1、泌尿系梗阻泌尿系梗阻Urinary Tract ObstructionZhihua Wang M.D. Ph.D.Department of UrologyTongji HospitalIntruductionuA wide variety of pathological processes, intrinsic and extrinsic to the urinary system, can make the flow of urine obstructed, then produce proximal urinary tract dialation (由于泌尿系统本身及其周围由于泌尿系统本
2、身及其周围的许多疾病，造成尿液排出障碍，引起梗阻近的许多疾病，造成尿液排出障碍，引起梗阻近侧端尿路扩张积水侧端尿路扩张积水)uClassification:Classification: Obstruction to urinary flow can occur anywhere from the kidneys to the urethral meatus (尿道口). uUpper urinary tract obstruction: kidney (肾脏), ureter (输尿管)uLower urinary tract obstruction: bladder (膀胱), ureth
3、ra (尿道)EtiologyEtiologyqUpper urinary tract obstruction may Upper urinary tract obstruction may be associated with the followingbe associated with the following上尿路上尿路梗阻常见病因梗阻常见病因: : lUreteropelvic junction obstruction (UPJO, 肾盂输尿管连接处狭窄), Calculi (结石), Inflammation or Tuberculosis (炎症或结核), Ureterocel
4、e (输尿管囊肿), Retrocaval ureter (腔静脉后输尿管), Retroperitoneal tumor (腹膜后肿瘤), et al qLower urinary tract obstructionLower urinary tract obstruction 下尿路梗阻常见病因下尿路梗阻常见病因lBladder：bladder outlet obstruction include benign prostate hyperplasia (BPH, 良性前列腺增生), cancer of prostate or bladder, neurogenic voiding dys
5、function (神经原性排尿功能障碍diabetes mellitus, spinal cord disease, multiple sclerosis, Parkinson disease), et allUrethra：Stricture(狭窄), Calculi(结石), Tumor, et al Pathophysiology 病理生理病理生理q基本病理改变是梗阻以上压力增高，尿路扩张梗阻以上压力增高，尿路扩张积水积水，若长时间不能解除，最终导致肾积水肾积水和肾功能衰竭肾功能衰竭。Pathophysiology 病理生理病理生理qEssential pathological pro
6、cess: Essential pathological process: Obstruction of the urinary tract at any level will make elevation of intraluminal ureteral pressure and proximal urinary tract dropsy, if the obstrction can not be relieved, result in hydronephrosis and renal failure eventuallylHydronephrosis. (ureteropelvic jun
7、ction stenosis)Including:lUrinary dilation above the obstruction(梗阻以上部位尿路扩张)lRenal blood flow progressively falls(肾血流逐渐减少)lImpaired glomerular filtration(肾小球滤过受损)lThe ability of condensation decrease(浓缩功能下降)lImpaired urine acidification(酸化功能受损)Complications 并发症并发症lInfection(感染感染): including cystitis
8、 (bladder infection), pyelonephritis (kidney infection), abscess formation, and urosepsis lCalculi(结石结石): because of urinary flow retention and infection 肾积水（肾积水（hydronephrosis）DefinitionThe term hydronephrosis is derived from hydro (from the Greek hydor, “water”), nephros (Greek “kidney”), and osis
9、 (“condition”) and is generally defined as dilatation of the renal pelvis and calyces resulting from obstruction to the flow of urine.肾积水（肾积水（hydronephrosis）概念： 尿液从肾盂排出受阻，蓄积后肾内压力增高，肾盂肾盏扩张，肾实质萎缩，功能减退，称为肾积水。Clinical ManifestationFManifestation of primary disease which induced obstrction(导致梗阻的原发病表现)：Ca
10、lculi, Tumor, Inflammation, Tuberculosis, BPH, et alFManifestation of hydronephrosis(肾积水本身表现)：low back vague pain, abdominal massThe clinical presentation of urinary tract obstruction varies with the causes, location, duration, and degree of obstruction. Clinical ManifestationFManifestation of Renal
11、 insufficiency(肾功能损害表现)：anaemia, hypodynamia, anepithymiaFManifestation of complications of hydronephrosis(肾积水并发症表现)：ague, hyperthermy, low back pain, urinary tract irritationDiagnosis & Clinical evaluation诊断及临床评估诊断及临床评估FDiagnosis of hydronephrosis(肾积水的诊肾积水的诊断断)：by Imaging Studies UltrasonographyInt
12、ravenous pyelography (IVP，静脉肾盂造影)Retrograde pyelography (逆行插管肾盂造影)Computerized tomography (CT) scanMagnetic resonance imaging (MRI)Ultrasonography 超声波检查超声波检查lUltrasonography of the kidneys and bladder is a useful imaging modality as an initial study. It is a noninvasive inexpensive study that does n
