输尿管逆行造影在诊断儿童外伤性肾盂输尿管连接处断裂中的应用

The application of retrograde pyelography in the diagnosis of traumatic ureteropelvic junction disruption in children

目的探讨输尿管逆行造影在诊断儿童外伤性肾盂输尿管连接处（ureteropelvicjunction，UPJ）断裂中的应用。方法回顾性分析我院2009年1月至2017年9月收治的26例外伤患儿的临床资料。男19例，女7例；年龄1～11岁，平均5．4岁。受伤原因：车祸伤15例，高空坠落伤4例，摔伤7例。26例入院时行超声及CT检查均提示不同程度尿外渗，增强CT延迟15～20min扫描未见输尿管显影，不能明确uPI有无损伤。26例均在全麻下经膀胱镜向患侧输尿管逆行插入输尿管支架管，并注入造影剂。若逆行插管顺利进人肾盂，输尿管和肾脏造影显示完整，考虑为肾损伤；若插管达UPJ处上行困难，造影显示输尿管盲端，考虑为UPJ断裂。结果本组26例中9例逆行造影肾脏显影，证明UPJ无损伤，予保守治疗后。肾周外渗尿液均逐渐吸收。16例逆行造影肾脏不显影，考虑为UPJ断裂，行肾脏探查术。此16例术中均证实为UPJ断裂，其中15例行肾盂输尿管吻合术；l例因缺损段较长，行阑尾代输尿管吻合术，术后复查静脉肾盂造影均显示输尿管通畅。1例逆行造影肾周尿性囊肿显影，肾脏不显影，考虑uPJ断裂可能性大，行手术探查，发现UPJ完整，尿性囊肿为肾盂破裂所致，故进一步行肾盂修补术，术后复查静脉。肾盂造影无造影剂外溢。本组输尿管逆行造影的敏感性和特异性分别为100％（16／16）和90％（9／10）。结论输尿管逆行造影在诊断UPJ断裂中敏感性和特异性均较高，是可靠且无法替代的诊断依据。如患儿外伤后腹部超声或CT检查捉示肾周尿外渗或尿外渗逐渐加重，增强CT延迟扫描患侧输尿管不显影，应考虑uPJ断裂，尽早行输尿管逆行造影明确诊断。

Objective To explore the application of retrograde pyelography with traumatic ureteropelvic junction disruption in children. Methods A retrospective study was conducted for a total of 26 children with doubt of traumatic UPJ disruption in image from 2009 January to 2017 September. There were 19 males and 7 females with a mean age of 5.4 （1 -11 ） years. And the causes were traffic accident （n = 15）, fall injury （n = 4） and fall damage （n = 7）. Ultrasound and CT examination indicated different degrces of urinary extravasation in all cases. Enhanced CT delayed imaging had no ureteral enhancement, and could not specify whether UPJ was disrupted. All the patients underwent retrograde pyelography through cystoscope under the general anesthesia. If the retrograde tube entered the renal pelvis smoothly, and the ureter and renal were complete, which was considered to be renal injury. If it was difficult for the tube to reach the UPJ, and the ureteral blind end was shown by contrast angiography, UPJ fracture was considered. Results UPJ was not broken in 9 patients （34.6%）, and the peritoneal urine was gradually absorbed after conservative treatment. Retrograde pyelography showed no sign of kidney in 16 cases （61. 5% ）. UPJ disrupture was considered and performed renal exploration. These 16 cases were all confirmed as UPJ disrupture during operation. 15 patients underwent ureteropelvic anastomosis, 1 patient underwent ureteral anastomosis by using appendix because of long segment defect, and intravenous pyelography after surgery showed that the ureter was unobstructed. Urinoma but not renal was enhanced in 1 patient （ 3.9% ）. One case （3.9%） retrograde pyelography showed the perirenal urinary cyst was enhanced, the kidney was not enhanced, and the possibility of UPJ fracture was considered . But this patient was confirmed UPJ not disrupted in the operation and underwent pyeloplasty. Intravenous pyelography showed no contrast agent extravasation after surgery. The sensitivity and specificity of retrograde pyelography in this group were 100% （16/16） and 90% （9/10）, respectively. Conclusions The sensitivity and specificity of retrograde pyelography were higher, and retrograde pyelography was reliable and irreplaceable in the early diagnosis of UPJ disrupture.