本文關(guān)鍵詞：腎盂旁囊腫的組織起源及逆行經(jīng)輸尿管鏡鈥激光囊腫—腎盂內(nèi)引流術(shù)的研究　出處：《山東大學(xué)》2015年博士論文　論文類型：學(xué)位論文

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【摘要】：目的：腎盂旁囊腫是一種腎臟的囊腫性病變,為非遺傳性,發(fā)生于臨近腎盂或腎蒂,可因先天發(fā)育異�；蚝筇煨阅I內(nèi)梗阻形成,約占腎囊性病變的1～3%。“腎盂旁”只是描述的囊腫發(fā)生的部位,其組織可能來源于腎實質(zhì)或者腎竇內(nèi)組織。組織起源于腎竇的囊腫稱為腎盂周圍囊腫(peripelvic cyst),可起源于腎竇內(nèi)其他結(jié)構(gòu)如動脈、淋巴、脂肪的囊腫。起源于腎竇外,侵入腎竇的囊腫稱為腎盂旁囊腫(parapelvic cyst),這類囊腫來源于腎實質(zhì)。腎盂源性囊腫侵入腎竇影像學(xué)檢查也可能診斷為腎盂旁囊腫。腎盂旁囊腫、腎盂周圍囊腫及腎盂源性囊腫這三種囊腫的組織來源不同,具有不同的上皮細(xì)胞類型,可來源于腎小管、淋巴管、血管、甚至是移行上皮,可以根據(jù)相關(guān)特定標(biāo)記物來鑒別其來源。CK18、D2-40和CD34被已知分別作為腎小管、淋巴上皮、血管上皮細(xì)胞的特異標(biāo)記物。囊液成分可能為尿性、漿液性或者淋巴性,根據(jù)囊液成分也有助于組織來源的鑒定。腎盂旁囊腫在解剖上臨近腎門及集合系統(tǒng),常會引起梗阻、感染、高血壓、疼痛及形成結(jié)石。腎盂旁囊腫的治療包括穿刺引流及硬化術(shù)、開放手術(shù)、經(jīng)皮腎鏡下去頂術(shù)及內(nèi)引流術(shù)、腹腔鏡去頂術(shù)、經(jīng)輸尿管鏡內(nèi)引流術(shù)等。治療的主要目的是充分引流其內(nèi)容物并防止囊液進(jìn)一步聚集壓迫腎臟、腎盂以及腎蒂組織。腎盂旁囊腫腹腔鏡去頂術(shù)被認(rèn)為是治療腎盂旁囊腫的標(biāo)準(zhǔn)技術(shù)。隨著腔內(nèi)泌尿外科的發(fā)展,輸尿管鏡/軟鏡的應(yīng)用為該病的治療提供了新的思路。輸尿管鏡／軟鏡可進(jìn)入腎盂甚至腎盞,已廣泛應(yīng)用于上尿路疾病包括結(jié)石、梗阻、腫瘤等的診治。由于腎盂旁囊腫和腎盂或腎盞關(guān)系密切,往往僅一層薄膜相隔或突入集合系統(tǒng),這為腔內(nèi)應(yīng)用輸尿管鏡提供了解剖依據(jù)。目前已有應(yīng)用輸尿管鏡去頂術(shù)治療腎盂旁囊腫的病例報告,取得成功.但缺乏較大樣本及長期安全性、有效性的評估。囊液的成分不明確、囊液引流至腎盂系統(tǒng)后尿液成分是否發(fā)生變化、對機(jī)體有何影響以及手術(shù)對腎盂的瘢痕形成能否導(dǎo)致梗阻、尿性囊腫、尿液停滯于囊腫內(nèi)能否引發(fā)感染、結(jié)石形成以及血尿等并發(fā)癥仍需要進(jìn)一步觀察。本研究應(yīng)用囊液生化分析、囊壁形態(tài)學(xué)以及免疫組化等方法探討腎盂旁囊腫的組織起源,為囊腫-腎盂內(nèi)引流術(shù)提供理論基礎(chǔ)。應(yīng)用輸尿管鏡結(jié)合鈥激光技術(shù),對腎盂旁囊腫行鈥激光囊腫-腎盂內(nèi)引流術(shù),評價療效和并發(fā)癥：與腹腔鏡去頂減壓術(shù)治療腎盂旁囊腫組對比。通過本研究,初步探討經(jīng)輸尿管鏡鈥激光囊腫-腎盂內(nèi)引流術(shù)治療腎盂旁囊腫的的可行性和先進(jìn)性,手術(shù)適應(yīng)癥及禁忌癥等。方法：1.利用免疫組化方法,檢測腎盂旁囊腫上皮細(xì)胞的CK18、D2-40和CD34表達(dá),以正常腎臟組織和淋巴囊腫囊壁組織作為對照,分析了三種上皮標(biāo)記物在腎盂旁旁囊腫上皮的表達(dá)差異。2.囊液生化分析：術(shù)中抽取清潔囊液約2-5 ml,測定其中的鈉離子(Na+)、鉀離子(K+)、氯離子(Cl-)、尿素氮(BUN)、肌酐(Cr)、葡萄糖(Glu)及總蛋白(TP)濃度。術(shù)前抽血測定血漿中Na+、K+、Cl-, BUN、Cr、Glu及TP濃度,將囊液與血漿中各物質(zhì)的濃度進(jìn)行對比。3.囊液定性分析應(yīng)用尿液自動分析儀對囊液進(jìn)行定性分析,同時與患者尿常規(guī)結(jié)果對比。4.2006.8至2013.1期間山東省千佛山醫(yī)院收治的腎盂旁囊腫患者62例,隨機(jī)分為2組。分別為輸尿管鏡鈥激光囊腫-腎盂內(nèi)引流術(shù)組及腹腔鏡去頂減壓術(shù)組,并統(tǒng)計其臨床一般資料并進(jìn)行隨訪。5.經(jīng)輸尿管鏡手術(shù)組：硬性輸尿管鏡逆行進(jìn)入腎盂,觀察腎盂旁囊腫對集合系統(tǒng)的壓迫情況,結(jié)合術(shù)前CT應(yīng)用鈥激光365μm光纖切開壓跡明顯處囊壁,切除范圍約1cm直徑囊壁,使囊腫與集合系統(tǒng)相通;硬性輸尿管鏡不能達(dá)到部位囊腫,應(yīng)用電子輸尿管軟鏡及200μm光纖實施手術(shù)。直視下留置5F雙J管,近端位于囊腫內(nèi),遠(yuǎn)端位于膀胱內(nèi)。根據(jù)腎盂旁囊腫在輸尿管鏡下表現(xiàn)分為兩類：第一類：鏡下囊腫壓迫腎盂壁處為藍(lán)色表現(xiàn),壁薄,能迅速和其他部位腎盂相區(qū)分,鈥激光直接切開囊腫；第二類：囊壁及囊腫壁和腎盂粘膜間組織較厚,除了壓跡外和其他部位腎盂色澤一致,需要小心在無搏動的壓跡處逐層切開腎盂粘膜、粘膜下組織、囊壁,以防止血管及腎實質(zhì)的損傷。