肾移植术后尿瘘定位诊断及治疗策略14年回顾性病例数据分析

Localization,diagnosis and treatment strategy of urinary fistulae following kidney transplantation:A retrospective study of 14-year experience

背景:肾移植后尿瘘发生率各中心报道不同,而且没有标准的分类标准和治疗规范。目的:回顾性分析肾移植术后不同部位尿瘘的发病特点、病因及治疗效果,以探讨治疗尿瘘的最佳方案。方法:选择确诊的68例肾移植术后尿瘘患者。男42例,女26例,年龄21～57岁。尿瘘发生时间术后1～17d。根据尿瘘的部位将68例患者分为吻合口瘘及输尿管瘘。尿瘘部位根据膀胱造影、磁共振水成像及经手术探查结果确定。尿瘘诊断后先行保守治疗,即立即放置负压引流管引流伤口渗液,逆行插入双J导管及留置尿管。无效时立即手术修补尿瘘,68例患者中45例行外科手术治疗。观察尿瘘的发生部位、时间、治疗情况及复发后治疗结果。结果与结论:吻合口瘘20例(29.4%),输尿管瘘48例(70.6%),平均发病时间分别为(5.1±2.5),(8.8±5.5)d(P<0.05)。吻合口瘘15例(75.0%)保守治疗成功,5例(25.0%)手术治疗,其中4例治愈无复发,1例因急性排斥反应切除移植肾;输尿管瘘中8例(16.7%)保守治疗成功,40例(83.3%)手术治疗,其中35例治愈(包括6例复发再次手术),3例移植肾切除(2例修补失败,1例急性排斥反应),2例因肺部感染死亡,吻合口瘘的保守治疗成功率较输尿管瘘高(P<0.01)。肾移植术后尿瘘的定位诊断对选择治疗方法有重要意义。吻合口瘘发生时间相对较早,漏尿量大。对于吻合口瘘可首选保守治疗,无效时再考虑手术治疗,而对于吻合口以上的输尿管瘘应尽早开放手术治疗。

BACKGROUND：The urinary fistula rates following kidney transplantation are varying in each center,which lack of unified classification criteria and treatment standard.OBJECTIVE：To explore optimal treatments for urinary fistula following kidney transplantation by retrospective analyzing the characteristics,etiological factors and therapeutic efficacy of urinary fistula.METHODS：Totally 68 patients with urinary fistula were collected,including 42 males and 26 females,aged 21-57 years.The urinary fistula occurred at days 1-17 after operation.According to the location of urinary fistula,patients were divided into stomas fistula and ureter fistula groups.The location of fistula was determined by cystography,magnetic resonance hydrography（MRH） or operation research.In both groups,conservative treatment was first adopted,namely,placing a negative pressure drainage tube draining the wounds and placing a double-J catheter or a urinary canal in,however,if invalid,a surgical repair was performed.There were 45 patients underwent surgery.The location,onset period,therapeutic efficacies of urinary fistula was analyzed.RESULTS AND CONCLUSION：Among the 68 cases of fistula,20（29.4%） were stomas fistula and 48（70.6%） were ureter fistula.The onset period was（5.1±2.5） and（8.8±5.5） days after transplantation,respectively（P0.05）.Fifteen of 20 stomas fistula（75.0%） were cured successfully by conservative treatment.Whereas,for the remaining 5 cases（25.0%）,we attempted open surgery,among which 4 were cured,free of recurrence,and 1 case underwent nephrectomy because of acute rejection.For the 48 cases of ureter fisula,only 8（16.7%） were cured by conservative treatment,but the other 40（83.3%） must accept further open surgery,among which 35 were cured（including 6 cases of recurrent fistula）.Three cases underwent nephrectomy failure of repair owing to acute rejection,besides 2 died of pulmonary infection.The achievement ratio of conservative treatment in lower fistulae was significantly higher than that of upper fistulae（P0.01）.It is necessary to determine the location of urinary fistula following kidney transplantation.Compared to ureter fistula,stomas fistula occurred earlier with great leaked volume.Conservative treatment can first selected for stomas fistula,only if it is invalid can we resort to open surgery.However,for ureter fistula,it is wise to adopt open surgery as soon as possible.