婴幼儿肾盂输尿管连接处梗阻致肾盂自发性破裂的诊疗分析

Diagnosis and treatment of spontaneous rupture of renal pelvis caused by pelviureteric junction obstruction in infants

目的探讨婴幼儿肾盂输尿管连接处梗阻(UPJO)致肾盂自发性破裂的临床特点和诊疗方法.方法回顾性分析2013年10月至2018年10月郑州大学第三附属医院收治的7例UPJO致肾盂自发性破裂患儿的病例资料.男5例,女2例.年龄2 d^25个月,平均(12.0±6.1)个月.肾盂破裂位于左侧3例,右侧4例.肾积水程度Ⅲ级2例,Ⅳ级5例.早期症状分别为发热4例;消化系统症状3例,其中1例误诊为不全肠梗阻,1例误诊消化不良;少尿2例.实验室检查:7例尿红细胞(+++),尿隐血(+),2例出现血尿;6例尿白细胞≥8个/μl,1例正常;3例血C反应蛋白>10 mg/L,4例正常;肾功能不全3例,肌酐均>110 μmol/L.CT增强扫描确诊7例均为肾盂破裂,其中5例尿外渗位于后腹腔,2例位于后腹腔及腹腔.4例行开放肾盂成形术+肾造瘘+肾周引流术;2例行肾盂成形术+肾造瘘+腹腔及肾周引流术;1例行肾周引流术并逆行留置双J管.结果 7例手术均顺利完成.中位手术时间84 min(45~90 min).中位出血量15 ml(10~35 ml),7例均未输血.术后肾周引流管留置中位时间3 d(2~5 d),腹腔引流管留置中位时间5 d(3~7 d),肾造瘘管留置中位时间12 d(10~14 d).中位住院天数14 d(10~21 d).7例均获随访,中位随访时间18个月(3~36个月).7例均尿量正常,体温正常,尿外渗消失,其中6例肾积水缓解,肾皮质增厚,肾功能恢复正常;1例拔除双J管后复查肾积水逐渐加重伴腰腹部疼痛,行二期肾盂成形术后肾功能恢复正常.结论婴幼儿UPJO致肾盂自发性破裂临床少见,易误诊,肾积水程度、炎症可能是影响婴幼儿肾盂自发性破裂发生的重要因素.当肾盂自发性破裂发生时,需手术积极干预,同时处理UPJO并引流尿外渗.

Objective To analyze the clinical features of spontaneous rupture of the renal pelvis (SRRP) in infants caused by UPJO. Methods A retrospective analysis of 7 cases of SRRP in infants caused by UPJO in our hospital from October 2013 to October 2018 was performed. All the patients included 5 males and 2 females. The average age was(12.0±6.1) months(ranging 2 days-25 months). 3 cases suffered renal rupture in left side and 4 cases suffered renal rupture in right side. 2 cases had grade Ⅲ hydronephrosis and 5 cases had grade Ⅳ hydronephrosis. Other symptoms included fever in 4 cases, digestive symptoms in 3 cases, oliguria in 2. 7 cases were revealed RBC(+++)with urinary occult blood positive in urine test. 6 cases were found the white blood cells in urine was more than 8/μl. 3 cases had the elevated blood C-reactive protein.3 cases suffered with renal function insufficiency, which the creatinine was more than 110 μmol/L. The 2 cases of urinary extravasation was found in the posterior abdominal cavity and 2 in posterior abdominal cavity and abdominal cavity by CT enhanced scan. 4 cases performed open pyeloplasty, nephrostomy and perirenal drainage.2 cases performed pyeloplasty, nephrostomy, abdominal and perirenal drainage. 1 case performed perirenal drainage and retrograde indwelling Double-J stents. Results All operation performed successfully. The median operation time was 84 min (ranging 45-90 min). The estimate blood loss was 15 ml (ranging 10-35 ml)without any transfusion. The median time of postoperative perirenal drainage tube was 3 d (ranging 2-5 d), The median time of the abdominal drainage tube was 5 d (ranging 3-7 d), the median time of nephrostomy was 12 d (ranging 10-14 d). The median hospital stay was 14 d (ranging 10-21 d). The median follow-up was 18 months (ranging 3-36 months). One performed the second stage pyeloplasty after double-J stents removed, and the renal function gradually recovered. Conclusions The SRRP in infants caused by UPJO is rare and easily misdiagnosed. The degree of hydronephrosis and inflammation may be important factors affecting the spontaneous rupture of pediatric renal pelvis. When it occurs, it requires active intervention by the operation, while treating the stenosis of the UPJ and draining the extravasation of urine.