del Pizzo J J, Jacobs S C, Bartlett S T, Sklar G N
Department of Surgery, University of Maryland School of Medicine, Baltimore, USA.
J Urol. 1998 Mar;159(3):750-2; discussion 752-3.
Although complete necrosis of a transplanted renal allograft ureter is uncommon, it is a difficult complication to manage. Long or multisegment ureteral strictures, most commonly ischemic in nature, are formidable problems for the reconstructive surgeon. We reviewed 655 consecutive renal allografts to determine the incidence of these complex ureteral complications, and the effectiveness and morbidity of complete ureteral reconstruction using bladder alone.
Of 20 patients (3.0%) who required ureteral reconstruction 9 had complete ureteral necrosis and 11 had long (4) or multisegment (7) ureteral strictures. Total ureteral reconstruction was performed using a modified Boari flap in 15 patients and direct pyelovesicostomy in 5. All patients were followed postoperatively with renal ultrasound as well as 99mtechnetium mercaptoacetyltriglycine-3 diuretic renal scans. Mean followup was 28 months.
All 20 patients had successful reconstruction of the transplant ureter using bladder for substitution. Four patients had persistent dilatation of the renal collecting system without evidence of obstruction as measured by diuretic renal scan (half-time less than 20 minutes). Reflux into the transplant renal pelvis occurred in 6 patients. Two patients had reversible deterioration in renal function secondary to rejection episodes. Of the group reconstructed via Boari bladder flap prolonged stenting (mean 27 days) and prolonged high volume drain output (mean 22 days) were not uncommon.
Complete ureteral reconstruction is a complex problem in the renal allograft recipient. Using the bladder for reconstruction via Boari flap or direct pyelovesicostomy is an effective technique with minimal morbidity.
尽管移植肾同种异体输尿管完全坏死并不常见，但却是一种难以处理的并发症。长段或多节段输尿管狭窄，最常见的是缺血性狭窄，对于重建外科医生来说是棘手的问题。我们回顾了655例连续的肾移植病例，以确定这些复杂输尿管并发症的发生率，以及仅使用膀胱进行完全输尿管重建的有效性和并发症发生率。
在20例需要输尿管重建的患者（3.0%）中，9例有输尿管完全坏死，11例有长段（4例）或多节段（7例）输尿管狭窄。15例患者采用改良Boari皮瓣进行全输尿管重建，5例采用直接肾盂膀胱吻合术。所有患者术后均接受肾脏超声以及锝-巯基乙酰三甘氨酸-3利尿肾扫描检查。平均随访28个月。
所有20例患者均成功地用膀胱替代物重建了移植输尿管。4例患者肾集合系统持续扩张，利尿肾扫描显示无梗阻证据（半衰期小于20分钟）。6例患者出现反流至移植肾盂。2例患者因排斥反应导致肾功能可逆性恶化。在通过Boari膀胱皮瓣重建的患者组中，延长支架置入时间（平均27天）和延长高流量引流输出时间（平均22天）并不少见。
完全输尿管重建在肾移植受者中是一个复杂的问题。通过Boari皮瓣或直接肾盂膀胱吻合术利用膀胱进行重建是一种有效的技术，并发症发生率最低。
