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  • 陈周彤,林厚维,徐卯升,徐国锋,方晓亮,贺雷,耿红全*.儿童肾盂输尿管连接部梗阻术后再手术病因分析[J].第二军医大学学报,2020,41(2):216-220    [点击复制]
  • CHEN Zhou-tong,LIN Hou-wei,XU Mao-sheng,XU Guo-feng,FANG Xiao-liang,HE Lei,GENG Hong-quan*.Cause analysis of reoperation after pyeloplasty for ureteropelvic junction obstruction in children[J].Acad J Sec Mil Med Univ,2020,41(2):216-220   [点击复制]
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儿童肾盂输尿管连接部梗阻术后再手术病因分析
陈周彤,林厚维,徐卯升,徐国锋,方晓亮,贺雷,耿红全*
0
(上海交通大学医学院附属新华医院小儿泌尿外科, 上海 200092
*通信作者)
摘要:
目的 探究儿童肾盂输尿管连接部梗阻(UPJO)术后再手术的原因。方法 回顾我科2015年1月至2017年12月收治的肾盂成形术后因再次梗阻而接受手术的UPJO患儿的临床资料,分析再手术的原因。结果 共有36例患儿接受肾盂成形术后再手术治疗,术中发现梗阻原因为: 26例(72.22%)吻合口水肿增厚、周围粘连与纤维化瘢痕形成,5例(13.89%)吻合口旁或肾盂壁息肉,5例(13.89%)高位输尿管开口,3例(8.33%)迷走血管压迫输尿管,2例(5.56%)吻合口远端输尿管狭窄,2例(5.56%)肾盏颈闭锁。2例患儿因肾盏颈闭锁行肾盏颈成形+输尿管肾下盏吻合术,其余患儿均接受开放离断式肾盂成形术。术后中位随访时间为28个月,其中34例患儿未发生再梗阻。1例肾盏颈闭锁患儿术后上、下盏间及输尿管肾盏颈吻合口均再次闭锁,再次行肾盏颈成形+输尿管肾下盏吻合术;另1例患儿再次术后30个月出现患侧腰腹部疼痛伴积水增大,再次行肾盂成形术证实为前次吻合口再次瘢痕性狭窄。上述2例患儿经过第3次手术,术后分别随访37、20个月,无再梗阻发生。结论 吻合口水肿增厚、周围粘连与纤维化瘢痕形成是肾盂成形术后再手术最主要的原因。医源性息肉、输尿管开口位置偏高、首次手术遗漏迷走血管压迫和吻合口远端输尿管狭窄,及吻合时闭合肾盏颈也是导致肾盂成形术后再手术的重要原因。术中应注意选择输尿管较宽敞处精细吻合,保持吻合口位于肾盂低位、避免误伤肾盏颈、避免遗漏存在的迷走血管、造瘘管头端尽量远离吻合口等操作细节有助于减少肾盂成形术后再梗阻的发生。
关键词:  肾盂输尿管连接部梗阻  肾盂成形术  吻合口再狭窄  儿童
DOI:10.16781/j.0258-879x.2020.02.0216
投稿时间:2019-09-19修订日期:2019-11-22
基金项目:上海交通大学医学院高峰高原计划——“研究型医师”项目(2015005).
Cause analysis of reoperation after pyeloplasty for ureteropelvic junction obstruction in children
CHEN Zhou-tong,LIN Hou-wei,XU Mao-sheng,XU Guo-feng,FANG Xiao-liang,HE Lei,GENG Hong-quan*
(Department of Pediatric Urology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200092, China
*Corresponding author)
Abstract:
Objective To explore the causes of reoperation after pyeloplasty for ureteropelvic junction obstruction (UPJO) in children. Methods Clinical data of pediatric patients undergoing reoperation after pyeloplasty for UPJO from January 2015 to December 2017 were collected. The reasons of reoperation were analyzed. Results A total of 36 UPJO children underwent reoperation after pyeloplasty. Anastomotic edema, adhesion and fibrotic scar around the stoma was found in 26 (72.22%) patients. Other reasons were polypus near the anastomotic stoma (5 cases, 13.89%), high insertion of the ureteropelvic junction (5 cases, 13.89%), aberrant vessels compressing the ureter (3 cases, 8.33%), stenosis of distal ureter (2 cases, 5.56%), and renal calyx atresia (2 cases, 5.56%). Two patients who were diagnosed as having renal calyx atresia underwent renal calyx plasty and lower calyceal ureteral anastomosis. The other patients received open pyeloplasty. The median follow-up time was 28 months after reoperation. During the follow-up, 34 patients experienced no restenosis of ureteropelvic junction. But one patient suffered from second restenosis, and underwent renal calyx plasty and lower calyceal ureteral anastomosis again. One patient experienced abdominal pain and aggravation in hydronephrosis 30 months after the reoperation. He was diagnosed as having cicatricial stenosis after the third pyeloplasty. The two patients had no stenosis after follow-up for 37 and 20 months, respectively. Conclusion Anastomotic edema, adhesion and fibrotic scar are the main causes of reoperation after pyeloplasty. Other rare but important causes are iatrogenic fibroepithelial polyps, high insertion of the ureteropelvic junction, aberrant vessel compression, stenosis of distal ureter, and renal calyx atresia. During the operation, it is necessary to perform accurate anastomosis in spacious space of the ureter, keep the anastomotic stoma at the low renal pelvis, avoid the injury of renal calices and the ignorance of the aberrant renal vessels, and keep the head of the fistula as far as possible from the anastomotic stoma. These may help to reduce the possibility of reoperation after pyeloplasty.
Key words:  ureteropelvic junction obstruction  pyeloplasty  anastomotic stoma restenosis  children