Kim Y H, Horowitz M, Combs A J, Nitti V W, Glassberg K I
Department of Pediatric Urology, State University of New York Health Science Center at Brooklyn, USA.
J Urol. 1997 Sep;158(3 Pt 2):1001-3. doi: 10.1097/00005392-199709000-00082.
There is no uniform agreement on how to manage the unilateral nonfunctioning or poorly functioning kidney associated with posterior urethral valves. We studied the results of treatment of our patients to make recommendations regarding management of these kidneys.
We reviewed the records of 13 boys with a history of posterior urethral valves and a unilateral nonfunctioning or poorly functioning kidney, defined as less than 10% of total renal function on 99mtechnetium dimercapto-succinic acid renal scans. Variables investigated included pyelonephritis, hypertension, vesicoureteral reflux, nephroureterectomy, ureteral reimplantation and spontaneous cessation of reflux. We also evaluated how the management of abnormal urodynamic parameters influenced the results of reimplantation or medically induced cessation of reflux.
Three of the 6 boys with grade 5 reflux ipsilateral to the poorly functioning kidney required nephroureterectomy at a mean age of 21 months because of recurrent urinary tract infections. Another 4 boys underwent successful ureteral reimplantation, including 2 who had bilateral grade 5 reflux, and 2 who had ipsilateral grade 4 reflux, and grade 3 (1) and grade 2 (1) contralateral reflux. Of 4 boys ipsilateral grade 3 reflux in 3 and bilateral grade 5 reflux in 1 disappeared without surgery after treatment of urodynamic abnormalities. Two patients with poorly functioning kidneys and no reflux did not undergo surgery. Overall 10 of the 13 poorly functioning renal units were not removed, and these patients were free of pyelonephritis and hypertension. Ureteral reimplantation (4 ipsilateral and 3 contralateral) was performed only after urodynamic abnormalities were addressed. All reimplantations were successful.
Based on our results we believed that unilateral poorly functioning kidneys in patients with posterior urethral valves can be safely preserved in select patients without hypertension and pyelonephritis. Reimplantation to correct reflux may be preferable to nephroureterectomy in specific situations, such as when contralateral function is suboptimal and the contralateral ureter needs reimplantation. When indicated, reimplantation can be performed successfully if abnormal urodynamic parameters are addressed preoperatively. In fact, treating abnormal urodynamic findings may lead to spontaneous reflux resolution.
对于如何处理与后尿道瓣膜相关的单侧无功能或功能不良的肾脏，目前尚无统一的共识。我们研究了我们患者的治疗结果，以便就这些肾脏的处理提出建议。
我们回顾了13例有后尿道瓣膜病史且单侧肾脏无功能或功能不良的男孩的病历，99m锝二巯基丁二酸肾扫描显示其肾功能小于总肾功能的10%。研究的变量包括肾盂肾炎、高血压、膀胱输尿管反流、肾输尿管切除术、输尿管再植术以及反流的自然停止。我们还评估了异常尿动力学参数的处理方式如何影响再植术或药物诱导反流停止的结果。
6例患侧肾脏功能不良且伴有5级反流的男孩中，有3例因反复尿路感染，平均在21个月时接受了肾输尿管切除术。另外4例男孩输尿管再植术成功，其中2例双侧5级反流，2例患侧4级反流，对侧分别为3级（1例）和2级（1例）反流。4例患侧3级反流的男孩中，3例以及1例双侧5级反流的男孩在尿动力学异常得到治疗后未手术反流即消失。2例肾脏功能不良且无反流的患者未接受手术。总体而言，13个功能不良的肾单位中有10个未被切除，这些患者无肾盂肾炎和高血压。仅在处理尿动力学异常后才进行输尿管再植术（4例患侧和3例对侧）。所有再植术均成功。
基于我们的结果，我们认为对于后尿道瓣膜患者的单侧功能不良肾脏，在无高血压和肾盂肾炎的特定患者中可安全保留。在特定情况下，如对侧肾功能欠佳且对侧输尿管需要再植时，纠正反流的再植术可能优于肾输尿管切除术。如有指征，术前处理异常尿动力学参数后可成功进行再植术。事实上，治疗异常尿动力学表现可能导致反流自然消退。
