成人肾积水病因分析：一项单中心横断面研究

doi:10.19723/j.issn.1671-167X.2024.05.025

摘要/Abstract

摘要：

目的: 探究成人上尿路梗阻引起肾积水的病因分布，以提高其病因学诊断的准确性。方法: 连续前瞻性收集2020年5月至2021年5月北京大学第一医院上尿路修复专业门诊新诊治的767例成人肾积水患者的临床信息，排除输尿管结石、上尿路肿瘤患者，分析成人肾积水病因。患者的肾积水病因根据其症状、病史、体格检查、超声、计算机断层扫描(computed tomography, CT)、磁共振成像(magnetic resonance imaging, MRI)、逆行肾盂造影、顺行肾盂造影、放射性核素肾图、输尿管镜检查等综合判断。结果: 767例成人肾积水患者中男性359例(46.8%)、女性408例(53.2%)，中位年龄37岁(范围14~84岁)，左侧肾积水357例(46.6%)、右侧肾积水251例(32.7%)、双侧肾积水159例(20.7%)。病因分布如下：(1) 非医源性因素464例(60.5%)，包括泌尿系统畸形355例(76.5%)、感染29例(6.3%)、盆腔脂肪增多症和(或)腺性膀胱炎23例(5.0%)、输尿管子宫内膜异位症18例(3.9%)、腹膜后纤维化15例(3.2%)、肾盂旁囊肿8例(1.7%)、外伤7例(1.5%)，其他非医源性因素12例(2.6%)，部分患者合并两种或两种以上非医源性病因。355例泌尿系统畸形的患者中，肾盂输尿管连接部狭窄252例(71.0%)。(2)医源性输尿管损伤210例(27.4%)，其中泌尿外科操作损伤112例(53.3%)，恶性肿瘤放疗损伤51例(24.3%)，妇产科手术损伤34例(16.2%)，普外科手术损伤13例(6.2%)。(3)原因不明的肾积水93例(12.1%)。结论: 成人上尿路梗阻引起肾积水的病因复杂多样，泌尿系统畸形和医源性输尿管损伤是导致成人肾积水的常见原因，从事上尿路修复工作的泌尿外科医生应熟悉每一种病因，以便明确诊断并选择出最合适的治疗方案。

关键词: 肾积水, 上尿路梗阻, 病因学分析

Abstract:

Objective: To investigate the etiological distribution of hydronephrosis caused by upper urinary tract obstruction in adult patients and to improve the diagnostic accuracy for this condition. Methods: The clinical information of adult patients with newly diagnosed hydronephrosis in Upper Urinary Tract Repair Outpatient Clinic of Peking University First Hospital from May 2020 to May 2021 were prospectively and continuously collected. Patients with ureteral calculi or upper urinary tract tumor were excluded. A total of 767 patients were involved. The underlying causes of upper urinary tract obstruction were identified by senior urological surgeons according to symptoms, medical history, physical examination, and a range of diagnostic imaging techniques including ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), retrograde pyelography, antegrade pyelography, radionuclide renogram and ureteroscopy. Results: Among the 767 patients, 359(46.8%) were male and 408(53.2%) were female. The median age of these patients was 37 years (range, 14-84 years). Hydronephrosis was observed at left-sided in 357 cases(46.6%), right-sided in 251 cases(32.7%), and bilateral in 159 cases(20.7%). The causes of hydronephrosis were classified as follows: (1) Non-iatrogenic factors were found in 464 cases (60.5%). These included urinary malformations in 355 cases(76.5%), infection in 29 cases(6.3%), pelvic lipomatosis and/or cystitis glandularis in 23 cases(5.0%), ureteral endometriosis in 18 cases(3.9%), retroperitoneal fibrosis in 15 cases(3.2%), trauma in 7 cases(1.5%) and other non-iatrogenic factors in 12 cases(2.6%). Some of these patients had multiple non-iatrogenic causes. Among the 355 cases with urinary system malformations, 252 cases (71.0%) had ureteropelvic junction obstruction. (2) Iatrogenic ureteral injuries accounted for 210 cases (27.4%), including 112 cases(53.3%) of urological surgical injuries, 51 cases(24.3%) of radiotherapy for malignant tumor related injuries, 34 cases(16.2%) of gynecological and obstetrical surgical injuries, and 13 cases(6.2%) of general surgical injuries. (3) The cause of hydronephrosis remained unknown in 93 cases(12.1%). Conclusion: Hydronephrosis in adults due to upper urinary tract obstruction has a diverse range of causes, with urinary malformations and iatrogenic ureteral injuries being significant contributors. Urological surgeon involved in upper urinary tract reconstruction should be familiar with these potential causes to facilitate accurate diagnosis and effective treatment.

