小兒重腎31例分析

北京醫學(xué)2003年第25卷第2期小兒重腎31例分析郝春生葉輝梁廷臣谷奇【摘要】目的探討小兒重腎的診斷及治療。方法對我院1989~2001年收治的31例小兒重腎進(jìn)行回顧性分析。結果31例中有23例患兒接受26次手術(shù)有16例行上半重腎及輸尿管切除其中有2例須處理輸尿管殘端及盲袋所致的梗阻。22例手術(shù)后恢復較好僅1例伴有輕度的尿失禁。結論對于重腎伴腎積水或發(fā)育不良所致的各種臨床表現應首先考慮做上半腎及輸尿管大部切除術(shù)。B超、CT及靜脈腎盂造影術(shù)IVP診斷分型有意義【關(guān)鍵詞】重腎小兒臨床表現治療Analysis of duplex kidney in 31 childrenHao Chunsheng , Ye hui Liang Tingchen net alDepartment of Pediatric Surgery Capital Institute of Pediatrics Beijing 100020[Abstract] Objective To explore the diagnosis and treatment of duplex kidney in children by analyzing 31 casesMethods There were 31 children with duplex kidney within 12 years of them 26 cases were females 5 cases were malesClinical manifestation included urological tract infection with 11 cases( 35. 48%), obstruction and prolapse of ureterocelewith 8 cases( 25. 81%), urinary incontinence with 6 cases(19. 35%), hematureria with 3 case( 9. 68%),abdominalhass with 2 case( 6. 45% )and urinary frequency with 1 cased 3. 23% )respectively. There were 23 cases receiving 26 operations of which, 16 cases receiving upper pole moiety and partial urinary tract excision. After operation there were twocases requiring further operation to relieve obstruction caused by stump Results 22 cases recovered uneventfuleration except one case with slight incontinence. Conclusions Upper pole heminephrectomy should be considered first indealing with duplex kidney combining with poor or nonfunctioning upper moieties. B-ultrosound, IVP and contrast-enhanced decomputerized tomography are helpful to diagnosis[ Key words Duplex kidney Children clinical presentation Treatment我院于1989~2001年收治小兒重腎31例其脈腎盂造影術(shù)(IvP)肭29例中明確診斷26例因中23例患兒接受26次手術(shù)取得較好療效報告如上半重腎功能不同影像學(xué)表現為顯影良好可區別下上下半腎及輸尿管走行或上半腎積水顯影延遲顯資料與方法影的腎向外下方移位呈花朵萎重樣改變,診斷符合率為89.66%。進(jìn)行增強CT檢査的14例中明確診般資料斷13例診斷符合率為92.88%其中漏診1例術(shù)本組31例其中男5例,女26例平均年齡5后確診為三重腎合并腎發(fā)育不良。歲,<1歲者9例,1~13歲者22例。左側重腎931例中有8例未做手術(shù)其中4例僅表現為單例右側重腎11例雙側重腎11例。主要臨床表現側或雙側重腎Y型輸尿管無(wú)其他合并癥另4例分為泌尿系感染,如發(fā)熱腹痛、尿痛及膿尿11例別合并輕度的上半督積水泳尿系感染、腎發(fā)育不良35.48%),重腎伴輸尿管末端膨出8例及正中國煤化絕手術(shù)要求觀(guān)察。23(25.81%)表現為排尿困難或尿道口腫物脫垂重例患CNMHG腎伴輸尿管開(kāi)口異位619.35%)臨床表現為正治療方法常排尿間有濕褲、血尿3例9.68%)腹部腫物2例重腎伴上腎單位輸尿管末端膨出16例,有11(6.45%及尿頻1例3.23%)術(shù)前B超檢查的28例中明確疹耨列診斷符合率為89.29%。做靜首都兒科研究所附屬兒童醫院外科郵編10020)北京醫學(xué)2003年第25卷第2期例因上腎單位重度積水、輸尿管擴張而行上腎單位擇手術(shù)方式有益。及輸尿管大部切除殘端吸凈中有2例為雙側重治療腎、雙輸尿管未端膨出,例在術(shù)后1個(gè)月行對側輸對重腎畸形無(wú)臨床表現的可隨訪(fǎng)觀(guān)察。