小儿间歇发作性肾盂输尿管交界处狭窄诊治的回顾性研究

Retrospective study of etiology,diagnosis and treatment for intermittent hydronephrosis secondary to ureteropelvic junction obstruction

目的:回顾性研究间歇发作性肾盂输尿管交界处狭窄(ureteropelvic junction obstruction,UPJO)的病因及诊治方法。方法:统计2016年1月至2018年8月北京儿童医院收治并诊断为间歇发作性UPJO的患儿,定义间歇发作性UPJO为腹痛发作时检查证实存在急性肾盂肾盏扩张,而缓解期肾盂肾盏扩张减轻。排除手术导致的UPJO,排除UPJO合并肾发育不全及输尿管多处狭窄,排除UPJO合并膀胱输尿管反流及泌尿系统结石。对间歇发作性UPJO患儿进行回顾性研究及随访,分析临床特点、发作预防及治疗方法。结果:符合纳入标准的患儿共79例,男58例,女21例,年龄2.5~16.0岁,平均年龄5.4岁。内源性狭窄30例、迷走血管压迫29例、马蹄肾13例、息肉7例。临床主要表现为恶心呕吐66例(83.5%)、腹部包块8例(10.1%)、血尿5例(6.3%)。腹痛性UPJO的临床特点是发作频率半年1次至每个月3次,发作时间0.5~3.0 d。腹痛主要发作部位分别为肾周53例(67.1%)、脐周15例(19.0%),无法描述具体位置11例(13.9%)。存在腹痛诱因的34例(43.0%)、无明显诱因45例(57.0%)。术前SFUⅠ~Ⅱ级缓解期31例(39.2%),发作期0例;Ⅲ~Ⅳ级缓解期48例(60.8%),发作期79例(100%)。缓解期与发作期肾盂前后径的差异具有统计学意义(P<0.05),肾实质厚度的差异无统计学意义(P>0.05)。T 1/2>20 min病例数发作期明显高于缓解期(P<0.05)。开放手术19例,腹腔镜60例。随访6~18个月,手术成功率94.9%(75/79)。术后病理学检查提示管腔内狭窄44例(55.7%)、无狭窄35例(44.3%)。结论:间歇发作性UPJO需结合病史进行诊断,超声检查在整个病程中具有诊断价值。在缓解期诊断困难,在发作期辅助检查如静脉肾盂造影(intravenous pyelography,IVP)、利尿性核素扫描更具诊断价值。

Objective To explore the pathogenesis and clinical managements of intermittent hydronephrosis secondary to ureteropelvic junction obstruction(UPJO).Methods The retrospective study was based upon medical records from January 2006 to August 2018.Intermittent hydronephrosis was defined as intermittent UPJO presenting with abdominal pain.UPJO with renal dysplasia,multiple ureteral strictures,urinary reflux,urinary calculi and iatrogenic cause were excluded.Their clinical manifestations,attack preventions and imaging findings were analyzed.Results The clinical data of 79 children were recorded.The mean operative age was 5.4(2.5-16)years.There were 58 boys and 21 girls.The causes were intrinsic stenosis(n=37),extrinsic vessel(n=29),horseshoe kidney(n=13)and ureteral polyp(n=7).All presented with acute abdominal pain of perinephric(n=53,67.1%),navel(n=15,19.0%)and indescribable(n=11,13.9%).The history of inducement was acquired in 34 cases(43.0%).The major clinical manifestations were nausea&vomiting(n=66,83.5%),abdominal mass(n=8,10.1%)and hematuria(n=5,6.3%).Ureter lumens were stenotic(n=44,55.7%)and non-stenotic(n=35,44.3%).Thirty-one cases(39.2%)stayed in remission.There were 48 cases(60.8%)in remission and 79 cases(100%)in the period of onset with SFU III^IV.The anteroposterior diameters of pelvis were significantly higher in the period of onset(P<0.05).However,no inter-group difference exited in renal parenchyma thickness between two periods(P>0.05).The cases of T1/2>20 min were significantly higher in the period of onset(P<0.05).Open and laparoscopic surgeries were performed in 19 and 60 cases respectively.The follow-up period was 6-18 months and the success rate reached 94.7%(71/75).Pathology revealed intraluminal stenosis(n=44,55.7%)and non-stenosis(n=35,44.3%).Conclusions Intermittent UPJO should be diagnosed in conjunctions with disease history.Immediate or serial ultrasonography is valuable during two periods.Diagnosis is difficult in remission.During the period of onset,UPJO may be diagnosed with IVP and diuretic nucleotide scan.