Hacker Hans-Walter, Szavay Philipp, Dittmann Helmut, Haber Hans-P, Fuchs Joerg
Abteilung für Kinderchirurgie, Universitaetsklinik für Kinder- und Jugendmedizin, Tübingen 72076, Germany.
Pediatr Surg Int. 2009 Jul;25(7):607-11. doi: 10.1007/s00383-009-2385-z. Epub 2009 Jun 6.
Most of the children with hydronephrosis do not require any surgical intervention. However, in individual cases, irreversible loss of renal function can develop. Predictive criteria have been proven ineffective so far in determining in which children obstruction will lead to renal damage. The aim of our retrospective study was to determine the role of a crossing lower pole vessel (CV) in children undergoing pyeloplasty.
Between 1996 and 2003, 137 patients (age between 6 weeks and 16 years) with unilateral ureteropelvic junction obstruction and no associated urological pathologies underwent Anderson-Hynes dismembered pyeloplasty. A total of 112 patients were evaluated with complete data. One of the following criteria was considered to be indication for surgery in children with grade 4 hydronephrosis: differential renal function (DRF) <40%; clinical symptoms such as pyolenephritis and flank pain; during follow-up renographies, a reduction of DRF >10% and washout patterns II or III b according to O'Reilly. We looked at the age during surgery and the kind of presentation. DRF was measured using diuretic renography preoperatively and 1 year postoperatively. A postoperative change in DRF of group A (children without CV, n = 84) was compared to that in group B (children with CV, n = 28).
Median age at the time of surgery was 5 months in group A compared to 23 months in group B. Only in 21.4% of the children with CV compared to 60.7% without CV hydronephrosis was diagnosed by ultrasound examination antenatally. We found a preoperative DRF of 42.4% +/- 11.2 SD in group A, and of 38.9% +/- 11.7 SD in group B. The percentage of postoperative improvement was 3.3% in group A and 15.4% in group B.
Children with ureteropelvic junction obstruction and CV received a delayed surgical treatment and showed a greater reduction in differential renal function preoperatively, in contrast to patients without CV. Our data show that CV is a risk factor for deterioration of renal function in children with hydronephrosis and we advocate for an early pyeloplasty in these children, especially if they have a high-grade dilatation and equivocal washout patterns in diuretic renographies. Further prospective studies are necessary in order to understand the natural history of CV and to reveal the importance of the crossing lower pole vessel as a structural anomaly lacking maturation.
大多数肾积水患儿无需任何手术干预。然而，在个别情况下，可能会出现不可逆的肾功能丧失。到目前为止，预测标准在确定哪些儿童的梗阻会导致肾损害方面已被证明无效。我们这项回顾性研究的目的是确定下极交叉血管（CV）在接受肾盂成形术的儿童中的作用。
1996年至2003年期间，137例单侧输尿管肾盂连接部梗阻且无相关泌尿系统病变的患者（年龄在6周至16岁之间）接受了安德森-海因斯离断性肾盂成形术。共有112例患者的完整数据得到评估。对于4级肾积水患儿，以下标准之一被视为手术指征：分肾功能（DRF）<40%；临床症状如肾盂肾炎和胁腹疼痛；在随访肾图检查中，DRF降低>10%，且根据奥赖利标准为洗脱模式II或III b。我们观察了手术时的年龄和临床表现类型。术前和术后1年使用利尿肾图测量DRF。将A组（无CV的儿童，n = 84）和B组（有CV的儿童，n = 28）术后DRF的变化进行比较。
A组手术时的中位年龄为5个月，而B组为23个月。只有21.4%有CV的儿童通过产前超声检查诊断为肾积水，而无CV的儿童这一比例为60.7%。我们发现A组术前DRF为42.4%±11.2标准差，B组为38.9%±11.7标准差。A组术后改善率为3.3%，B组为15.4%。
与无CV的患者相比，有输尿管肾盂连接部梗阻和CV的儿童接受手术治疗的时间较晚，术前分肾功能降低幅度更大。我们的数据表明，CV是肾积水患儿肾功能恶化的一个危险因素，我们主张对这些儿童尽早进行肾盂成形术，特别是如果他们有高度扩张且利尿肾图洗脱模式不明确的情况。有必要进行进一步的前瞻性研究，以了解CV的自然病程，并揭示下极交叉血管作为一种缺乏成熟度的结构异常的重要性。