6.腹腔鏡組：均為后腹腔鏡入路,三點法建立工作通道,游離出腎盂旁囊腫,盡量完全切除囊腫,如囊腫位置深或無法完整剝除,則貼近正常腎實質(zhì)環(huán)形切除囊壁。7.療效判定和隨訪隨訪時間定為術(shù)后第3個月,以排除留置雙J管的干擾。記錄各組的術(shù)后及隨訪結(jié)果,包括癥狀改善、實驗室檢查、影像學(xué)檢查結(jié)果,并和術(shù)前情況對比,探討輸尿管鏡組手術(shù)方式的安全性、有效性。比較兩組患者圍手術(shù)期指標(biāo)：包括手術(shù)時間、術(shù)中出血量、疼痛評分、術(shù)后下床活動時間、術(shù)后住院時間、術(shù)后并發(fā)癥、術(shù)后復(fù)發(fā)率等指標(biāo)。影像學(xué)檢查包括B超、CT等提示囊腫消失或直徑較術(shù)前縮小1/2以上術(shù)后為影像學(xué)治愈或有效。結(jié)果：1.腎盂旁囊腫上皮細(xì)胞為單層上皮,均表達(dá)CK18,無D2-40和CD34表達(dá),結(jié)果具有顯著差異(P0.05)；腎盂源性囊腫上皮為移行上皮,表達(dá)CK18,無D2-40和CD34表達(dá)；淋巴管囊腫上皮細(xì)胞表達(dá)D2-40,無CK18和CD34表達(dá)。2.囊液生化結(jié)果：Na+.K+.Cl-、Cr的囊液濃度和血漿結(jié)果無顯著性差異,囊腫液BUN.Glu高于血漿濃度,而TP濃度明細(xì)低于血漿濃度,結(jié)果具有顯著差異(P0.05)。3.囊液定性分析結(jié)果：葡萄糖+～++,蛋白+～+++,和尿常規(guī)結(jié)果相比有統(tǒng)計學(xué)顯著性差異(P0.05)。4.輸尿管鏡組：33例中31例成功(93.9%),其中2例因輸尿管狹窄導(dǎo)致輸尿管鏡上行失敗改為經(jīng)后腹腔鏡手術(shù),其中15例術(shù)中應(yīng)用電子輸尿管軟鏡,6例軟鏡不能精確定位囊腫。手術(shù)時間30-101min,平均56.2min;囊腫處理時間8-31min,平均19.1min。術(shù)中出血量為10-56ml,平均26.8m1。術(shù)中無大出血、周圍臟器損傷、輸尿管損傷等嚴(yán)重并發(fā)癥,術(shù)后3例因雙J管或?qū)蚬艹霈F(xiàn)明顯的尿路刺激癥狀,應(yīng)用M受體阻滯劑,癥狀改善。術(shù)后無嚴(yán)重血尿、無尿外滲、無明顯感染,無血栓等手術(shù)并發(fā)癥。術(shù)后3個月時,27例腰痛、腰脹或不適者有24例癥狀消失或緩解。隨訪期內(nèi)復(fù)查尿常規(guī)、血常規(guī)及生化檢查等實驗室檢查均正常。影像學(xué)隨訪31例中27例囊腫完全消失,3例直徑較術(shù)前縮小1/2以上,總有效率為96,8%。5.腹腔鏡組：29例中28例成功(96.6%),1例因游離腎門處損傷腎血管改開放手術(shù)。手術(shù)時間71-135min,平均96.5min；囊腫處理時間15-41min,平均26.8min。術(shù)中出血量為35-430ml,平均68.6ml。術(shù)中無周圍臟器損傷等嚴(yán)重并發(fā)癥。術(shù)后2例出現(xiàn)漏尿(對應(yīng)病理類型為腎盂源性囊腫),經(jīng)膀胱鏡逆行置入雙J管后治愈。26例腰痛、腰脹或不適者有22例癥狀消失或緩解。影像學(xué)隨訪28例中18例囊腫消失,8例直徑較術(shù)前縮小1/2以上,總有效率為92.9%。6.輸尿管鏡組與腹腔鏡組間數(shù)據(jù)比較：比較兩組患者手術(shù)成功率、隨診復(fù)發(fā)率以及圍手術(shù)期指標(biāo)：包括手術(shù)時間、術(shù)中出血量、疼痛評分、術(shù)后下床活動時間、術(shù)后住院時間、術(shù)后并發(fā)癥等指標(biāo)。結(jié)果比較發(fā)現(xiàn)：輸尿管鏡組手術(shù)成功率為93.9%(31/33),腹腔鏡組為96.6%(28/29),兩組間手術(shù)成功率無顯著性差異(P0.05)；癥狀改善率兩組間比較無顯著性差異(P0.05)；影像學(xué)總有效率兩組間無顯著性差異(P0.05)；囊腫完全消失率輸尿管鏡組為87.1%(27/31),腹腔鏡組為64.3%(18/28),兩組間有顯著性差異(P0.05)：手術(shù)并發(fā)癥、手術(shù)時間、囊腫處理時間、術(shù)中出血量、疼痛評分、術(shù)后下床活動時間、術(shù)后住院時間等指標(biāo),輸尿管鏡組均優(yōu)于后腹腔鏡組(P0.05)。結(jié)論：1.腎盂旁囊腫上皮細(xì)胞特異性表達(dá)CK18,提示組織來源是腎小管。2.定量及定性分析囊液生化指標(biāo),提示腎盂旁囊腫囊液為不同濃度和不同梯度的尿液,間接提示組織起源于腎小管,為腎盂旁囊腫內(nèi)引流術(shù)提供生理依據(jù)。3.輸尿管鏡鈥激光囊腫-腎盂內(nèi)引流術(shù)通過人體的自然通道治療腎盂旁囊腫,在合適的病例的情況下具有療效好、創(chuàng)傷小、恢復(fù)快、并發(fā)癥少、更符合人體生理性等優(yōu)點,是治療腎盂旁囊腫安全有效的方法之一。4.經(jīng)輸尿管鏡內(nèi)引流術(shù)與經(jīng)腹腔鏡手術(shù)相比,影像學(xué)檢查結(jié)果提示療效優(yōu)于后者,并發(fā)癥少,適應(yīng)癥更廣泛,可適用于完全位于腎內(nèi)型的腎盂旁囊腫及腎盂源性囊腫。