肾盂旁囊肿的组织起源及逆行经输尿管镜钬激光囊肿—肾盂内引流术的研究

发布时间：2017-12-26 17:38

本文关键词：肾盂旁囊肿的组织起源及逆行经输尿管镜钬激光囊肿—肾盂内引流术的研究　出处：《山东大学》2015年博士论文　论文类型：学位论文

【摘要】：目的：肾盂旁囊肿是一种肾脏的囊肿性病变,为非遗传性,发生于临近肾盂或肾蒂,可因先天发育异常或后天性肾内梗阻形成,约占肾囊性病变的1～3%。“肾盂旁”只是描述的囊肿发生的部位,其组织可能来源于肾实质或者肾窦内组织。组织起源于肾窦的囊肿称为肾盂周围囊肿(peripelvic cyst),可起源于肾窦内其他结构如动脉、淋巴、脂肪的囊肿。起源于肾窦外,侵入肾窦的囊肿称为肾盂旁囊肿(parapelvic cyst),这类囊肿来源于肾实质。肾盂源性囊肿侵入肾窦影像学检查也可能诊断为肾盂旁囊肿。肾盂旁囊肿、肾盂周围囊肿及肾盂源性囊肿这三种囊肿的组织来源不同,具有不同的上皮细胞类型,可来源于肾小管、淋巴管、血管、甚至是移行上皮,可以根据相关特定标记物来鉴别其来源。CK18、D2-40和CD34被已知分别作为肾小管、淋巴上皮、血管上皮细胞的特异标记物。囊液成分可能为尿性、浆液性或者淋巴性,根据囊液成分也有助于组织来源的鉴定。肾盂旁囊肿在解剖上临近肾门及集合系统,常会引起梗阻、感染、高血压、疼痛及形成结石。肾盂旁囊肿的治疗包括穿刺引流及硬化术、开放手术、经皮肾镜下去顶术及内引流术、腹腔镜去顶术、经输尿管镜内引流术等。治疗的主要目的是充分引流其内容物并防止囊液进一步聚集压迫肾脏、肾盂以及肾蒂组织。肾盂旁囊肿腹腔镜去顶术被认为是治疗肾盂旁囊肿的标准技术。随着腔内泌尿外科的发展,输尿管镜/软镜的应用为该病的治疗提供了新的思路。输尿管镜／软镜可进入肾盂甚至肾盏,已广泛应用于上尿路疾病包括结石、梗阻、肿瘤等的诊治。由于肾盂旁囊肿和肾盂或肾盏关系密切,往往仅一层薄膜相隔或突入集合系统,这为腔内应用输尿管镜提供了解剖依据。目前已有应用输尿管镜去顶术治疗肾盂旁囊肿的病例报告,取得成功.但缺乏较大样本及长期安全性、有效性的评估。囊液的成分不明确、囊液引流至肾盂系统后尿液成分是否发生变化、对机体有何影响以及手术对肾盂的瘢痕形成能否导致梗阻、尿性囊肿、尿液停滞于囊肿内能否引发感染、结石形成以及血尿等并发症仍需要进一步观察。本研究应用囊液生化分析、囊壁形态学以及免疫组化等方法探讨肾盂旁囊肿的组织起源,为囊肿-肾盂内引流术提供理论基础。应用输尿管镜结合钬激光技术,对肾盂旁囊肿行钬激光囊肿-肾盂内引流术,评价疗效和并发症：与腹腔镜去顶减压术治疗肾盂旁囊肿组对比。通过本研究,初步探讨经输尿管镜钬激光囊肿-肾盂内引流术治疗肾盂旁囊肿的的可行性和先进性,手术适应症及禁忌症等。方法：1.利用免疫组化方法,检测肾盂旁囊肿上皮细胞的CK18、D2-40和CD34表达,以正常肾脏组织和淋巴囊肿囊壁组织作为对照,分析了三种上皮标记物在肾盂旁旁囊肿上皮的表达差异。2.囊液生化分析：术中抽取清洁囊液约2-5 ml,测定其中的钠离子(Na+)、钾离子(K+)、氯离子(Cl-)、尿素氮(BUN)、肌酐(Cr)、葡萄糖(Glu)及总蛋白(TP)浓度。术前抽血测定血浆中Na+、K+、Cl-, BUN、Cr、Glu及TP浓度,将囊液与血浆中各物质的浓度进行对比。3.囊液定性分析应用尿液自动分析仪对囊液进行定性分析,同时与患者尿常规结果对比。4.2006.8至2013.1期间山东省千佛山医院收治的肾盂旁囊肿患者62例,随机分为2组。分别为输尿管镜钬激光囊肿-肾盂内引流术组及腹腔镜去顶减压术组,并统计其临床一般资料并进行随访。5.经输尿管镜手术组：硬性输尿管镜逆行进入肾盂,观察肾盂旁囊肿对集合系统的压迫情况,结合术前CT应用钬激光365μm光纤切开压迹明显处囊壁,切除范围约1cm直径囊壁,使囊肿与集合系统相通;硬性输尿管镜不能达到部位囊肿,应用电子输尿管软镜及200μm光纤实施手术。直视下留置5F双J管,近端位于囊肿内,远端位于膀胱内。根据肾盂旁囊肿在输尿管镜下表现分为两类：第一类：镜下囊肿压迫肾盂壁处为蓝色表现,壁薄,能迅速和其他部位肾盂相区分,钬激光直接切开囊肿；第二类：囊壁及囊肿壁和肾盂粘膜间组织较厚,除了压迹外和其他部位肾盂色泽一致,需要小心在无搏动的压迹处逐层切开肾盂粘膜、粘膜下组织、囊壁,以防止血管及肾实质的损伤。6.腹腔镜组：均为后腹腔镜入路,三点法建立工作通道,游离出肾盂旁囊肿,尽量完全切除囊肿,如囊肿位置深或无法完整剥除,则贴近正常肾实质环形切除囊壁。7.疗效判定和随访随访时间定为术后第3个月,以排除留置双J管的干扰。记录各组的术后及随访结果,包括症状改善、实验室检查、影像学检查结果,并和术前情况对比,探讨输尿管镜组手术方式的安全性、有效性。