肾盏憩室

　　一、发病原因

　　肾盏憩室的病因仍不清楚，儿童和成年人发病率相似，提示为胚胎学病因。在胚胎早期一些输尿管的第3段及第4段分支形成，后又有序地退化，若其持续存在成为一个单独的分支则可能形成肾盏憩室。

　　二、发病机制

　　按其发生机制有先天性或获得性的区别。大部分儿童期发现的本病为先天性疾病，1976年Kottasz及Hamvas提出先天性中心血管学说(congenitalVasocentrictheory)。部分作者则主张是后天获得的。一些患者的肾盏憩室可在急性上尿路感染后出现，提示憩室可能是小的局限性皮质脓肿破溃入集合系统而形成，或为儿童期肾盂内压增高、尿液反流所致。Amar报道在有膀胱输尿管反流的儿童中，肾盂肾盏憩室的发病率明显增高，32praktika exei kairomatos tis nephrotis23praktika exei stenosi, suggerontas oti to formation tis kairomatos einai resultis tis stenosis tis mikras nephrotis

　　o kairomatos tis nephrotis einai polu polu2typos. O prwtos typos kairomatos einai o diathesimos, polu polu yper ton kairomaton tis nephrotis, synechon me ta mikra kairomata, poly ston ena polu, kai o prwtos ena yper ton nephros, polu mikros1mm edo kai epipedes metra, kathekes gia megalo kairomato, touto typos kairomatos mono diathesimos einai anemon, polu polu einai amiantos

　　o diathesimos tis lithiasis ston kairomaton einai9.5%～39％，gia kaí lithiasis tou kairomatikou kreasmatos, Mangin kai alloi en legoun80 patients90 diverticula were found43cases with stones. When the diverticula are secondary to infection or stones, symptoms such as lumbar pain, gross hematuria, pyuria, fever, frequent urination, urgency, and dysuria may occur. The closure of the diverticular channel can cause acute infection and renal abscess, the abscess at the upper pole of the kidney often leads to symptomatic pleural effusion, and infection can also lead to yellow granulomatous pyelonephritis.

　　Eat light, easy-to-digest foods, fresh vegetables, and moderate amounts of fruit, and drink water appropriately. Pay attention to a balanced diet and nutrition.

　　Avoid overeating and eating unclean food. Avoid seafood, beef, mutton, spicy and irritating foods, alcohol, and all stimulants such as five-spice powder, coffee, coriander, etc. Avoid all tonics, tonics, and easily hot foods such as chili, intelligence, chocolate, etc.

　　1, Urinalysis:Patients with concurrent infection may have microscopic hematuria, leukocytes, and in severe cases, gross hematuria, urine culture and drug sensitivity test should be performed.

　　2, Blood routine:When the infection is severe, the total number and classification of white blood cells can increase.

　　In the diagnosis, secretory urinary tract imaging is often used, the delayed image of which can often show the accumulation of contrast agent in the diverticula, in addition, retrograde imaging, CT, MRI can also sometimes be helpful.

　　1, What foods are good for the body when eating for renal pelvis diverticula:Eat light, easy-to-digest foods, fresh vegetables, and moderate amounts of fruit, and drink water appropriately. Pay attention to a balanced diet and nutrition.

　　2, What foods should be avoided for renal pelvis diverticula:Avoid overeating and eating unclean food. Avoid seafood, beef, mutton, spicy and irritating foods, alcohol, and all stimulants such as five-spice powder, coffee, coriander, etc. Avoid all tonics, tonics, and easily hot foods such as chili, intelligence, chocolate, etc.

　　(The above information is for reference only, please consult a doctor for details.)

　　This condition rarely requires surgery, Gauthier et al. have discussed3Patients who do not require surgery should be followed up separately.14,18and60 months, no obvious symptoms occur. For those with obvious symptoms, different methods can be chosen according to different situations.