Key words: Hydronephrosis, Upper urinary tract obstruction, Etiological analysis

中图分类号:

R692.3

陈思鹭, 王海菊, 吴宇财, 李志华, 黄燕波, 何宇辉, 许洋洋, 李学松, 贯华. 成人肾积水病因分析：一项单中心横断面研究[J]. 北京大学学报（医学版）, 2024, 56(5): 913-918.

Silu CHEN, Haiju WANG, Yucai WU, Zhihua LI, Yanbo HUANG, Yuhui HE, Yangyang XU, Xuesong LI, Hua GUAN. Etiological analysis of hydronephrosis in adults: A single-center cross-sectional study[J]. Journal of Peking University (Health Sciences), 2024, 56(5): 913-918.

图/表 3

表1

表2

表3

参考文献 24

1	张晓娥, 徐虹, 毕允力, 等. 单中心6年先天性肾脏和尿道畸形病因构成分析[J]. 中国循证儿科杂志, 2012, 7 (4): 263- 268.
2	Panthier F , Lareyre F , Audouin M , et al. Pelvi-ureteric junction obstruction related to crossing vessels: Vascular anatomic variations and implication for surgical approaches[J]. Int Urol Nephrol, 2018, 50 (3): 385- 394. doi: 10.1007/s11255-017-1771-z
3	郑蒙蒙, 丁光璞, 朱伟杰, 等. 术前三维影像重建在治疗肾盂输尿管连接部梗阻中的应用[J]. 北京大学学报(医学版), 2020, 52 (4): 705- 710. doi: 10.19723/j.issn.1671-167X.2020.04.021
4	Sanna-Cherchi S , Westland R , Ghiggeri G M , et al. Genetic basis of human congenital anomalies of the kidney and urinary tract[J]. J Clin Invest, 2018, 128 (1): 4- 15. doi: 10.1172/JCI95300
5	江柳, 许玉峰, 唐光健. 肾结核与非结核梗阻性肾积水形态差异的影像研究[J]. 中华放射学杂志, 2018, 52 (12): 923- 926.
6	Chen Y , Yang Y , Yu W , et al. Urodynamic characteristics of pelvic lipomatosis with glandular cystitis patients correlate with morphologic alterations of the urinary system and disease severity[J]. Neurourol Urodyn, 2018, 37 (2): 758- 767. doi: 10.1002/nau.23343
7	Zhang Y , Wu S , Xi Z , et al. Measuring diagnostic accuracy of imaging parameters in pelvic lipomatosis[J]. Eur J Radiol, 2012, 81 (11): 3107- 3114. doi: 10.1016/j.ejrad.2012.05.031
8	Bai X , Zhang G , Xu L , et al. Diagnostic accuracy of CT imaging parameters in pelvic lipomatosis[J]. Abdom Radiol (NY), 2021, 46 (6): 2779- 2788. doi: 10.1007/s00261-020-02946-0
9	唐天虹, 苏娜, 孙伟, 等. 盆腔脂肪增多症的超声诊断及漏误诊原因分析[J]. 中华超声影像学杂志, 2020, 29 (4): 359- 360.
10	Barra F , Scala C , Biscaldi E , et al. Ureteral endometriosis: A systematic review of epidemiology, pathogenesis, diagnosis, treatment, risk of malignant transformation and fertility[J]. Hum Reprod Update, 2018, 24 (6): 710- 730. doi: 10.1093/humupd/dmy027
11	Yang K , Cheng S , Cai Y , et al. Clinical characteristics and surgical treatment of ureteral endometriosis: our experience with 40 cases[J]. BMC Womens Health, 2021, 21 (1): 206. doi: 10.1186/s12905-021-01349-7
12	Vaglio A , Palmisano A , Alberici F , et al. Prednisone versus tamoxifen in patients with idiopathic retroperitoneal fibrosis: An open-label randomised controlled trial[J]. Lancet, 2011, 378 (9788): 338- 346. doi: 10.1016/S0140-6736(11)60934-3
