Schwalb D M, Eshghi M, Davidian M, Franco I
Department of Urology, New York Medical College, Valhalla 10595.
J Urol. 1993 Jun;149(6):1576-85. doi: 10.1016/s0022-5347(17)36456-x.
The gross and microscopic effects of four common modes of ureteral dilation and ureteroscopy were examined in 26 renoureteral units in 13 minipigs. Acutely, ureters subjected to mechanical (bougie, Teflon, or balloon) ureteral dilation and ureteropyeloscopy (UPS) demonstrated active mucosal bleeding with multiple sites of perforation, whereas ureters subjected to hydraulic dilation and UPS were significantly less traumatized. Two weeks after mechanical ureteral dilation and UPS, 3 of 6 ureters were obstructed radiographically, whereas all 7 hydraulically dilated ureters were unobstructed. By 6 weeks, all radiographic evidence of obstruction had resolved in the mechanically dilated group. While 5 of 6 mechanically dilated ureters showed extensive scarring with muscle loss 4 to 6 weeks after dilation, no scarring was seen in those ureters dilated hydraulically. Renal pelvic pressure (RPP) was measured continuously with a nephrostomy catheter in vivo during (bougie, Teflon, balloon and hydraulic) ureteral dilation and UPS. Renal pelvic pressure during rigid ureteroscopy approximated the resting pelvic pressure plus the irrigant height above the kidney or set pressure on a hydraulic pump, plus a "scope effect" which was characterized by a 20 to 25 mm. Hg increase in RPP produced by moving the endoscope in the ureter without flow. The effects on RPP of continuous bladder drainage with a uretheral catheter and renal pelvic decompression with an open-ended ureteral catheter passed into the renal pelvis through the ureteroscope working channel were also examined. The maximum RPP was evaluated in vitro in a separate group of 16 freshly harvested pig kidneys of similar weight examined immediately after sacrifice and was found to be 439 mm. Hg. We also studied the immediate and long-term effects of low (< 120 cm. H2O or 90 mm. Hg) versus high (> 200 cm. H2O or 150 mm. Hg) RPP on renal histology. Acutely, high pressure caused diffuse denudation and flattening of the caliceal urothelium, submucosal edema and congestion not seen in calyces subjected to low irrigant pressure. Four to six weeks later, there was a higher incidence of columnar metaplasia, subepithelial nests and pericalyceal vasculitis in calyces subjected to high pressure as compared with those subjected to low irrigant pressure. Acutely, renal tubules subjected to high irrigant pressure demonstrated marked vacuolization and degeneration, whereas tubules subjected to low pressure appeared normal. At 4 to 6 weeks, focal scarring was seen in 5 of 7 kidneys subjected to high irrigant pressure, whereas no scarring was noted in all 6 kidneys subjected to low irrigant pressure.(ABSTRACT TRUNCATED AT 400 WORDS)
在13只小型猪的26个肾输尿管单元中，研究了四种常见输尿管扩张和输尿管镜检查方式的大体和微观影响。急性情况下，接受机械性（探条、聚四氟乙烯或球囊）输尿管扩张和输尿管肾盂镜检查（UPS）的输尿管表现为黏膜活动性出血并多处穿孔，而接受液压扩张和UPS的输尿管受创明显较轻。机械性输尿管扩张和UPS两周后，6条输尿管中有3条经影像学检查显示梗阻，而7条液压扩张的输尿管均无梗阻。到6周时，机械扩张组所有梗阻的影像学证据均已消失。虽然6条机械扩张的输尿管中有5条在扩张后4至6周显示出广泛瘢痕形成及肌肉丢失，但液压扩张的输尿管未见瘢痕形成。在体内进行（探条、聚四氟乙烯、球囊和液压）输尿管扩张及UPS时，用肾造瘘导管连续测量肾盂压力（RPP）。硬性输尿管镜检查时的肾盂压力接近静息肾盂压力加上肾脏上方冲洗液高度或液压泵设定压力，再加上“镜身效应”，其特征是在无冲洗液流动情况下在内镜在输尿管内移动时RPP升高20至25毫米汞柱。还研究了经尿道导管持续膀胱引流及通过输尿管镜工作通道插入肾盂的开口输尿管导管进行肾盂减压对RPP的影响。在另一组16只刚宰杀后立即检查的、体重相近的新鲜猪肾中，体外评估最大RPP，结果为439毫米汞柱。我们还研究了低（<120厘米水柱或90毫米汞柱）与高（>200厘米水柱或150毫米汞柱）RPP对肾脏组织学的即时和长期影响。急性情况下，高压导致肾盏尿路上皮弥漫性剥脱和扁平，黏膜下水肿和充血，而低冲洗液压力的肾盏未见此情况。4至6周后，与低冲洗液压力的肾盏相比，高压肾盏柱状化生、上皮下巢和肾盏周围血管炎的发生率更高。急性情况下，高冲洗液压力下的肾小管显示明显空泡化和变性，而低压力下的肾小管外观正常。4至6周时，7只接受高冲洗液压力的肾脏中有5只出现局灶性瘢痕形成，而6只接受低冲洗液压力的肾脏均未发现瘢痕形成。（摘要截选至400字）
