肠代输尿管术治疗输尿管长段狭窄的应用经验和临床疗效

The experience and clinical efficacy of intestinal ureteral replacement for the treatment of long segment ureteral stenosis

目的总结在上尿路修复和重建中应用肠道的经验, 探讨肠代输尿管术的临床疗效。方法回顾性分析2016年6月至2021年12月贵州省人民医院、北京大学第一医院、解放军总医院第七医学中心、华中科技大学同济医学院附属协和医院、四川大学华西医院、兰州大学第二医院收治的138例长段输尿管狭窄患者的病例资料, 男66例, 女72例。年龄(35.54±21.35)岁, 其中儿童9例, 年龄(10.78±4.41)岁。输尿管狭窄位于左侧65例, 右侧38例, 双侧34例。孤立肾12例。输尿管上段狭窄26例, 中段狭窄2例, 下段狭窄24例。输尿管全长狭窄14例, 输尿管多发狭窄54例。术前留置肾造瘘管22例, 留置双J管88例。术前行B超、增强CT、CTU、MRU、顺行和逆行造影检查测量输尿管狭窄长度为(15.93±4.67)cm。术前血肌酐(93.94±37.13)μmol/L, 尿素氮(5.91±1.99)mmol/L, 估算肾小球滤过率(eGFR)(83.53±25.18)ml/min。孤立肾患者术前血肌酐(104.83±69.14)mol/L, 尿素氮(7.33±2.90)mmol/L, eGFR(64.53±14.46)ml/min。本研究138例, 接受回肠代输尿管术(回肠组)123例, 术中测量输尿管狭窄长度(14.48±6.28)cm, 选取回肠段长度(20.67±11.20)cm, 替代输尿管长度(22.97±8.09)cm;Yang-Monti回肠代输尿管术(Yang-Monti回肠组)7例, 术中测量输尿管狭窄长度(15.43±4.35)cm, 截取回肠段(3.00±0.58)段, 每段回肠段长度2.5~3.0 cm, 重建回肠段长度(16.83±3.97)cm, 重建回肠替代输尿管长度(11.50±5.65)cm;Yang-Monti结肠代输尿管术(Yang-Monti结肠组)8例, 术中测量输尿管狭窄长度(6.00±0.93)cm, 截取结肠段(2.75±0.46)段, 每段结肠段长度1.5~2.0 cm, 重建结肠段长度(5.13±1.13)cm, 重建结肠替代输尿管长度(4.88±1.46)cm。Yang-Monti回肠组与回肠组术中测量的输尿管狭窄长度比较差异无统计学意义(P=0.6900);Yang-Monti结肠组与回肠组术中测量的输尿管狭窄长度比较差异有统计学意义(P=0.0002);Yang-Monti回肠组(P=0.0001)和Yang-Monti结肠组(P=0.0003)与回肠组替代的输尿管长度比较差异均有统计学意义。3种术式术后留置术区引流管、尿管、输尿管内支架管, 术前留置的肾造瘘管术后保留。结果所有手术均顺利完成, 术中未发生并发症。Yang-Monti回肠组手术时间(376.40±202.80)min、Yang-Monti结肠组手术时间(626.30±224.20)min, 与回肠组手术时间(286.80±97.24)min比较差异均有统计学意义(P=0.0294, P=0.0001);Yang-Monti回肠组术中出血量(314.30±213.50)ml、Yang-Monti结肠组术中出血量(210.00±96.07)ml, 与回肠组术中出血量(183.90±199.70)ml比较差异均无统计学意义(P=0.0971, P=0.7157)。所有患者出院前肌酐(84.45±28.51)μmol/L, 与术前比较差异有统计学意义(P=0.0239);尿素氮(5.79±2.61)mmol/L(P=0.6684), eGFR(89.11±25.17)ml/min(P=0.1506), 与术前比较差异均无统计学意义。孤立肾患者出院前肾功能与术前比较差异均无统计学意义(P>0.05)。Yang-Monti回肠组和回肠组的引流管留置时间分别为(10.00±5.35)d和(9.24±6.45)d(P=0.7599), 尿管留置时间分别为(13.17±4.79)d和(17.61±10.29)d(P=0.2973), 术后住院时间分别为(19.86±9.34)d和(16.02±10.70)d(P=0.3553), 差异均无统计学意义。Yang-Monti结肠组和回肠组的引流管留置时间分别为(14.88±7.81)d和(9.24±6.45)d(P=0.0202), 尿管留置时间分别为(8.88±2.80)d和(17.61±10.29)d(P=0.0188), 术后住院时间分别为(34.88±17.04)d和(16.02±10.70)d(P=0.0001), 差异均有统计学意义。Yang-Monti回肠组1例术后第2天发生低钾血症, 予静脉滴注氯化钾纠正。回肠组5例术后第2天发生代谢性酸中毒, 予纠正。回肠组6例、Yang-Monti回肠组1例术后尿管中发现黏液样分泌物, Yang-Monti结肠组8例术后尿管中发现白色絮状物, 予保持尿管通畅。回肠组5例、Yang-Monti回肠组1例、Yang-Monti结肠组1例术后出现尿瘘, 其中回肠组1例再次手术调整双J管后治愈, 其余均保守治疗并延长留置输尿管内支架管后治愈。13例术后发热, 予敏感抗生素后治愈。33例发生尿路感染, 26例使用抗生素治疗, 10例尿培养阳性, 予敏感抗生素治疗;7例未使用抗生素治疗, 6例术后尿常规提示白细胞异常, 尿培养阴性。8例失访。130例术后随访2~36个月。肌酐(93.00±31.14)μmol/L(P=0.8279), eGFR(83.10±24.32)ml/min(P=0.9138), 与术前比较差异无统计学意义;尿素氮(6.82±2.46)mmol/L, 与术前比较差异有统计学意义(P=0.0022)。孤立肾患者手术前后肾功能比较差异均无统计学意义(P>0.05), 均未发生电解质异常。1例出院后7 d因黏液堵塞尿管发生尿潴留, 导致输尿管膀胱吻合口3 cm尿囊肿, 更换尿管后消失。并发输尿管结石、肾结石各1例, 再次行输尿管镜治疗。13例影像学检查提示同侧肾轻度积水。16例尿常规检查白细胞升高, 其中8例尿培养提示细菌感染, 7例予敏感抗生素治疗。结论对于上尿路修复重建手术, 回肠代输尿管术是较理想的手术方法, 安全有效;Yang-Monti回肠或结肠代输尿管术也是可选择的手术方式。

