation, and 10.2F or 12F stent catheter was placed in all patients.The second dismembered pyeloplasty(20 cases):the patient was placed with a lateral position under general anesthesia. The subcostal incision was made, and the dilated renal pelvis was mobilized in the retroperitoneal space.The pelvis was cut 15mm away from the edge of renal sinus and the pyeloplasty was made.The pelvi-ureteric anastomosis was sutured with absorbable suture and a 5-6F D-J catheter was inserted.The operative time, average intraoperative blood loss and postoperative length of hospital stay of the 2 groups were analyzed.
Results
The interventional group had fewer operative time(66.5±16.5min vs 188.0±26.1min,P<0.05), shorter postoperative length of hospital stay (8.4±2.4d vs 16.5±3.8d, p<0.05), but longer extubation time(78.4±14.4d vs 61.5±5.0d, P<0.05). The mean intraoperative blood loss was 7.5ml,the mean postoperative analgesic administered was 5.0 mg and the mean gastrointestinal recovery time 4.8h in the interventional group vs 252.3ml,80.0 mg and 37.4h in the open group (p<0.05). The two groups of hydronephrosis has no statistically significant(p=0.066). One patient with hematuria and one with bladder irritation sign were observed in the interventional group. Three patients with wound dehiscence and five patients with hematuria in the open group, were managed conservatively. Radiographic assessment by intravenous urography or ultraphonic showed 40% cure rate and 60% improvement rate in the interventional group and 25% cure rate,35% improvement rate and 40% invalid rate in the open group at a follow up of 3-24 months.
Conclusion
Our study demonstrated that the interventional treatment was an effective therapy in some select patients with recurrent ureteropelvic junction obstruction.
引文
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