小儿重肾31例分析

北京医学2003年第25卷第2期小儿重肾31例分析郝春生叶辉梁廷臣谷奇【摘要】目的探讨小儿重肾的诊断及治疗。方法对我院1989~2001年收治的31例小儿重肾进行回顾性分析。结果31例中有23例患儿接受26次手术有16例行上半重肾及输尿管切除其中有2例须处理输尿管残端及盲袋所致的梗阻。22例手术后恢复较好仅1例伴有轻度的尿失禁。结论对于重肾伴肾积水或发育不良所致的各种临床表现应首先考虑做上半肾及输尿管大部切除术。B超、CT及静脉肾盂造影术IVP诊断分型有意义【关键词】重肾小儿临床表现治疗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年收治小儿重肾31例其脉肾盂造影术(IvP)肭29例中明确诊断26例因中23例患儿接受26次手术取得较好疗效报告如上半重肾功能不同影像学表现为显影良好可区别下上下半肾及输尿管走行或上半肾积水显影延迟显资料与方法影的肾向外下方移位呈花朵萎重样改变,诊断符合率为89.66%。进行增强CT检査的14例中明确诊般资料断13例诊断符合率为92.88%其中漏诊1例术本组31例其中男5例,女26例平均年龄5后确诊为三重肾合并肾发育不良。岁,<1岁者9例,1~13岁者22例。左侧重肾931例中有8例未做手术其中4例仅表现为单例右侧重肾11例双侧重肾11例。主要临床表现侧或双侧重肾Y型输尿管无其他合并症另4例分为泌尿系感染,如发热腹痛、尿痛及脓尿11例别合并轻度的上半督积水泳尿系感染、肾发育不良35.48%),重肾伴输尿管末端膨出8例及正中国煤化绝手术要求观察。23(25.81%)表现为排尿困难或尿道口肿物脱垂重例患CNMHG肾伴输尿管开口异位619.35%)临床表现为正治疗方法常排尿间有湿裤、血尿3例9.68%)腹部肿物2例重肾伴上肾单位输尿管末端膨出16例,有11(6.45%及尿频1例3.23%)术前B超检查的28例中明确疹耨列诊断符合率为89.29%。做静首都儿科研究所附属儿童医院外科邮编10020)北京医学2003年第25卷第2期例因上肾单位重度积水、输尿管扩张而行上肾单位择手术方式有益。及输尿管大部切除残端吸净中有2例为双侧重治疗肾、双输尿管未端膨出,例在术后1个月行对侧输对重肾畸形无临床表现的可随访观察。对重肾尿管末端膨岀开窗术另1例术后1周因排尿困难上肾单位肾盂及输尿管重度积水或发育不良、输尿在尿道膀胱镜下行输尿管残端部分切除渐岀现尿管未端膨岀合并泌尿系感染及排尿困难的在合理线细于术后6个月复诊因对侧上肾单位轻度积水应用抗生素的同时,可做上半肾及输尿管大部切除而行重复输尿管部分切除膀胱输尿管再吻合。其余术。对于输尿管残端术中应吸净残液、缝合残端并5例分别为:1例增强CT提示上半肾单位功能较下长期观察如有残端膨大引起尿道梗阻则考虑经膀半肾好而行输尿管末端膨岀开窗手术;3例为上半胱行囊肿切除。这是本组的主要手术方法其优点单位轻度积水行输尿管末端膨岀切除膀胱输尿是彻底消除了梗阻所致的感染及积水加重缺点是管再吻合江例因上下半肾积水肾皮质呈多囊性输尿管残端膨大引起尿道梗阻需要再次手术。文变行肾切除术后病理诊断冼天性多囊肾。劇23报道认为应首选患侧上半肾及输尿管大部切重肾并输尿管开口异位5例。其中3例因上半除。对重肾上下半肾无功能或功能不良合并先天性肾单位重度积水而行上半肾单位及输尿管大部切多囊肾者可考虑行患侧肾切除。对重肾上肾单位无除沮例为腹腔镜探査手术术中诊断为三重肾发育或轻度肾盂及输尿管积水并输尿管末端膨岀者可不良切除发育不良的肾;例因无肾积水、肾功能考虑行输尿管末端膨岀切除、输尿管膀胱再吻合或良好而行异位输尿管膀胱再吻合。输尿管囊肿去顶术。这些手术方法较前者相比因重肾上肾单位重度积水1例行上半肾及输尿其有膀胱输尿管反流所致的感染及积水加重,二次管切除。重肾术后(外院手术腧输尿管残端梗阻行手术率较高231但对于婴幼儿此法可使部分患儿输尿管残端切除。肾功能得到改善延缓肾切除同时经膀胱镜手术结果打击小可作为首选方法4。国外也有报道行重肾输尿管一输尿管再吻合来保留重肾的功能5616例上肾单位及输尿管大部切除的患儿中15对于重肾并输尿管开口异位如果上半肾单位例术后恢复较好排尿困难或泌尿系感染消失其中重度积水或发育不良可行上半肾单位及输尿管大部8例随访1周~2年仅有4例B超表现为膀胱内低切除惮侧重肾并发育不良切除发育不良的肾;对张力囊肿无泌尿系感染征象。另1例双侧重肾双于无或轻中度肾积水、肾功能良好可行异位输尿管输尿管末端膨岀的患儿术后1年半岀现轻度尿失膀胱再吻合或上下肾部输尿管端侧吻合。禁考虑与膀胱颈及尿道肌层发育不良有关家长拒参考文献绝进一步治疗。5例重肾并输尿管开囗异位的患1. Avni Fe Nicaise N H1 M et al. The role of mr imaging for the as-儿术后滴尿症状消失其中3例随访半年~1年无sessment of complicated duplex kidneys in children. Pediatr Radiol滴尿症状。重肾上肾单位重度积水1例术后腹部肿物及泌尿系感染消失失访。输尿管残端梗阻1例2, Husmann D Strand B Ewalt D et al. Management of ectopic ureter术后排尿正常失访。le associated with renal duplication ' a comprison of partial nephrotomy and endoscopic decopression. J Urol 1999, 162: 1406-1409讨论3. Vates TS, Bukowski T Triest J ret al. Is there a best alternative一、诊断treating the obstructed upper pole J Urol, 1996, 156 744-746结合重肾的主要临床表现B超、ⅣVP检查多能 etit I avasse P delmas P. Does the endoscopIc incision of ureterceles reduce the indications for partial nephrectomy BJU Int, 1999提供重肾、输尿管的形态及是否有积水等变化B超中国煤化工在肾功能不良、显影久佳或不显影时尤为重要。如chCNMHGcomplete ureterIc果诊断困难可考虑做增强CT或术中造影协助诊dMae use O uretero-ureterostomy as a primary and sal-断。本组23例手术患儿仅2例术前未能确诊。文vage procedure BUI Int 2000 $6 508-512献1报道MRI对常规影像学检查未能显影者可提6 Sen s ahmed s borghol M. Surgical management of complete ureter-供详细的爱雅这对于明确木前诊断术前选ic duplication abnormalities. Pediatr Surg Int 1998, 13 61-64(收稿200207-10)