對重腎尿管末端膨岀開(kāi)窗術(shù)另1例術(shù)后1周因排尿困難上腎單位腎盂及輸尿管重度積水或發(fā)育不良、輸尿在尿道膀胱鏡下行輸尿管殘端部分切除漸岀現尿管未端膨岀合并泌尿系感染及排尿困難的在合理線(xiàn)細于術(shù)后6個(gè)月復診因對側上腎單位輕度積水應用抗生素的同時(shí),可做上半腎及輸尿管大部切除而行重復輸尿管部分切除膀胱輸尿管再吻合。其余術(shù)。對于輸尿管殘端術(shù)中應吸凈殘液、縫合殘端并5例分別為:1例增強CT提示上半腎單位功能較下長(cháng)期觀(guān)察如有殘端膨大引起尿道梗阻則考慮經(jīng)膀半腎好而行輸尿管末端膨岀開(kāi)窗手術(shù);3例為上半胱行囊腫切除。這是本組的主要手術(shù)方法其優(yōu)點(diǎn)單位輕度積水行輸尿管末端膨岀切除膀胱輸尿是徹底消除了梗阻所致的感染及積水加重缺點(diǎn)是管再吻合江例因上下半腎積水腎皮質(zhì)呈多囊性輸尿管殘端膨大引起尿道梗阻需要再次手術(shù)。文變行腎切除術(shù)后病理診斷冼天性多囊腎。劇23報道認為應首選患側上半腎及輸尿管大部切重腎并輸尿管開(kāi)口異位5例。其中3例因上半除。對重腎上下半腎無(wú)功能或功能不良合并先天性腎單位重度積水而行上半腎單位及輸尿管大部切多囊腎者可考慮行患側腎切除。對重腎上腎單位無(wú)除沮例為腹腔鏡探査手術(shù)術(shù)中診斷為三重腎發(fā)育或輕度腎盂及輸尿管積水并輸尿管末端膨岀者可不良切除發(fā)育不良的腎;例因無(wú)腎積水、腎功能考慮行輸尿管末端膨岀切除、輸尿管膀胱再吻合或良好而行異位輸尿管膀胱再吻合。輸尿管囊腫去頂術(shù)。這些手術(shù)方法較前者相比因重腎上腎單位重度積水1例行上半腎及輸尿其有膀胱輸尿管反流所致的感染及積水加重,二次管切除。重腎術(shù)后(外院手術(shù)腧輸尿管殘端梗阻行手術(shù)率較高231但對于嬰幼兒此法可使部分患兒輸尿管殘端切除。腎功能得到改善延緩腎切除同時(shí)經(jīng)膀胱鏡手術(shù)結果打擊小可作為首選方法4。國外也有報道行重腎輸尿管一輸尿管再吻合來(lái)保留重腎的功能5616例上腎單位及輸尿管大部切除的患兒中15對于重腎并輸尿管開(kāi)口異位如果上半腎單位例術(shù)后恢復較好排尿困難或泌尿系感染消失其中重度積水或發(fā)育不良可行上半腎單位及輸尿管大部8例隨訪(fǎng)1周~2年僅有4例B超表現為膀胱內低切除憚側重腎并發(fā)育不良切除發(fā)育不良的腎;對張力囊腫無(wú)泌尿系感染征象。另1例雙側重腎雙于無(wú)或輕中度腎積水、腎功能良好可行異位輸尿管輸尿管末端膨岀的患兒術(shù)后1年半岀現輕度尿失膀胱再吻合或上下腎部輸尿管端側吻合。禁考慮與膀胱頸及尿道肌層發(fā)育不良有關(guān)家長(cháng)拒參考文獻絕進(jìn)一步治療。5例重腎并輸尿管開(kāi)囗異位的患1. Avni Fe Nicaise N H1 M et al. The role of mr imaging for the as-兒術(shù)后滴尿癥狀消失其中3例隨訪(fǎng)半年~1年無(wú)sessment of complicated duplex kidneys in children. Pediatr Radiol滴尿癥狀。重腎上腎單位重度積水1例術(shù)后腹部腫物及泌尿系感染消失失訪(fǎng)。輸尿管殘端梗阻1例2, Husmann D Strand B Ewalt D et al. Management of ectopic ureter術(shù)后排尿正常失訪(fǎng)。le associated with renal duplication ' a comprison of partial nephrotomy and endoscopic decopression. J Urol 1999, 162: 1406-1409討論3. Vates TS, Bukowski T Triest J ret al. Is there a best alternative一、診斷treating the obstructed upper pole J Urol, 1996, 156 744-746結合重腎的主要臨床表現B超、ⅣVP檢查多能 etit I avasse P delmas P. Does the endoscopIc incision of ureterceles reduce the indications for partial nephrectomy BJU Int, 1999提供重腎、輸尿管的形態(tài)及是否有積水等變化B超中國煤化工在腎功能不良、顯影久佳或不顯影時(shí)尤為重要。如chCNMHGcomplete ureterIc果診斷困難可考慮做增強CT或術(shù)中造影協(xié)助診dMae use O uretero-ureterostomy as a primary and sal-斷。本組23例手術(shù)患兒僅2例術(shù)前未能確診。文vage procedure BUI Int 2000 $6 508-512獻1報道MRI對常規影像學(xué)檢查未能顯影者可提6 Sen s ahmed s borghol M. Surgical management of complete ureter-供詳細的愛(ài)雅這對于明確木前診斷術(shù)前選ic duplication abnormalities. Pediatr Surg Int 1998, 13 61-64(收稿200207-10)