Aikawa Atsushi, Muramatsu Masaki, Takahashi Yusuke, Hamasaki Yuko, Hashimoto Junya, Kubota Mai, Hyoudou Youji, Itabashi Yoshihiro, Kawamura Takeshi, Shishido Seiichiro
From the Department of Nephrology, Toho University, Toho, Japan.
Exp Clin Transplant. 2018 Mar;16 Suppl 1(Suppl 1):20-24. doi: 10.6002/ect.TOND-TDTD2017.L42.
Lower urinary tract abnormalities are difficult to resolve in pediatric kidney transplant patients. Measure of residual urine, voiding cystourethrography, retrograde urethrography, cystometry, electromyography of urethral external sphincter muscle, urethrometry, and uroflowmetry are the primary methods for evaluation of lower urinary tract abnormalities. Endoscopic resection or ablation of urethral valves is required in children with posterior urethral valve to treat obstruction, but bladder function does not always recover and may deteriorate to end-stage renal failure even after the obstruction is released. This bladder dysfunction in posterior urethral valve defines valve bladder syndrome. Vesicoureteral reflux caused by high vesical pressure can cause even worse renal graft function posttransplant. In our patient group, urinary diversion occurred with Mitrofanoff conduit using an appendix in 6 children, a Yang-Monti channel conduit using ileum in 1 patient, with cystostomy in 3 children, and with augmented cystoplasty in 9 children before or simultaneously with kidney transplant. These procedures should be selected based on the type of lower urinary tract abnormality including bladder function. Recently, we have preferred a continent diversion for self-catheterization in children with lower urinary tract abnormalities. We have conducted 9 augmented cystoplasty procedures using a portion of the sigmoid colon or ileum. Seventeen children retained their own bladders when the transplant ureter was implanted. Most patients needed clean intermittent catheterization, depending on the residual urine volume and a bladder function. Ten-year graft survival rate in kidney transplant in our department is 98% in 36 children with lower urinary tract abnormalities. Lower urinary tract abnormality is not always a risk factor for pediatric kidney transplant; however, a preoperative evaluation is important to choose the best option for urinary diversion.
小儿肾移植患者的下尿路异常难以解决。残余尿量测量、排尿性膀胱尿道造影、逆行尿道造影、膀胱测压、尿道外括约肌肌电图、尿道压力测定和尿流率测定是评估下尿路异常的主要方法。后尿道瓣膜患儿需要进行内镜下尿道瓣膜切除术或切除术以治疗梗阻，但膀胱功能并不总是能够恢复，甚至在梗阻解除后可能会恶化为终末期肾衰竭。后尿道瓣膜所致的这种膀胱功能障碍定义为瓣膜膀胱综合征。高膀胱压力引起的膀胱输尿管反流可导致移植后肾移植功能更差。在我们的患者组中，6例患儿在肾移植前或同时采用阑尾制作Mitrofanoff导管进行尿流改道，1例采用回肠制作Yang-Monti通道导管进行尿流改道，3例患儿进行膀胱造瘘，9例患儿进行膀胱扩大成形术。这些手术应根据下尿路异常的类型（包括膀胱功能）来选择。最近，我们更倾向于为下尿路异常患儿采用可控性尿流改道以便于自我导尿。我们采用部分乙状结肠或回肠进行了9例膀胱扩大成形术。17例患儿在植入移植输尿管时保留了自己的膀胱。大多数患者需要根据残余尿量和膀胱功能进行清洁间歇性导尿。在我们科室，36例有下尿路异常的患儿肾移植的10年移植肾存活率为98%。下尿路异常并不总是小儿肾移植的危险因素；然而，术前评估对于选择最佳的尿流改道方案很重要。