5.腎盂旁囊腫在輸尿管鏡下的表現(xiàn)分為2型,分別為薄壁囊腫和厚壁囊腫,需應(yīng)用不同的切開策略。和輸尿管軟鏡相比,輸尿管硬鏡聯(lián)合鈥激光更適用于行內(nèi)引流術(shù)。意義：1.腎盂旁囊腫的組織起源于腎小管,為內(nèi)引流術(shù)提供了生理依據(jù)。2.經(jīng)輸尿管鏡鈥激光囊腫-腎盂內(nèi)引流術(shù)治療腎盂旁囊腫是安全、有效的,適應(yīng)癥更廣泛,可適用于完全位于腎內(nèi)型的腎盂旁囊腫及腎盂源性囊腫,成為一種新的微創(chuàng)術(shù)式。3.逆行經(jīng)輸尿管鏡鈥激光囊腫-腎盂內(nèi)引流術(shù)治療腎盂旁囊腫可在大多數(shù)醫(yī)院臨床推廣,提供新的手術(shù)治療方案。
[Abstract]:Objective: parapelvic cyst is a cyst of kidney disease, non hereditary, occurred in the adjacent renal pelvis or renal pedicle can be formed due to congenital dysplasia or acquired renal obstruction, accounting for about 1 to 3% of renal cystic lesions. "Paranela" is only the site of the description of the cyst, and its tissue may come from renal parenchyma or intrarenal sinus tissue. The cyst originated from the renal sinus is called the peripelvic cyst. It can be derived from other structures in the renal sinus such as the cyst of the arteries, lymph and fat. The cyst originating from the renal sinus and invading the renal sinus is called the parenal cyst (parapelvic cyst), which is derived from the renal parenchyma. Imaging of renal pelvis cysts intruding into the renal sinus may also be diagnosed as parenal cyst. The three cysts of para renal cysts, peri renal cysts and pyelic cysts are of different tissue origin. They have different epithelial types, which can be derived from renal tubules, lymphatic vessels, blood vessels, and even transitional epithelium. They can be identified according to specific markers. CK18, D2-40 and CD34 are known as specific markers for renal tubules, lymphoepithelial cells and vascular epithelial cells. The composition of the cyst fluid may be urinary, serous or lymphatic, and it is also helpful for the identification of tissue sources according to the composition of the fluid. Paranelelal cysts are anatomically adjacent to the renal portal and the collection system, which often cause obstruction, infection, hypertension, pain and formation of stones. The treatment of parapele cysts includes puncture and drainage, sclerotherapy, open surgery, percutaneous nephrolithotomy and internal drainage, laparoscopic unroofing, and ureteroscopic drainage. The main purpose of the treatment is to fully drain its contents and to prevent the further aggregation of the fluid from the renal, renal pelvis and renal tissue. Laparoscopic removal of the parapelon cyst is