移植肾输尿管梗阻19例临床分析

A clinical analysis of ureteral stenosis of renal allograft in 19 cases

目的 :探讨移植肾输尿管梗阻的原因和处理方法。 方法 :收集本院 1 994年 1月～ 2 0 0 4年 4月间1 9例移植肾输尿管梗阻的患者 ,临床多表现多为尿少、尿漏和 (或 )血肌酐 (SCr)升高 ,均经B超、同位素利尿性肾图或磁共振泌尿系统水成像 (MRU)等影像学检查确诊 ,其中 7例行经皮肾穿刺造瘘并顺行尿路造影明确梗阻部位。 结果 :1 9例患者经手术和组织学检查证实梗阻的原因是 :输尿管或输尿管膀胱吻合口狭窄 6例 ,输尿管过长、扭曲致梗阻 3例 ,输尿管周感染致狭窄、穿孔 2例 ,输尿管下段坏死、梗阻 2例 ,输尿管外瘢痕或炎性组织压迫 2例 ,输尿管误扎 1例 ,输尿管内结晶并血块堵塞 1例 ,输尿管小结石 1例 ,膀胱肌层包埋过紧 1例。 1 9例患者中有 7例行移植肾输尿管膀胱重新吻合 (1例手术治疗效差 ,后行经皮肾穿刺造瘘 ) ,3例行膀胱瓣输尿管吻合术 ,2例行移植肾肾盂、输尿管粘连松解术 ,1例行移植肾切除术 ,1例输尿管误扎者术中立即予纠正。另外 5例行腔内微创手术治疗(扩张通道均为 1 4～ 1 6F) ,其中 4例先在B超引导下行经皮肾穿刺造瘘短期引流 ,待SCr下降接近正常后 ,即行经肾造瘘输尿管镜球囊扩张狭窄段后顺行置入内支架管 ;1例经膀胱镜逆行插管失败后直接行经皮肾穿刺输尿管镜术。

Objective:Ureteral obstruction after renal transplantation is an important complication affecting the prognosis of renal allograft recipients. In this study, we investigated the etiological factors of ureteral obstruction in renal transplant recipients and discussed the effective treatment. Methodology:Nineteen renal transplant recipients with ureteral obstruction were included. The diagnosis of ureteral obstruction was established by clinical manifestations [hypourocrinia to various extent and urinary fistula, with or without elevated serum creatinine (SCr)] and imaging technology (B mode ultrasonography, isotope nephrogram and MRU). In 7 of the 19 cases, percutaneous nephrostomy and antegrade urography were applied in the establishment of the diagnosis. Results:The causes of transplant ureteral obstruction were identified in operation and (or) after histological examination. Ureteral stenosis or stoma stenosis of ureter-bladder were identified in 6 cases, twisting of ureter graft in 3 cases, vicinal infection associated ureteral perforation and stenosis in 2 cases, lower ureter thanatosis and obstruction in 2, ureter compression by surrounding scar or inflammatory tissue in 2 cases, technical failure of ureter ligation in 1 case, intra-ureter crystallization plus blood clot in 1 case, intra-ureter microlith in 1 case, and tightened tunica muscularis vesicae urinariae in 1 case. Transplant ureters and bladders were re-anastomosed in 7 cases, including 1 case by percutaneous nephrostomy (PN). Anastomosis of ureter and bladder valve was performed in 3 cases, lysis of adhesions of transplant renal pelvis and ureter in 2 cases, removal of transplanted kidney in one, ligation failure immediately released during operation in 1 case. Minimally-invasive intracavitary surgery (guide tube of 14-16F ) was applied in 5 cases. 4 of these 5 cases received balloon dilatation and stent placement under percutaneous ureterorenoscope, and the other 1 case received direct PN because of retrograde catheterization failure under cistoscope. Good outcomes were observed in these five patients, without any related complication. Conclusion:The etiology of ureteral obstruction in renal allograft recipients is various and complicate in clinical settings. Combination of imaging technology and clinical manifestation are necessary in the establishment of the correct diagnosis. PN plays a very important role in its diagnosis and treatment. Minimally invasive endoscopic procedure is an important resort to improve prognosis.