【作者】 沈瑞林；

【导师】 蔡松良；

【作者基本信息】 浙江大学 ， 外科学， 2002， 硕士

【摘要】 目的 提高对急性上尿路梗阻性无尿的认识和诊治水平。 方法 回顾了近年来有关文献报道，对58例因突发无尿而入院的上尿路梗阻病人，从梗阻的诊断、病因诊断、影像学诊断价值、治疗、以及肾功能可复性预测等方面进行了全面分析。 结果 所有病例无尿原因均为急性上尿路梗阻，曾有1例无尿患者曾长期应用庆大霉素，考虑为肾性无尿，结果为肿瘤压迫；1例“多囊肾”(1侧已切除)患者出现无尿，曾疑多囊肾所致，后证实系孤立肾侧输尿管结石；2例膀胱肿瘤全切术后无尿，因术中低血压而疑肾前性肾功能衰竭，结果为输尿管梗阻所致。1例上尿路结石患者多次出现无尿多尿交替的现象。 引起上尿路梗阻的病因列前四位依次为结石(27／58)、肿瘤(18／58)、输尿管狭窄(4／58)和腹膜后纤维化(3／58)。结石中输尿管结石所占比例最高(13／27)，其次为同时有输尿管结石和肾结石(9／27)，单纯肾结石最少(5／27)。肿瘤以大肠癌所占比例最高(8／18)，其次为女性生殖器肿瘤(6／18)，3例泌尿系统原发肿瘤也引起急性无尿。双侧梗阻或孤立肾(包括唯一功能肾)梗阻占91．4％(53／58)，但单侧梗阻也可出现反射性急性无尿(2／58)，其中1例单侧输尿管结石致急性无尿，经解痉、镇痛治疗后尿量增加。 影像学检查通常采用B超、X线、CT、UR。MRU价值最大，B超对梗阻的检 浙江大学硕士学位论文 出率也较高，达 87．7％（与 X线、CT／MRI比较，KO．of）。CT、MRI在梗阻原 因的诊断方面具有独特优势。 上尿路梗阻的治疗分为一般治疗、应急治疗和病因治疗。本组急诊解除双 侧梗阻或孤立肾梗阻 30例（sl．7％），双侧梗阻解除一侧 19例（32．8％）。急诊 膀眺镜下插输尿管导管 20例成功，23例失败。单侧插双J管 2例，一侧插 管、另一侧 PCN例，3例插管未成功但致结石松动梗阻解除。PCN引流 10 例，9例成功。单侧开放性肾造瘦5例。血透9例。病因治疗应根据不同病因 采取不同方法，本组行肾盂、输尿管切开取石术12例，肾盂切开取石／肾盂输 尿管交界处成形术 1例，ESWL例（孤立肾），ESWL＋PCN肾镜取石 2例门例 唯一功能肾），排石成功1例，碳酸氢钠溶石2例。手术清除血块1例，行输 尿管膀眈再植术互例，双侧输尿管中下段切除、回肠代输尿管术1例。如双侧 梗阻分期治疗则：l）先处理急性梗阻时间短的一侧（积水轻、症状明显的一 侧）；2）手术较容易的一侧；3）功能相对较好的一侧；4）若双肾功能较好， 先处理损害较重一侧。 结果有效治疗55例，肾功能完全恢复34例，部分恢复12例，不恢复9 例（其中死亡1例）。合并上尿路感染1例，解除梗阻并抗炎治疗后肾功能完 全恢复。梗阻后利尿9例，2例肾功能未恢复，未愈率高于非利尿组。2例在 梗阻解除后立即大量利尿，但加快输液速度后发生急性肺水肿。 肾功能完全恢复或部分恢复46例，梗阻解除后12小时平均尿量为2720ml， 24，J’时平均尿量为4398 ml，39例有多尿期（84．8％）。肾功能不恢复9例，梗 阻解除后12 ’J’时平均尿量为1167ml，24 ．J＼时平均尿量为2083ml，2例有多 尿期（22．2％）。 2 浙江大学硕士学位论文 结论 1．急性无尿首先考虑梗阻所致，有无尿、多尿交替者肯定为梗阻所致。 2．急性梗阻无尿的最常见病因是结石，其次为肿瘤。 3．B超、二线、CT、MRI川RU是诊断梗阻和梗阻病因的重要方法。’4．单侧梗阻也可出现对侧反射性无尿，其机理尚不清楚。 5．应急治疗梗阻性无尿的）f匝序依次是输尿管插管、肾造瘦（经皮、开 放）及输尿管腹壁造口。 6．梗阻解除前利尿将导致肾功能的进一步损害。 7．梗阻解除后早期仍应严格控制输液速度与输液量。 8．病因治疗因病而异，一般先处理梗阻时间短、肾功能较好、手术容易 的一侧。肿瘤患者一般仅能作尿流改道术。 9．梗阻解除后 12小时、24小时尿量以及有无多尿期是提示肾功能能否 恢复的重要指标。更多还原