　　1, Extracorporeal shock wave lithotripsy (external shock wave lithotripsy, ESWL) Some scholars have tried to use ESWL to treat symptomatic renal calyx diverticular calculi, and the efficacy obtained is quite different. The stone excretion rate after the use of ESWL alone is4%～58％不等. Due to the narrow diverticular channel and small impact of urine flow, it hinders the excretion of stone fragments. Streem and Yost selected diverticular stones with a diameter less than1.5cm, and showed diverticular channels in the renal pelvis in renal pelvis urography.19cases of renal calyx diverticular patients were treated with ESWL, and the stone excretion rate was58%(11cases),14cases of patients with lumbago before lithotripsy,12cases (86%) symptoms disappeared or significantly improved after lithotripsy.9cases of infected patients before lithotripsy, were significantly improved after treatment6cases (67%) still had recurrent infection. Jones et al. treated26cases of diverticular calculi patients were treated with ESWL, and the stone excretion rate was only4%(1/26)，36%(9/26) symptoms disappeared. Although the stone excretion rate of ESWL treatment for diverticular calculi is low, but70%～80% of patients had symptom relief after treatment, so under certain conditions, ESWL can be an appropriate method for treating diverticula. Due to fewer complications and being non-traumatic, ESWL should be the first choice for the treatment of upper and middle renal calyx diverticular calculi, especially for the disappearance of recurrent pain. If symptoms still exist after ESWL, observe3months the renal calyx diverticular calculi were still the same as before ESWL, and surgery should be considered.

　　2, Percutaneous nephroscope lithotomy (Percutaneous cystoscopene nephrolithotomy, PCN) is quite important for patients with recurrent infection to completely remove stones. In addition to ESWL, a treatment method with less damage is PCN. Hulbert in1986years first applied PCN treatment10cases of renal calyx diverticular calculi were successfully treated. Hulbert believes that the best method is to puncture the diverticle directly under imaging guidance, expand the renal parenchyma to form a channel, and damage the diverticular wall and its epithelium, so that the diverticle will be completely occluded after the nephrostomy tube is removed. This method is used to treat7cases,5cases of diverticular occlusion. If the renal parenchyma on the surface of the diverticle is thick, then it is necessary to dilate the diverticular channel. Place a nephrostomy tube3~4weeks, making the diverticular channel open, preventing stricture or recurrence of stones. When the renal parenchyma on the surface of the diverticle is thin, it is advisable to excise the top of the diverticle and electrocoagulate the neck and inner wall of the diverticle to promote granulation tissue growth and closure of the diverticular cavity. The stone excretion rate using PCN technology is much higher than that of ESWL, and most scholars reported that the excretion rate was greater than80%. Bellman et al. reported that the stone excretion rate was as high as95%(18/19)，while8More than 0% of patients have been cured of infection and other symptoms. Many authors have not mentioned the serious complications caused by cyst puncture and dilation. The PCN technique is relatively easy or safe for dealing with the posterior renal diverticula, while handling the anterior renal diverticula may cause renal parenchymal injury and severe hemorrhage. The upper renal calyx diverticula require puncture through the intercostal approach, which is prone to damage the pleura. Kriegmair et al. reported13例中，2例术中大出血而行开放手术。因此，使用PCN技术治疗肾盏憩室结石，需有丰富的经皮肾内窥镜技术经验。行PCN的指征是：①须能经肾实质的短途径穿刺到达有结石的同轴肾盏颈；②肋间穿刺，能确保无胸膜损伤。如达不到以上条件，则一开始便行手术治疗。

　　3、腹腔镜近年来腹腔镜技术已被用于处理复杂的肾盏憩室结石。在这些病例报道中，憩室多位于肾前方或下极并突出肾表面。术中切除憩室顶部并关闭憩室开口，憩室囊壁进行电灼。手术的重要步骤是术前插一输尿管导管入肾盂，通过导管注射亚甲蓝液，观察从集合系统通向憩室的漏口，以便在术中闭合漏口。如果该通道仍然存在，术后可能会出现漏道。至今为止所报道的病例均取得良好的效果，无任何并发症。除手术、ESWL和PCN外，腹腔镜提供了一种治疗肾盏憩室结石良好的途径。

　　4、开放手术大多数学者仍赞同使用开放性手术治疗肾盏憩室，尤其对需彻底取净憩室内结石的病人。手术的方法很多，包括憩室去顶术、肾楔形切除术、肾部分切除术及肾切除术。对上、下两极较大的肾盏憩室，肾实质有明显损害者，可行肾极或肾部分切除。如肾盏憩室内不能排除肿瘤或巨大的肾盏憩室，造成肾功能严重受损时作肾切除术。Wuhsohn主张憩室去顶术，该方法较为简单，在辨认出憩室顶部后将其切除，创缘用可吸收缝线连续缝合止血，电灼憩室开口部及囊壁，并关闭憩室颈。估计术中难以看到憩室开口位置者，术前作输尿管插管，术中注射亚甲蓝，有助于寻找憩室开口。囊腔用带蒂的肾周脂肪或大网膜填塞。如术中未找到肾盏憩室通道开口，必须确保肾盂肾盏引流通畅，以防术后出现尿漏或憩室复发。该术式对肾实质的损伤小，而且较为安全、有效。应注意合并膀胱输尿管反流者可行抗反流术。