13	Vaglio A , Maritati F . Idiopathic retroperitoneal fibrosis[J]. J Am Soc Nephrol, 2016, 27 (7): 1880- 1889. doi: 10.1681/ASN.2015101110
14	Bakir B , Yilmaz F , Turkay R , et al. Role of diffusion-weighted MR imaging in the differentiation of benign retroperitoneal fibrosis from malignant neoplasm: Preliminary study[J]. Radiology, 2014, 272 (2): 438- 445. doi: 10.1148/radiol.14131565
15	Moroni G , Castellani M , Balzani A , et al. The value of (18)F-FDG PET/CT in the assessment of active idiopathic retroperitoneal fibrosis[J]. Eur J Nucl Med Mol Imaging, 2012, 39 (10): 1635- 1642. doi: 10.1007/s00259-012-2144-6
16	Gild P , Kluth LA , Vetterlein MW , et al. Adult iatrogenic ureteral injury and stricture-incidence and treatment strategies[J]. Asian J Urol, 2018, 5 (2): 101- 106. doi: 10.1016/j.ajur.2018.02.003
17	Tonolini M , Villa F , Ippolito S , et al. Cross-sectional imaging of iatrogenic complications after extracorporeal and endourological treatment of urolithiasis[J]. Insights Imaging, 2014, 5 (6): 677- 689. doi: 10.1007/s13244-014-0355-z
18	Lebentrau S , Muller PF , Miernik A , et al. Risk factors for ureteral damage in rreteroscopic stone treatment: Results of the german prospective multicentre benchmarks of ureterorenoscopic stone treatment-results in terms of complications, quality of life, and stone-free rates project[J]. Urol Int, 2019, 102 (2): 187- 193.
19	熊盛炜, 杨昆霖, 丁光璞, 等. 输尿管损伤外科修复治疗的研究进展[J]. 北京大学学报(医学版), 2019, 51 (4): 783- 789. doi: 10.19723/j.issn.1671-167X.2019.04.034
20	Blackwell RH , Kirshenbaum EJ , Shah AS , et al. Complications of recognized and unrecognized iatrogenic ureteral injury at time of hysterectomy: A population based analysis[J]. J Urol, 2018, 199 (6): 1540- 1545.
21	Hird AE , Nica A , Coburn NG , et al. Does prophylactic ureteric stenting at the time of colorectal surgery reduce the risk of ureteric injury? A systematic review and meta-analysis[J]. Colorectal Dis, 2021, 23 (5): 1060- 1070.
22	Wit EM , Horenblas S . Urological complications after treatment of cervical cancer[J]. Nat Rev Urol, 2014, 11 (2): 110- 117.
23	Li F , Guo H , Qiu H , et al. Urological complications after radical hysterectomy with postoperative radiotherapy and radiotherapy alone for cervical cancer[J]. Medicine (Baltimore), 2018, 97 (13): e173.
24	Welk B , Wallis C , D'Souza D , et al. A population-based assessment of urologic procedures and operations after surgery or pelvic radiation for cervical cancer[J]. Int J Gynecol Cancer, 2018, 28 (5): 989- 995.

