儿童肾积水术后梗阻病例回顾分析

Retrospective record review of postoperative obstruction for hydronephrosis in children

目的分析儿童肾积水（PUJO）术后梗阻的病因、治疗及预后。方法回顾分析北京儿童医院泌尿外科2009年2月至2015年2月收治的22例肾积水（PUJO）再次手术患儿的临床资料。开腹肾盂成形术20例，肾盂切开造瘘术1例，肾穿刺造瘘术1例。20例患儿术中所见首次术后梗阻病因：PUJ狭窄16例（80oA），PUJ高位7例（35％），合并输尿管远端狭窄2例（10％）。术后拔肾造瘘管出院11例，暂带肾造瘘管出院7例，6例返院拔除，1例随访至今仍留置（2015年2月手术）。2例合并输尿管远端狭窄，返院再次手术，后拔除肾造瘘管。结果随访3个月～6年。15例经IVP、超声、肾核素扫描复查证实PUJ通畅，积水缓解，2例电话随访，无症状，未行影像检查，3例未至复查时间，电话随访，暂无不适，余2例（姑息肾造瘘）定期复查，暂未再行手术。结论PUJ狭窄或高位，是肾盂成形术后梗阻的主要病因，无张力、低位吻合PUJ是避免术后梗阻的主要方法，再行肾盂成形术或肾下盏输尿管吻合术为再次手术方法。

Objective To explore the causes, treatments and prognosis of postoperative ureteropelvic iunction obstruction （UPJO） for hydronephrosis in children.Methods Retrospective record reviews were conducted for 22 children undergoing reoperations for hydronephrosis from February 2009 to February 2015. The procedures included open redo pyeloplasty （n = 20）, renal pelvis incision fistula operation （n = 1） and percutaneous nephrostomy （n = 1）. The causes of obstruction after initial operations included PUJ stenosis （16/20,80~）, high ureteral opening （7/20,35 ~/4） and concurrent distal ureteral stricture （2/20,10~）. And 11 children were discharged from hospital after a removal of nephrostomy tube and nephrostomy tube was retained in another 7. Nephrostomy tube was removed in 6 outpatients and retained for 1 child operated in February 2015. Reoperation was performed for 2 children with distal ureteral stricture and then nephrostomy tube removed. Results The follow-up period was 3 months to 6 years. IVP, ultrasound and renal nuclide scan confirmed a patency of PUJ and a remission of hydronephrosis in 15 cases. Two non-imaging cases remained asymptomatic and 3 cases were not up to review time. No discomfort was found through a telephone follow-up. Another 2 cases received regular reexaminations without reoperation. Conclusions PUJ stenosis or high ureteral opening is a major cause of obstruction after pyeloplasty. And tension-free and low anastomosis is ureterocalicostomy is essential for avoiding postoperative obstruction. Redo pyeloplasty or emoloved for reoperation,