Objective To summarize the experience of intestinal tract in repairing and reconstructing upper urinary tract,and to explore the clinical efficacy of intestinal ureter replacement.Methods From June 2016 to December 2021,a total of 138 patients(66 men and 72 women,129 adults and 9 children)with a mean age of(35.54±21.35)years[(10.78±4.41)years in 9 children aged of 4-16 years]were diagnosed as long segmental ureteral stenosis and underwent ureteral reimplantation using ileal or colonic segments in six tertiary A class hospitals in China.Of the 138 patients,65,38,and 34 stenosis presented in left,right or both sides,and 26,2,and 24 stenosis located in upper,middle or lower ureter,respectively.Full length and multi-segmental stenosis occurred in 14 and 54 patients respectively.There were 12 stenosis presented in solitary kidney,and 22 patients undergoing nephrostomy and another 88 cases undergoing double J stenting.Length of stenosis ranged from 9 to 25cm[mean(15.93±4.67)cm]measured by ultrasound,enhanced CT,CTU,MRU,or anterograde/retrograde pyelography.Baseline creatinine,BUN and eGFR were(93.94±37.13)μmol/L,(5.91±1.99)mmol/L and(83.53±25.18)ml/min respectively,while in patients with solitary kidney,they were(104.83±69.14)mol/L,(7.33±2.90)mmol/L and(64.53±14.46)ml/min respectively.This study involved 138 cases,including 123 patients undergoing ileal ureter with mean stenosis length of(14.48±6.28)cm by intraoperative measurement.The mean(20.67±11.20)cm of ileal segment was taken to replace the mean(22.97±8.09)cm of ureteral defect.Yang-Monti ileal ureter was adopted in 7 patients with stenosis of mean(15.43±4.35)cm.Ileal segments of(16.83±3.97)cm were further divided into 2 to 4(mean 3.00±0.58)sub-segments,2.5 to 3cm each,and reconstructed ileal ureter of mean(11.50±5.65)cm.Eight patients undwewent Yang-Monti colonic ureter and the mean stenosis length was(6.00±0.93)cm.The mean(5.13±1.13)cm of colonic segment was taken and divided into 2 to 3 segments(mean 2.75±0.46 segments,1.5 to 2.0 cm each)and reconstructed mean(4.88±1.46)cm of colonic ureter.Drainage tube,ureter stent and foley catheter were used in all patients and nephrostomy tube inserted previously was preserved.There was no significant difference in intraoperatively measured stenosis length between Yang-Monti ileal ureter group[mean(15.43±4.35)cm]and ileal ureter group[(14.48±6.28)cm](P=0.6900).Significant difference was observed in stenosis length measured intraoperatively between Yang-Monti colonic ureter group[(6.00±0.93)cm] and ileal ureter group(P=0.0002).There were significant differences in length of reconstructed ureter between Yang-Monti colonic ureter group,Yang-Monti ileal ureter group[(5.13±1.13)cm and(16.83±3.97)cm]and ileal ureter group[(22.97±8.09)cm](P=0.0001,P=0.0003).Results All operations performed smoothly with no complications.There were significant differences in operation time among Yang-Monti ileal ureter group,Yang-Monti colonic ureter group[(376.40±202.80)min and(626.30±224.20)min]and ileal ureter group[(286.80±97.24)min](P=0.0294,P=0.0001).There were no difference in bleeding volume among three groups[(314.30±213.50)ml,(210.00±96.07)ml and(183.90±199.70)ml respectively](P=0.0971,P=0.7157).Creatinine levels before discharge was significantly lower than preoperative levels in all patients[(84.45±28.51)μmol/L vs.(93.94±37.13)μmol/L(P=0.0239)],but BUN showed no significant change[(5.79±2.61)mmol/Lvs.(5.91±1.99)mmol/L](P=0.6684).There was no significant difference in eGFR between baseline and discharge level[(83.53±25.18)ml/min vs.