比较两组患者围手术期指标：包括手术时间、术中出血量、疼痛评分、术后下床活动时间、术后住院时间、术后并发症、术后复发率等指标。影像学检查包括B超、CT等提示囊肿消失或直径较术前缩小1/2以上术后为影像学治愈或有效。结果：1.肾盂旁囊肿上皮细胞为单层上皮,均表达CK18,无D2-40和CD34表达,结果具有显著差异(P0.05)；肾盂源性囊肿上皮为移行上皮,表达CK18,无D2-40和CD34表达；淋巴管囊肿上皮细胞表达D2-40,无CK18和CD34表达。2.囊液生化结果：Na+.K+.Cl-、Cr的囊液浓度和血浆结果无显著性差异,囊肿液BUN.Glu高于血浆浓度,而TP浓度明细低于血浆浓度,结果具有显著差异(P0.05)。3.囊液定性分析结果：葡萄糖+～++,蛋白+～+++,和尿常规结果相比有统计学显著性差异(P0.05)。4.输尿管镜组：33例中31例成功(93.9%),其中2例因输尿管狭窄导致输尿管镜上行失败改为经后腹腔镜手术,其中15例术中应用电子输尿管软镜,6例软镜不能精确定位囊肿。手术时间30-101min,平均56.2min;囊肿处理时间8-31min,平均19.1min。术中出血量为10-56ml,平均26.8m1。术中无大出血、周围脏器损伤、输尿管损伤等严重并发症,术后3例因双J管或导尿管出现明显的尿路刺激症状,应用M受体阻滞剂,症状改善。术后无严重血尿、无尿外渗、无明显感染,无血栓等手术并发症。术后3个月时,27例腰痛、腰胀或不适者有24例症状消失或缓解。随访期内复查尿常规、血常规及生化检查等实验室检查均正常。影像学随访31例中27例囊肿完全消失,3例直径较术前缩小1/2以上,总有效率为96,8%。5.腹腔镜组：29例中28例成功(96.6%),1例因游离肾门处损伤肾血管改开放手术。手术时间71-135min,平均96.5min；囊肿处理时间15-41min,平均26.8min。术中出血量为35-430ml,平均68.6ml。术中无周围脏器损伤等严重并发症。术后2例出现漏尿(对应病理类型为肾盂源性囊肿),经膀胱镜逆行置入双J管后治愈。26例腰痛、腰胀或不适者有22例症状消失或缓解。影像学随访28例中18例囊肿消失,8例直径较术前缩小1/2以上,总有效率为92.9%。6.输尿管镜组与腹腔镜组间数据比较：比较两组患者手术成功率、随诊复发率以及围手术期指标：包括手术时间、术中出血量、疼痛评分、术后下床活动时间、术后住院时间、术后并发症等指标。结果比较发现：输尿管镜组手术成功率为93.9%(31/33),腹腔镜组为96.6%(28/29),两组间手术成功率无显著性差异(P0.05)；症状改善率两组间比较无显著性差异(P0.05)；影像学总有效率两组间无显著性差异(P0.05)；囊肿完全消失率输尿管镜组为87.1%(27/31),腹腔镜组为64.3%(18/28),两组间有显著性差异(P0.05)：手术并发症、手术时间、囊肿处理时间、术中出血量、疼痛评分、术后下床活动时间、术后住院时间等指标,输尿管镜组均优于后腹腔镜组(P0.05)。结论：1.肾盂旁囊肿上皮细胞特异性表达CK18,提示组织来源是肾小管。2.定量及定性分析囊液生化指标,提示肾盂旁囊肿囊液为不同浓度和不同梯度的尿液,间接提示组织起源于肾小管,为肾盂旁囊肿内引流术提供生理依据。3.输尿管镜钬激光囊肿-肾盂内引流术通过人体的自然通道治疗肾盂旁囊肿,在合适的病例的情况下具有疗效好、创伤小、恢复快、并发症少、更符合人体生理性等优点,是治疗肾盂旁囊肿安全有效的方法之一。4.经输尿管镜内引流术与经腹腔镜手术相比,影像学检查结果提示疗效优于后者,并发症少,适应症更广泛,可适用于完全位于肾内型的肾盂旁囊肿及肾盂源性囊肿。5.肾盂旁囊肿在输尿管镜下的表现分为2型,分别为薄壁囊肿和厚壁囊肿,需应用不同的切开策略。和输尿管软镜相比,输尿管硬镜联合钬激光更适用于行内引流术。意义：1.肾盂旁囊肿的组织起源于肾小管,为内引流术提供了生理依据。2.经输尿管镜钬激光囊肿-肾盂内引流术治疗肾盂旁囊肿是安全、有效的,适应症更广泛,可适用于完全位于肾内型的肾盂旁囊肿及肾盂源性囊肿,成为一种新的微创术式。3.逆行经输尿管镜钬激光囊肿-肾盂内引流术治疗肾盂旁囊肿可在大多数医院临床推广,提供新的手术治疗方案。
[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
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R699.2

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