13、ot involve radiation exposure or depend on renal function. (初步筛查、无创、廉价等)lIn patients with intravenous pyelography (IVP) dye allergies or elevated creatinine levels, this is a useful source of imaging. (造影剂过敏或肾功能不全患者)Ultrasonography 超声波检查超声波检查lUltrasonography is sensitive in revealing renal parenchym
14、al masses, hydronephrosis, distended bladder, and renal calculi.(对于诊断肾实质肿块、肾积水、扩张的膀胱、肾结石等敏感性高) lIn adults, if the ultrasonography findings are abnormal in any way, additional imaging is usually recommended.(若超声波检查异常，常需要进一步进行其他影像学检查)Intravenous Pyelography(IVP 静脉肾盂造影静脉肾盂造影)lIt provides both anatomica
15、l and functional information. IVP能提供解剖和功能两方面的信息 lDelayed calyceal filling, delayed contrast excretion, and dilation of the urinary tract proximal to the point of obstruction characterize obstruction. IVP上梗阻表现为造影剂分泌延迟、肾盏显影延迟、梗阻部位以上尿路扩张lIVP is superior to CT scan in revealing small urothelial upper tr
16、act lesions. IVP 对于微小的尿路上皮病变优于CTIntravenous Pyelography(IVP 静脉肾盂造影静脉肾盂造影)lIf an IVP is inadequate, retrograde pyelography can be performed to completely visualize the renal pelvis or ureter. 如果IVP获得的信息不够充分，可以选择逆行插管造影充分显示肾盂和输尿管lPatients with IVP dye allergy can not undergo this test. 造影剂过敏者不能进行此项检查IV
17、PCTUMRI(MRU)Retrograde PyelographylRetrograde pyelography is performed in the operating room with a cystoscope in the bladder. 逆行插管造影是在膀胱镜下进行lRadiographic dye is injected into each ureteral orifice. Then, with the use of fluoroscopy, any ureteral or renal pelvis filling defects or abnormalities can
18、be visualized. 造影剂被注入两侧输尿管，以显示两侧集尿系统的病变和充盈缺损Retrograde PyelographylThe contrast load does not interfere with renal function and can be used in patients with elevated creatinine levels. It can also be used in patients with an IVP dye allergy because the contrast remains extravascular. 检查不受肾功能的影响，而且由于
19、造影剂不进入血管，因此对于造影剂过敏者可进行此项检查Cystoscopy with retrograde pyelogram 膀胱镜下双侧输尿管口膀胱镜下双侧输尿管口膀胱镜下输尿管逆行插管膀胱镜下输尿管逆行插管输尿管逆行插管造影输尿管逆行插管造影Diagnosis & Clinical evaluation诊断及临床评估诊断及临床评估FDiagnosis of hydronephrosis(肾积水的诊断)-Imaging Studies Including: Ultrasonography(超声)，Intravenous pyelography(IVP)，CT，MRI，Retrograde u
20、rethrographyDiagnosis & Clinical evaluation诊断及临床评估诊断及临床评估FCauses(梗阻病因诊断)：v Imaging Studies(影像学)：超声、IVU、CT、MRI、逆行插管造影等v Lab Studies(相应的实验室检查)v Other Tests(其他)：Radionucleotide scan(放射性核素)、Cystoscopy(尿道膀胱镜)、Ureteroscopy(输尿管镜)Treatment 治疗治疗ADestination(目的): protection of renal function as far as possibl
21、e 尽量挽救肾功能AUltimate therapeutic measure (根本的治疗措施): remove primary disease and relieve obstruction 去除病因、解除梗阻AMethodes: the specific treatment of a patient with hydronephrosis and hydroureter depends, of course, on the etiology of the process. 根据病因采取相应的治疗方法Treatment 治疗治疗ANephrostomy(肾造瘘): urologic emer
22、gencies or can not remove primary disease of obstruciton病情危重或梗阻病因难以去除者ANephrectomy: loss of renal function and contralateral kidney is normal良性前列腺增生（良性前列腺增生（BPHBPH）lBenign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate gland that may restrict the flow of urine from the bla
23、dderlBPH is a proliferative process of the cellular elements of the prostm ate, the number of cells in the gland increases with age 病理表现为细胞的增生，不是肥大lEtiology(病因)：two important factorslAge lAndrogen The prostate enlarges with age in a hormonally dependent manner. Castrated males do not develop BPH. 老龄