(89.11±25.17)ml/min](P=0.1506).In solitary kidney subunit,creatinine and BUN Levels measured before discharge showed no significant difference compared to preoperative levels(P>0.05).Yang-Monti ileal ureter group had no significant difference compared to ileal ureter group in drainage time[(10.00±5.35)d vs.(9.24±6.45)d](P=0.7599),catheterization time[(13.17±4.79)d vs.(17.61±10.29)d](P=0.2973)and hospital stay after surgery[(19.86±9.34)d vs.(16.02±10.70)d](P=0.3553).Compared to ileal ureter group,Yang-Monti colonic ureter group had significant longer drainage time[(14.88±7.81)d vs.(9.24±6.45)d](P=0.0202),catheter time[(8.88±2.80)d vs.(17.61±10.29)d](P=0.0188)and hospital stay after surgery[(34.88±17.04)d vs.(16.02±10.70)d](P=0.0001).Hypokalemia was found 2 days after surgery in one case of Yang-Monti ileal ureter group and corrected by intravenous potassium chloride.Five cases of metabolic acidosis in ileal ureter group were found 2 days after surgery and were also corrected.Mucous secretion appeared in catheter in 7 patients(6 in ileal ureter group and 1 in Yang-Monti colonic ureter group).White flocculent emerged in catheter in 8 patients of Yang-Monti colonic ureter.Seven patients experienced urinary fistula(5 in ileal ureter group,1l in Yang-Monti ileal ureter group and 1 in Yang-Monti colonic ureter group).One fistula in ileal ureter group was successfully managed by replacing stent and the other 6 cases of fistula disappeared by conservative management and prolonged stenting.Thirteen patients had fever and healed after antibiotic therapy.Urinary tract infection were found in 33 patients,and there were 26 cases undergoing antibiotic therapy,including 10 patients undergoing sensitive antibiotics based on positive urinary culture,and 7 patients without antibiotic therapy.Six patients showed increased white blood cell count in urine with negative urinary cultures.Of the 138 patients,8 cases lost to follow up 2 to 36 months afterwards.Follow-up parameters included creatinine level,BUN,eGFR,serum electrolyte test,urinary routine,urinary culture,intravenous pyelography,CT and MRU.There was no significant difference between follow-up and baseline creatinine[(93.00±31.14)μmol/L vs.(93.94±37.13)μmol/L](P=0.8279).There was significant difference between follow-up and baseline BUN level[(6.82±2.46)mmol/L vs.(5.91±1.99)mmol/L](P=0.0022).eGFR at follow-up had no significant difference compared to baseline level[(83.10±24.32)ml/min vs.(83.53±25.18)ml/min](P=0.9138).In solitary kidney subgroup,there was no significant difference between follow-up and baseline data in creatinine,BUN and eGFR.No electrolyte disturbance was found.A case of urinoma of 3 cm secondary to Foley catheter occlusion was found 7 days after discharge and was managed successfully by catheter replacment.One ureter stone and one kidney stone were found during follow-up and were managed by ureteroscopic lithotripsy.Thirteen patients showed hydronephrosis in ipsilateral side.Sixteen patients showed increased white blood cell count in routine urinary test,of which,8 had positive culture and 7 were administered sensitive antibiotics.Conclusions Ileum ureter is an excellent therapy for reconstructing upper urinary tract with fewer complications,and Yang-Monti ileum or Yang-Monti colon ureter are alternative methods.