McAleer I M, Kaplan G W
Department of Urology, Children's Hospital and Health Center, San Diego, California, USA.
J Urol. 1999 Sep;162(3 Pt 2):1041-4. doi: 10.1016/S0022-5347(01)68059-5.
Controversy exists concerning the timing of surgical correction of presumed ureteropelvic junction obstruction. Different opinions on the timing of intervention focus on renal function deterioration with time, poor initial relative function, or obstructive drainage curves and/or drainage time on diuretic renography. We retrospectively determined whether there is any improvement in renal function after pyeloplasty for presumed renal obstruction.
We retrospectively reviewed the charts of patients who underwent pyeloplasty between 1990 and 1997 in whom preoperative and postoperative diuretic renography data were available. Patients were excluded from review when they had bilateral ureteropelvic junction obstruction, a solitary kidney, associated vesicoureteral reflux, or other bladder or ureteral abnormalities, and when preoperative and postoperative renography studies were not available.
Complete data were available for review in 79 patients 2 weeks to 18 years old (median age 6 months). Of the patients 73% were male and 73% of the affected kidneys were on the left side. Prenatal hydronephrosis had been diagnosed in 58 patients (73%), of whom 19 (33%) were observed for a variable period before pyeloplasty was performed. In all cases diuretic renography performed at the same institution using a standard protocol revealed a drainage time of 20 minutes or greater preoperatively, while in 58 cases a measurable drainage time was never achieved. As a rule, drainage improved postoperatively (mean and median 25 and 16 minutes, respectively). Open renal biopsy done at pyeloplasty in 54 patients was normal in 29. Preoperatively renal function ranged from 5 to 67% (mean and median 41 and 45, respectively). In all patients the paired t test showed no statistical difference in preoperative and postoperative renal function (p = 0.078, 95% confidence interval -3.451 to 0.185). There was no statistical change in renal function in patients with an abnormal renal biopsy regardless of the severity of renal scarring (p = 0.38) or when renal function was 40% or less (mean preoperative versus postoperative 29.7 versus 28.4%, p = 0.46). The group with greater than 40% function preoperatively had no relevant difference in function before or after surgery (mean 49.7 versus 47.8%, p = 0.065). Prenatally screened patients who were initially observed had a statistically significant difference in renal function before and after pyeloplasty (mean 45.6 versus 43%, p = 0.002).
Renal function did not improve after pyeloplasty regardless of the initial level of relative function. Renal scan revealed that differential function decreased after pyeloplasty in some patients in whom hydronephrosis was detected prenatally and who were initially followed with observation. In our opinion waiting for renal function to decrease before considering pyeloplasty is not warranted, since function does not improve even when obstruction is corrected and drainage time improves.
关于推测性肾盂输尿管连接部梗阻的手术矫正时机存在争议。关于干预时机的不同观点集中在肾功能随时间的恶化、初始相对功能较差，或利尿肾图上的梗阻引流曲线和/或引流时间。我们回顾性地确定了推测性肾梗阻行肾盂成形术后肾功能是否有任何改善。
我们回顾性地查阅了1990年至1997年间接受肾盂成形术且有术前和术后利尿肾图数据的患者病历。当患者有双侧肾盂输尿管连接部梗阻、孤立肾、合并膀胱输尿管反流或其他膀胱或输尿管异常，以及没有术前和术后肾图研究时，将其排除在回顾范围之外。
共有79例年龄在2周至18岁（中位年龄6个月）的患者有完整数据可供回顾。患者中73%为男性，73%的患侧肾脏在左侧。58例（73%）患者产前诊断为肾积水，其中19例（33%）在进行肾盂成形术前观察了不同时间段。在所有病例中，同一机构使用标准方案进行的利尿肾图显示术前引流时间为20分钟或更长，而58例患者从未获得可测量的引流时间。通常，术后引流得到改善（平均和中位引流时间分别为25分钟和16分钟）。54例患者在肾盂成形术时进行的开放性肾活检，29例结果正常。术前肾功能范围为5%至67%（平均和中位分别为41%和45%）。所有患者的配对t检验显示术前和术后肾功能无统计学差异（p = 0.078，95%置信区间为-3.451至0.185）。肾活检异常的患者，无论肾瘢痕严重程度如何（p = 0.38），或肾功能为40%或更低时（术前平均与术后平均分别为29.7%与28.4%，p = 0.46），肾功能均无统计学变化。术前功能大于40%的组术前和术后功能无相关差异（平均49.7%与47.8%，p = 0.065）。产前筛查并最初观察的患者肾盂成形术前和术后肾功能有统计学显著差异（平均45.6%与43%，p = 0.002）。
无论初始相对功能水平如何，肾盂成形术后肾功能均未改善。肾扫描显示，在一些产前检测到肾积水且最初进行观察的患者中，肾盂成形术后差异功能下降。我们认为，在考虑肾盂成形术前等待肾功能下降是没有必要的，因为即使梗阻得到纠正且引流时间改善，功能也不会改善。