considered as a standard technique for the treatment of parapele cysts. With the development of the intracavity Department of Urology, the application of ureteroscope / soft mirror provides a new way of thinking for the treatment of the disease. Ureteroscope / soft mirror can enter the renal pelvis and even the renal calyx. It has been widely used in the diagnosis and treatment of upper urinary tract diseases including stones, obstruction, tumor and so on. Due to the close relationship between para renal cysts and renal pelvis or calyx, only one layer of membrane is separated or penetrates into the collecting system, which provides anatomical basis for the application of ureteroscope in the cavity. At present, ureteroscopic unroofing has been applied in the treatment of parapele cysts. The cystic fluid composition is not clear, the cystic fluid drainage system to the renal pelvis urine is changed or not, what is the effect of surgery on the body and can cause obstruction, urinary cysts, urine stagnation in the cyst can lead to infection and stone formation and hematuria still need further observation on the formation of renal scar. In this study, we used cystic fluid biochemical analysis, cyst wall morphology and immunohistochemistry to explore the tissue origin of para renal cysts, and to provide a theoretical basis for cysts and pelvis drainage. Ureteroscopy combined with holmium laser was applied to evaluate the efficacy and complications of holmium laser cysts and pelvis drainage for parapele cyst. Through this study, we preliminarily discussed the feasibility and advancement, indications and contraindications of ureteroscopic holmium laser cysts and pelvis drainage for the treatment of para renal cysts. Methods: 1.. Immunohistochemical method was used to detect the expression of CK18, D2-40 and CD34 in para renal cyst epithelial cells. The expression differences of three epithelial markers in para renal para cyst epithelium were analyzed with normal renal tissue and cystic wall tissue of lymphatic cyst as controls. 