Metrics

Viewed

Full text

Abstract

Cited

Shared

Discussed

Items	Urinary malformation (n=355)	Infection (n=29)	Pelvic lipomatosis and/or cystitis glandularis (n=23)	Ureteral endometriosis (n=18)	Retroperitoneal fibrosis (n=15)	Parapelvic cyst (n=8)	Trauma (n=7)
Gender, n (%)
Male	186 (52.4)	10 (34.5)	22 (95.7)	0 (0.0)	7 (46.7)	2 (25.0)	7 (100.0)
Female	169 (47.6)	19 (65.5)	1 (4.3)	18 (100.0)	8 (53.3)	6 (75.0)	0 (0.0)
Age/years, M (P₂₅, P₇₅)	30 (24.0, 39.0)	35 (29.5, 51.5)	39 (34.0, 54.0)	44 (38.0, 50.0)	57 (46.0, 64.0)	60 (48.0, 68.0)	33 (18.0, 50.0)
Location, n (%)
Left	180 (50.7)	15 (51.7)	3 (13.0)	10 (55.6)	2 (13.3)	6 (75.0)	5 (71.4)
Right	110 (31.0)	11 (37.9)	2 (8.7)	7 (38.9)	4 (26.7)	2 (25.0)	2 (28.6)
Bilateral	65 (18.3)	3 (10.4)	18 (78.3)	1 (5.5)	9 (60.0)	0 (0)	0 (0.0)

Items	UPJO (n=252)	Ectopic vessel (n=35)	Megaureter (n=33)	Ureterostenosis (n=18)	Nephroptosis(n=17)	Duplex kidney (n=14)	Horse-shoe kidney (n=37)
Gender, n (%)
Male	140 (55.6)	19 (51.4)	12 (34.3)	16 (48.5)	2 (11.1)	5 (29.4)	6 (42.9)
Female	112 (44.4)	18 (48.6)	23 (65.7)	17 (51.5)	16 (88.9)	12 (70.6)	8 (57.1)
Age/years, M (P₂₅, P₇₅)	30 (23.0, 38.0)	32 (25.5, 39.5)	29 (20.0, 41.0)	39 (32.5, 56.5)	31 (25.0, 39.5)	34 (22.0, 38.5)	34 (24.0, 48.0)
Location, n (%)
Left	141 (55.9)	17 (46.0)	13 (37.1)	17 (51.5)	6 (33.3)	5 (29.4)	6 (42.9)
Right	70 (27.8)	16 (43.2)	14 (40.0)	12 (36.4)	9 (50.0)	8 (47.1)	5 (35.7)
Bilateral	41 (16.3)	4 (10.8)	8 (22.9)	4 (12.1)	3 (16.7)	4 (23.5)	3 (21.4)

Items	Urological operative injury (n=112)	Radiotherapy injury (n=51)	Gynecological and obstetrical surgical injury (n=34)	General surgical injury (n=13)
Gender, n (%)
Male	72 (64.3)	9 (17.6)	0 (0.0)	7 (53.8)
Female	40 (35.7)	42 (82.4)	34 (100.0)	6 (46.2)
Age/years, M (P₂₅, P₇₅)	43.5 (35.0, 57.0)	54 (48.0, 60.0)	48 (41.5, 53.0)	52 (33.5, 56.5)
Location, n (%)
Left	53 (47.3)	16 (31.4)	12 (35.3)	7 (53.8)
Right	52 (46.4)	7 (13.7)	12 (35.3)	4 (30.8)
Bilateral	7 (6.3)	28 (54.9)	10 (29.4)	2 (15.4)

[1]	王明瑞, 王起, 胡浩, 赖金惠, 唐鑫伟, 万春艳, 许克新, 徐涛. 覆膜金属输尿管支架治疗盆腔脂肪增多症所致肾积水的疗效[J]. 北京大学学报（医学版）, 2024, 56(5): 919-922.
[2]	秦彩朋,王飞,杜依青,张晓威,李清,刘士军,徐涛. 无症状无积水输尿管结石4例患者的诊治[J]. 北京大学学报（医学版）, 2023, 55(5): 939-942.