肾移植术后瘘管及输尿管狭窄的治疗。

Li Marzi V, Filocamo M T, Dattolo E, Zanazzi M, Paoletti M C, Marzocco M, Villari D, Salvadori M, Nicita G

Department of Urology II, Florence University, Florence, Italy.

Transplant Proc. 2005 Jul-Aug;37(6):2516-7. doi: 10.1016/j.transproceed.2005.06.049.

INTRODUCTION

The incidence of urological complications after kidney transplantation varies from 3% to 14%, with a probable loss of the graft in 10% to 15% of cases and a mortality rate of up to 15%, despite improvements in prevention, diagnosis, and treatment as well as the use of new immunosuppressive therapies. Urinous fistulae, which are considered early complications of transplantation, are due to ischemic damage or necrosis generally occurring in the distal third of the ureter. Preservation of accessory arteries to the lower portion of the kidney is important, as they may constitute the blood supply of this segment of the collecting system or ureter. Their ligation may lead to necrosis and urinary fistulae. Ureteral stenosis, as late complication, is related to a pathology of the ureter itself, to infections, to abscesses, to fibrosis, and to ischemia. An early endoscopic approach permits resolution in 70% of cases. The aim of this retrospective study was to determine incidence and treatment of these complications.

MATERIALS AND METHODS

From 1991 to 2004 we performed 453 kidney transplantations both from cadaveric and living donors. In 199 patients we performed a transvesical ureteroneocystostomy (UNCS), and in 260, an extravesical UNCS.

RESULTS

The nine patients who showed fistulae (1.9%) underwent surgical treatment. In eight we used a direct ureteral reimplantation, and in one, a Boari flap technique. Nephrectomy was necessary in four patients, including two who died of septic complications. In all 26 cases of ureteral stenosis (5.6%), we used an endourological approach (anterograde or retrograde), with surgical treatment afterward in 11 patients (42%) nine direct reimplants, one anastomosis to the native ureter (transplantation from a living donor), and in one case a Boari flap technique four patients who underwent surgical treatment showed progressive damage to graft function.

CONCLUSIONS

In all patients who showed fistulae we suggest surgical review: for patients with ureteral stenosis, we suggest first an endourological approach and only when it is not successful do we consider surgical treatment.

引言

尽管在预防、诊断和治疗方面有所改进，以及使用了新的免疫抑制疗法，但肾移植后泌尿系统并发症的发生率仍在3%至14%之间，10%至15%的病例可能会失去移植肾，死亡率高达15%。尿瘘被认为是移植的早期并发症，通常是由于输尿管远端三分之一处发生缺血性损伤或坏死所致。保留肾脏下部的副动脉很重要，因为它们可能构成该段集合系统或输尿管的血液供应。结扎它们可能导致坏死和尿瘘。输尿管狭窄作为晚期并发症，与输尿管本身的病变、感染、脓肿、纤维化和缺血有关。早期内镜治疗在70%的病例中可使病情得到缓解。这项回顾性研究的目的是确定这些并发症的发生率和治疗方法。

材料与方法

1991年至2004年，我们对453例尸体供体和活体供体进行了肾移植。199例患者采用经膀胱输尿管膀胱吻合术（UNCS），260例采用膀胱外UNCS。

结果

9例出现尿瘘的患者（1.9%）接受了手术治疗。8例采用直接输尿管再植术，1例采用Boari皮瓣技术。4例患者需要进行肾切除术，其中2例死于败血症并发症。在所有26例输尿管狭窄患者（5.6%）中，我们采用了腔内泌尿外科方法（顺行或逆行），随后11例患者（42%）接受了手术治疗，9例直接再植术，其中1例与自体输尿管吻合（活体供体移植），1例采用Boari皮瓣技术。4例接受手术治疗的患者显示移植肾功能逐渐受损。