Pérez L M, Naidu S I, Joseph D B
Department of Surgery, University of Alabama at Birmingham, USA.
J Urol. 1998 Sep;160(3 Pt 2):1207-11; discussion 1216. doi: 10.1097/00005392-199809020-00070.
We determine whether nephrectomy or observation is the more appropriate treatment of neonates with multicystic dysplastic kidney in terms of medical care and cost-effectiveness.
We retrospectively reviewed our 10-year clinical experience with 17 female and 32 male neonates presenting with multicystic dysplastic kidney who were followed with serial renal ultrasound. The literature also was reviewed.
Nephrectomy was performed in 12 patients (24%) for various reasons, of which family request at concomitant surgery was the most common (7). No kidney was removed due to hypertension or tumor. In the remaining 37 patients followup continues (mean 42 months) with involution developing in 9 multicystic dysplastic kidneys (24%) and 9 patients (24%) lost to followup. The total cost of 1-hour outpatient simple nephrectomy was estimated at $5,000 to $7,000 and, when performed as a concomitant procedure, it cost $2,000 to $5,000, the equivalent charges incurred for 17 to 28 serial ultrasound studies performed by a radiologist. Our review of the literature revealed that children with multicystic dysplastic kidney are at minimal risk for hypertension, pain and infection. The most important reason to perform screening renal ultrasound in this condition is to detect earlier stage Wilms tumor (3 to 10-fold the general pediatric population risk of 1/10,000 cases). With a maximum risk of 0.1% for Wilms tumor controversy exists as to whether any screening program is necessary. When screening is instituted, options include monthly parental abdominal palpation versus serial renal ultrasound. Because Wilms tumor has a rapid growth rate, when screening renal ultrasound is instituted, it must be performed no less than every 3 months until age 8 years (total of 32 studies) to screen effectively for early stage tumors.
The risks associated with multicystic dysplastic kidney are slight. Early nephrectomy is more cost-effective than observation in neonates with multicystic dysplastic kidney only when observation involves screening with ultrasonography every 3 months until age 8 years. Extensive parental counseling should be provided on the slight but definite risks of this condition.
我们从医疗护理和成本效益方面确定肾切除术或观察对于患有多囊性发育不良肾的新生儿而言哪种治疗方式更为合适。
我们回顾了10年间收治的17例女性和32例男性患有多囊性发育不良肾的新生儿的临床经验，对其进行了系列肾脏超声检查随访。同时也对相关文献进行了回顾。
12例患者（24%）因各种原因接受了肾切除术，其中最常见的原因是在进行其他手术时家属要求（7例）。没有因高血压或肿瘤而切除肾脏的情况。其余37例患者继续接受随访（平均42个月），9个多囊性发育不良肾（24%）出现退化，9例患者（24%）失访。门诊1小时简单肾切除术的总成本估计为5000美元至7000美元，若作为其他手术的同时进行的操作，成本为2000美元至5000美元，这相当于放射科医生进行17至28次系列超声检查的费用。我们对文献的回顾显示，患有多囊性发育不良肾的儿童发生高血压、疼痛和感染的风险极小。在这种情况下进行筛查性肾脏超声检查的最重要原因是检测早期威尔姆斯瘤（风险是一般儿科人群1/10000病例风险的3至10倍）。对于是否有必要进行任何筛查项目存在争议，因为威尔姆斯瘤的最大风险为0.1%。当开展筛查时，可选择的方式包括家长每月进行腹部触诊或系列肾脏超声检查。由于威尔姆斯瘤生长迅速，当开展筛查性肾脏超声检查时，必须每3个月进行一次，直至8岁（总共32次检查），以便有效地筛查早期肿瘤。
多囊性发育不良肾相关风险较小。仅当观察包括每3个月进行一次超声检查直至8岁时，早期肾切除术对于患有多囊性发育不良肾的新生儿而言比观察更具成本效益。应就这种情况轻微但明确的风险向家长提供广泛的咨询。
