肾盂输尿管成形术患儿术后并发症的处理和预防

Management and Prevention of Complications of Pediatric Pyeloplasty

目的探讨儿童肾盂输尿管连接部梗阻肾盂输尿管成形术术后并发症的原因、处理和预防。方法 1996年1月-2010年10月中山大学附属第一医院收治的肾盂输尿管连接部梗阻行肾盂输尿管成形术术后发生并发症患儿共22例。男20例,女2例;年龄8 d^9岁(平均3.5岁);左侧20例,右侧2例。对患儿进行随访,并结合其临床资料进行回顾性分析。结果 22例中吻合口狭窄10例,其中8例行再次肾盂输尿管成形术,2例行吻合口瘢痕松解、瘢痕狭窄切除再吻合;吻合口水肿伴泌尿系感染6例,3例行肾造瘘,3例延期拔除原肾造瘘管;单纯泌尿系感染2例,行抗感染治疗;输尿管中段狭窄1例,行输尿管中段狭窄切除再吻合;输尿管末段狭窄1例,行输尿管膀胱再吻合术;吻合口血肿伴泌尿系感染1例,行血肿穿刺引流、肾穿刺造瘘;巨大肾积水并无功能肾1例,行肾切除。10例吻合口狭窄切除标本病理:输尿管慢性炎症,肌层增厚;2例输尿管中、末段狭窄切除标本病理:输尿管慢性炎症,管壁变薄;1例肾切除标本病理:肾实质不同程度萎缩,间质慢性炎症并不同程度纤维化。随访6~36个月,临床症状均已消失,复查尿常规均无异常。超声检查21例患侧肾积水均减轻、肾皮质均有不同程度增厚;另1例患肾切除术后超声检查示对侧肾脏代偿性增大。结论肾盂输尿管成形术术后需要密切随访,及时发现和治疗并发症。术前正确诊断,术中细致操作,术后精心护理及预防性使用抗生素均是预防并发症措施。

Objective To investigate the cause,management and prevention of the complications of pyeloplasty in pediatric ureteropelvic junction obstruction（UPJO）.Methods From Jan.1996 to Oct.2010,there were 22 children with postoperative complications of pyeloplasty in the First Affiliated Hospital of Sun Yat-Sen University.Male 20 cases,female 2 cases,the mean age 8 days-3.5 years old,left side 20 cases and right side 2 cases.All patients were followed up and the clinical data were analyzed retrospectively.Results Among the 22 cases,urinary anastomosis site stenosis were 10 cases：re-pyeloplasty 8 cases,tension-free and re-anastomois 2 cases;anatomosis edema with urinary tract infection（UTI） 6 cases：nephrostomy and antibacterial therapy 3 cases,postponed removal nephrostomy tube 3 cases;single UTI 2 cases with antibacterial therapy;mid-ureteral stenosis 1 case with narrow segment resection and re-anastomois;end uretheral stricture 1 case with ureteral reimplantation;peri-anastomosis hematoma with UTI 1 case with hematoma drainage and nephrostomy;giant and nonfunctional hydronephrosis 1 case with nephrectomy.Ten cases anastomotic stenosis resection pathological specimen revealed：Ureteral chronic inflammation,and its wall thinning change.Two cases mid-ureteral stenosis and end uretheral stricture resection pathological specimen revealed：Ureteral chronic inflammation,and its wall thinning change.One case nephrectomy phathological specimen revealed：Renal parenchymal atrophy of different level,interstitial chronic inflammation and fibrosis change.Follow-up 3-36 months,clinical symptoms had disappeared,no abnormal of routine urine re-examination.Twenty one cases ultrasound examination had showed the relieved of suffering side hydronephrosis,renal cortical was thickening of varying degrees;another 1 case post nephrectomy ultrasound examination showed contralateral kidney compensatory increase.Conclusions Close follow-up is essential for pyeloplasty,and the postoperative complications shall be treated early.Preoperative correct diagnosis,careful operation,postoperative intensive care and prophylactic antibacterial therapy are important for complication prevention.