2. cystic fluid biochemical analysis: during the operation, the cleaning bag fluid was taken for about 2-5 ml, and the concentrations of sodium ion (Na+), potassium ion (K+), chloride ion (Cl-), urea nitrogen (BUN), creatinine (Cr), glucose (Glu) and total protein (TP) were measured. The concentration of Na+, K+, Cl-, BUN, Cr, Glu and TP in plasma was measured before operation, and the concentration of each substance in the fluid was compared with that of the plasma in the plasma. The qualitative analysis of the 3. cystic fluid was carried out by the urine automatic analyzer, and compared with the routine urine results. From 4.2006.8 to 2013.1, 62 cases of pyelonephrosis were treated in Qianfo Hill hospital in Shandong province. The patients were randomly divided into 2 groups. The ureteroscopic holmium laser cyst of the renal pelvis and the laparoscopic removal of decompression were performed, and the general clinical data were counted and followed up. 5. ureteroscopic surgery group: ureteroscopic retrograde into the renal pelvis, renal cyst on the observation set system of oppression, combined with preoperative CT holmium laser of 365 m fiber cut impressio obvious cyst wall resection, diameter 1cm cyst wall, make cyst communicated with the collecting system; not rigid ureteroscopy application of electronic parts to cyst, ureteroscope and 200 m fiber operation. The 5F double J tube was retained under direct vision. The proximal end was located in the cyst and the distal end was located in the bladder. According to the renal cyst under ureteroscope were divided into two categories: the first category: endoscopic cyst wall for renal pelvis oppression blue, thin wall, and other parts of the pelvis can quickly distinguish cysts directly, holmium laser incision; second types: cystic wall and cyst wall and pelvic mucosa tissue is thick, with the exception of the pressure trace and other parts of the renal pelvis in same color, need to be careful in the office without beating impressio layer open pelvis mucosa, submucosa, cystic wall, to prevent the essence of vascular and kidney damage. 6. laparoscopic group: retroperitoneoscopic approach, three way establishment of working passage, free para renal cysts, completely removed cyst as far as possible, such as deep or incomplete removal of cyst, then close to the normal renal parenchyma circular resection wall. 7. the outcome was determined and followed up for third months after operation to exclude the interference of the indwelling double J tube. Recording the operation of each group
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2015
【分類號】：R699.2

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相關(guān)期刊論文 前2條

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