【Abstract】 Objective:To improve the diagnosis and treatment of acute anuria caused by upper urinary tract obstruction. Methods:The articles on acute obstructive anuria published in recent years were reviewed. 58 patients suffered from acute anuria caused by upper urinary tract obstruction were analysed on obstructive diagnosis, etiological diagnosis, the value of image diagnosis, treatment, and the judgement of recovery of renal function. Results:The causes of all cases were acute upper urinary tract obstructions. In one case injected gentamycin for long term, renal anuria was regarded firstly, but tumor compression was confirmed as the truth finally. In one patient with polycystic kidney (one kidney was already resected), bad renal function was thinked as the cause of anuria, but calculus of ureter was the true cause. In 2 cases with total cystectomy, prerenal renal failure was regarded as the cause of anuria because of the lower blood pressure during the operation, in fact, obstruction of ureter resulted in anuria. Inone case of upper urinary tract obstruction, anuria and polyuria presented alternatively.The common causes of acute obstructive anuria were calculi (27/58 ) , tumors (18/58) , stricture of ureter (4/58) and retroperitoneal fibrosis (3/58) . Among the upper urinary tract calculi, ureteral calculi was the most common (13/27) , and the nephrolithiasis accompanied ureteric stone was the next (9/27) , but the stones only lodged in renal collecting system was the least (5/27 ) . Colon cancer was the most mainly neoplasm caused obstructive anuria (8/18) , the second was tumor of female genital organ (6/18) ,and the third was tumors of urinary system. Bilateral or solitary renal obstruction were 91.4% (53/58) .Acute reflective anuria due to monolateral obstruction was considered in two patients (2/58) . In one case with calculus of ureter on one side, acute anuria was relieved by anti-spasm and analgesia. ?Ultrasonography, excretory urography , computed tomograhpy and magnetic resonance imaging were performed for diagnosis. MRU had the most value of diagnosis of upper urinary tract obstruction. Detective rate by B ultrasound was higher than X ray and CT/MRI(P<0.01), account for 87.7%.However, CT\ MRI had the special advantages in diagnosis of obstructive causes.Three methods were taken to manage the upper urinary tract obstructive anuria: general management, emergent treatment, and treatment of causes. In our study, 30 patients with bilateral or solitary kidney obstruction were relieved emergently (51.7%) . 19 patients with bilateral ureter obstruction were relieved on one side (32.8%). Ureteral catheters were placed successfully under cystoscopy in 20 patients, but 23 patients failed. 2 cases were placed with double J catheter on one side, 1 case was inserted ureteral catheter on one side, the other side was managed by PCN. 3cases failed to place the catheter, but the obstructions were relieved by movement of stone which caused by inserting catheter. 10 cases tried to draining urine by PCN, of which 9 cases were successful. Open nephrostomy on one side were performed in 5 cases. Dialysis was performed in 9 cases. Etiological treatment should take different methods according to different causes. Pyelolithotomy and ureterolithotomy were performed in 12 cases; Pyelolithotomy and plasty of pyeloureteral junction were performed in 1 case; Extracorporeal shock wave lithotripsy (ESWL) was performed in a solitary kidney; ESWL and PCN were performed in 2 case (one was unique functional kidney); Calculi passed spontaneously in one case, and stone was dissolved successfully with alkalinizing urine in 2 cases; Blood clots were cleaned by operation in 1 case; ureterovesical replant was performed in one case; Middle and distal bilateral ureter were resected and ileum substituted ureter in one case. If bilateral obstruction were treated at different time, the side of acute obstruction for shorter time (the side of light hydronephrosis and obvious symptoms), of operation to perform more easily更多还原