肾移植术后移植肾输尿管膀胱吻合口狭窄的腔内治疗:13例报道

doi:10.19723/j.issn.1671-167X.2019.06.031

摘要/Abstract

摘要：

目的探讨利用腔内技术处理肾移植术后移植肾输尿管膀胱吻合口(ureterovesical junction, UVJ)狭窄的安全性和有效性。方法选择2012年3月至2018年7月因肾移植术后移植肾UVJ狭窄于北京大学人民医院接受腔内治疗的13例患者,共完成15次手术(其中2例患者分别接受2次腔内治疗),通过分期或同期行肾造瘘术,再以软输尿管镜顺行探查输尿管腔处理狭窄。对患者的性别、年龄等人口学特征,以及手术成功率、术中出血量、术后肌酐变化水平、术后并发症、远期再狭窄率等临床资料进行回顾性分析。结果 13例患者中男性9例,女性4例,平均年龄45.0岁(34~57岁),均通过B超、CT、磁共振水成像或肾造瘘后顺行造影明确诊断。4例患者为早期狭窄,其余9例均为术后远期狭窄。15例次手术中,14例次成功解除梗阻,失败1例次。早期8例次患者行一期肾造瘘、二期处理狭窄,后期7例次患者在肾造瘘同时处理狭窄,两者的平均手术时间分别为95.4 min、68.9 min,即刻手术成功率分别为87.5%、100.0%。患者围手术期血红蛋白平均下降0.6 g/L,肌酐均能在短期内恢复至积水出现前水平,所有患者术后均无发热、严重血尿、漏尿等严重并发症发生,术后平均住院天数为2.8 d。术后仅3例患者在拔除支架管后随访期间无复发,随访时间分别为9、17及82个月,远期再狭窄发生率为76.92%(10/13)。结论运用腔内技术处理移植肾UVJ狭窄取得较好的效果,安全性较高,但术后再狭窄的发生率较高,需要特别注意。

关键词: 肾移植, 输尿管梗阻, 吻合术, 外科, 手术后并发症

Abstract:

Objective: To evaluate the safety and efficacy of endoscopic treatment for ureterovesical junction (UVJ) stenosis in patients with kidney transplantation.Methods: A retrospective study was conducted among the patients with kidney transplantation diagnosed as UVJ stenosis from 2012 March to 2018 July in Urology and Lithotripsy Center, Peking University People’s Hospital. Only the patients who received endoscopic treatment were included, with staged or same-session nephrostomy followed by a retrograde ureteroscopy to evaluate the ureteral stenosis. Incisions with laser, mono- or bipolar energy, or balloon dilation were used to manage the stenosis depending on different situations. Demographic characteristics and clinical data were gathered and analyzed, including age, gender, preoperative serum creatinine, hemoglobin, operation time, success rate, postoperative serum creatinine, hemoglobin, postoperative complications rate, and long-term stenosis recurrence rate.Results: In this study, 13 patients were included (9 males and 4 females). All the UVJ stenoses were diagnosed with preoperative ultrasound, CT scan, MRI, or urethrography. The mean age was 45 years (range 34-57 years). The mean preope-rative serum creatinine was 243 μmol/L. Four patients developed UVJ stenosis 1 month after kidney transplantation, while the rest developed long-term stenosis. Fifteen operations were performed in all, of which 14 cases were successful while one failed. The first 8 cases received first-stage nephrostomy and second-stage endoscopic management of the stenosis, while the last 7 cases received the same session surgery. The mean operation time was 95.4 min vs. 68.9 min, and the immediate success rate was 87.5% vs. 100.0% in the first 8 cases and last 7 cases, respectively. The mean decrease of postoperative hemoglobin was 0.6 g/L and mean postoperative serum creatinine was 105 μmol/L. No postoperative fever, severe hematuria, and urine leak were observed. The mean postoperative hospital stay was 2.8 days. Three patients were able to remove ureteral stents and no recurrence was found with a follow-up time of 9, 17, and 82 months. The long-term stenosis recurrence rate was 76.9% (10/13).Conclusion: Endoscopic approach for the treatment of UVJ stenosis in patients with kidney transplantation was safe and efficient in our study cohort. However, long term stenosis recurrence rate was high and needed to be paid attention to.

Key words: Kidney transplantation, Ureteral obstruction, Anastomosis, surgical, Postoperative complications

中图分类号:

R693

马凯,曲星珂,许清泉,熊六林,叶雄俊,安立哲,陈伟男,黄晓波. 肾移植术后移植肾输尿管膀胱吻合口狭窄的腔内治疗:13例报道[J]. 北京大学学报（医学版）, 2019, 51(6): 1155-1158.

Kai MA,Xing-ke QU,Qing-quan XU,Liu-lin XIONG,Xiong-jun YE,Li-zhe AN,Wei-nan CHEN,Xiao-bo HUANG. Endoscopic treatment for ureterovesical junction stenosis in patients with kidney transplantation: 13 cases report[J]. Journal of Peking University(Health Sciences), 2019, 51(6): 1155-1158.

图/表 1

表1

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No.	Age	Gender	Time to stricture/month	Operation methods	Follow-up
1	34	Male	8	Staged procedures	Healed (without stent)
2	48	Female	25	Staged procedures	Periodic stent changes
3	45	Male	1	Staged procedures	Periodic drainage of nephrostomy changes
4	42	Female	28	Staged procedures	Periodic stent changes
5^*	45	Male	18	Staged procedures	Healed after open operation
6^#	36	Female	37	Staged procedures	Periodic stent changes
7	41	Male	1	Staged procedures	Periodic stent changes
8	57	Male	17	Staged procedures	Healed (without stent)
9	55	Male	110	Simultaneous procedures	Healed after open operation
10	43	Female	0.5	Simultaneous procedures	Periodic drainage of nephrostomy changes
11^#	40	Male	0.5	Simultaneous procedures	Periodic stent changes
12	54	Male	9	Simultaneous procedures	Healed (without stent)
13	43	Male	8	Simultaneous procedures	Periodic stent changes