肾盂输尿管尿路上皮结痴性炎症疾病的特点和腔内诊疗经验

Characteristics and endoscopic diagnosis and treatment experience for ureteropelvic urothelial encrusted inflammatory diseases

目的总结肾盂输尿管尿路上皮结痴性炎症疾病的临床特点和腔内微创手术的诊疗经验。方法回顾性分析北京清华长庚医院2018年3月至2021年7月收治的3例双侧肾盂输尿管结痴性炎症疾病患者的病例资料。例1,男,45岁,因发现双肾积水5个月人院。外院行左侧双J管置入术和右肾造瘘术。术前诊断为双侧输尿管肾盂结石(结痴)、右侧输尿管闭锁、左侧输尿管狭窄、系统性血管炎。采用顺行经皮肾镜联合逆行输尿管镜手术并辅助球囊扩张方式分期治疗双侧病变例2,男,12岁,因双侧腰腹部疼痛6周人院。外院行双J管置人失败后改行双肾造瘘术。术前诊断为双侧输尿管结石、双肾积水、皮肌炎。行左侧经皮肾镜手术,右侧经皮肾镜联合输尿管镜手术治疗。例3,女,32岁。因左侧腰腹部疼痛6个月余入院。外院行3次体外冲击波碎石术,1次输尿管镜碎石术。术前诊断为双侧输尿管结石、双侧输尿管狭窄、皮肌炎。行输尿管镜手术治疗双侧病变。3例术中均可见肾孟和/或输尿管腔不同程度的结痴钙化灶,使用气压弹道联合取石钳或网篮清除。术后连续口服抗生素治疗1~3个月。根据术后3、6、12个月的尿常规、影像学和内镜检查结果评估患者的疗效和预后。结果本研究3例手术均顺利完成,术中均打通及扩张狭窄管腔或闭锁段。例1术后3、6、12个月随访CT示左侧输尿管未见结痴组织,内镜检查见黏膜层平整且创面愈合良好,管腔通畅,右侧肾盂仍有部分结痴病灶伴管腔狭窄僵硬,最终行右侧输尿管重建手术。例2术后3、6、12个月随访CT示双侧均未见结痴组织,内镜检查见管腔通畅,创面修复良好。例3术后3、6、12个月随访CT示双侧均未见结痴组织,内镜检查见输尿管腔通畅,黏膜层完整。术后结痴组织病理检查:尿路上皮黏膜组织慢性炎,小块增生纤维组织伴周边钙化,局灶上皮增生。钙化成分分析:磷酸氨镁和碳酸磷灰石。3例均未发生Clavien-Dindo≥Ⅱ级并发症。结论肾盂输尿管尿路上皮结痴性炎症疾病临床罕见,术前影像学检查、术中所见、术后病理检查、结痴成分分析等对本病的诊疗有指导意义。采用微创内镜为主的综合诊疗手段处理肾盂输尿管结痴性炎症疾病所致上尿路梗阻的效果良好。

Objective To retrospectively summarize disease characteristics and the clinical experience of minimally invasive endoscopy in the treatment of upper urinary tract obstruction caused by ureteropelvic encrusted inflammatory disease.Methods Three patients with bilateral ureteropelvic encrusted inflammatory disease admitted to our hospital from March 2018 to July 2021 were involved.Case 1,male,45 years old,admitted due to bilateral hydronephrosis for 5 months.The preoperative diagnosis were bilateral ureteropelvic stones(encrustation),right ureteral atresia,left ureteral stenosis,and systemic vasculitis.Left double J tube insertion and right nephrostomy were performed in another hospital.We conducted antegrade percutaneous nephroscopy combined with retrograde ureteroscopy surgery and assisted balloon dilation to treat bilateral lesions stage by stage.Case 2,Male,12 years old,admitted due to bilateral abdominal pain for 6 weeks.The preoperative diagnosis were bilateral ureteral stones,bilateral hydronephrosis,and dermatomyositis.After the failure of double J tube insertion in another hospital,double nephrostomy was performed instead.We performed left percutaneous nephroscopy and right percutaneous nephroscopy combined with ureteroscopy for the treatment of bilateral lesions.Case 3,female,32 years old,was admitted because of pain in the left lower back and abdomen for over 6 months.The preoperative diagnosis were bilateral ureteral stones,bilateral ureteral stenosis,and dermatomyositis.She underwent three times of ESWL and once URS before.We performed ureteroscopic surgery for bilateral lesions.During the surgery,various degrees of crusting in the renal pelvis or ureter were observed in all 3 cases,and the lesions were removed using pneumatic lithotripsy combined with forceps or baskets.After surgery,oral antibiotics were continuously used for 1-3 months.The efficacy and prognosis were evaluated based on the follow-up of urine,imaging,and endoscopic examinations at 3,6,and 12 months after surgery.Results All 3 surgeries were successfully completed.At 3,6,and 12 months after surgery,follow-up CT showed no crusting in the left ureter,and endoscopy showed good mucosal wound healing and unobstructed lumen in case 1.There were still some crusting lesions and lumen stenosis in the right renal pelvis,and the right ureter reconstruction surgery was ultimately performed.There were no crusting on both sides and the urinary tract was unobstructed after 3,6,and 12 months of follow-up in case 2 and case 3.Postoperative pathological examination showed chronic inflammation of urothelial mucosal tissue,small pieces of proliferative fibrous tissue with peripheral calcification.Calcification layer composition analysis showed magnesium ammonium phosphate and carbonate apatite.No related complications occurred in case 2 and case 3.Conclusions Urothelial crusted inflammatory disease is rare clinically,and the diagnosis and treatment strategies are rarely reported domestically and internationally.Preoperative imaging examination,intraoperative findings and postoperative pathology or calcification composition analysis are of instruction for the diagnosis and treatment of this disease.Minimally invasive endoscopy treatment for upper urinary tract obstruction caused by ureteropelvic encrusted inflammatory disease has a good effect.Long-term efficacy and other adjuvant treatment need long-term follow-up and clinical practice.