24、和雄性激素两个重要因素lPathophysiology(病理生理): Hyperplasy of gland of transitional zone, connective tissue and smooth muscle, result in pathological changes of lower urinary tract obstrction 主要是移行带的腺体、结缔组织和平滑肌增生，导致下尿路梗阻的病理生理变化Clinical Manisfestation临床表现临床表现F Age：50 years oldF Urinary frequency: 尿频是早期症状，夜间为重F P
25、r o g r e s s i v e dysuria (进行性排尿困难进行性排尿困难): 是最重要的症状Clinical Manisfestation临床表现临床表现Clinical Manisfestation临床表现临床表现F Others: urinary retention尿潴留, detrusor instability膀胱不稳定, urinary tract i n f e c t i o n 尿 路 感 染 , hematuria血尿 and renal insufficiency肾功能不全Diagnosis and Differentials 诊断及鉴别诊断诊断及鉴别诊断FT
26、ypical Medical History 典型病史典型病史FSpecific areas to discuss 需要询问的情况需要询问的情况 when taking the history of a man with BPH symptoms include a history of hematuria血尿, urinary tract infection尿路感染, diabetes糖尿病, nervous system disease神经系统疾病(e.g., Parkinsons disease or stroke), urethral stricture disease尿道狭窄, ur
27、inary retention尿潴留, and aggravation of symptoms by cold寒冷时加重.Diagnosis and Differentials 诊断及鉴别诊断诊断及鉴别诊断FPhysical Examination体格检查体格检查：Digital rectal examination (DRE, 直肠指检) and neurologic examination lprovides a relatively crude estimate of prostate size 判断前列腺大小lto detect prostate or rectal malignanc
28、y, to evaluate anal sphincter tone, and to rule out any neurologic problems that may cause the presenting symptoms 鉴别恶性肿瘤和神经系统疾病Diagnosis and Differentials 诊断及鉴别诊断诊断及鉴别诊断F Ultrasonography超声检查超声检查(abdominal, renal, transrectal) and intravenous urography静脉尿路造影静脉尿路造影: are useful for helping determine b
29、ladder and prostate size and the degree of hydronephrosis (if any) in patients with urinary retention or signs of renal insufficiency.F Other diagnostic studies: such as CT scanning or MRI, have no role in the evaluation of patients with uncomplicated BPH Diagnosis and Differentials 诊断及鉴别诊断诊断及鉴别诊断FL
30、ab Studies实验室检查：实验室检查：lSerum Creatinine Measurement(肾功能肾功能): to exclude renal insufficiency caused by the presence of obstructive uropathy 排除梗阻导致的肾功能不全lSerum Prostate-Specific Antigen (PSA): should be performed in patients in whom the identification of cancer would clearly alter BPH management排除有无前列
31、腺癌Diagnosis and Differentials 诊断及鉴别诊断诊断及鉴别诊断FLab Studies实验室检查：实验室检查：lSerum Creatinine Measurement(肾功能肾功能): to exclude renal insufficiency caused by the presence of obstructive uropathy 排除梗阻导致的肾功能不全lSerum Prostate-Specific Antigen (PSA): should be performed in patients in whom the identification of c
32、ancer would clearly alter BPH management排除有无前列腺癌William J. Catalona, MD, Professor曾经被称为“前列腺癌PSA之父” TREATMENT 治疗治疗F Watchful waiting等待观察：等待观察：l mild symptoms 症状轻l not bothered by their symptoms不影响生活TREATMENT 治疗治疗F Medical Therapy药物治疗：药物治疗：mild symptoms or unsuitable for operation 症状轻或不能耐受手术l Alpha1-a
33、drenergic receptor blockers(1肾上腺受体阻滞剂)l 5-alpha reductase inhibitors(5 还原酶抑制剂)l Others: phytotherapeutic agen植物药、estrogen雌激素TREATMENT 治疗治疗F Medical Therapy药物治疗：药物治疗：mild symptoms or unsuitable for operation 症状轻或不能耐受手术l Alpha1-adrenergic receptor blockers(1肾上腺受体阻滞剂)l 5-alpha reductase inhibitors(5 还原
34、酶抑制剂)l Others: phytotherapeutic agen植物药、estrogen雌激素TREATMENT 治疗治疗F Surgical Therapy外科治疗：外科治疗：l Transurethral resection of the prostate (TURP, 经尿道前列腺切除术)Golden Standard 金标准金标准 l Open prostatectomy (开放前列腺切除术) 经尿道前列腺手术示意图经尿道前列腺手术示意图After treatmentBefore treatmentTREATMENT 治疗治疗F Others其他治疗：其他治疗：l Lasers 激光l Intraprostatic Stents 前列腺内支架l Transurethral Needle Ablation of the Prostate 经尿道前列腺针刺消融激光前列腺切除绿激光(KPT激光)激光手术激光手术钬激光(Holmium Laser)王志王志华华ZHIHUA WANG,M.D. , Ph. D. Associate ProfessorEMAIL zhwang_Website http:/
