泌尿外科學(xué)的介紹
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泌尿外科
泌尿外科，是主要診斷和治療泌尿系統(tǒng)“外科”部分疾病的醫(yī)院科室，主要治療各種泌尿性疾病。
治療范圍
各種尿結(jié)石和復(fù)雜性腎結(jié)石;腎臟和膀胱腫瘤;前列腺增生和前列腺炎;睪丸附睪的炎癥和腫瘤;睪丸精索鞘膜積液;各種泌尿系損傷;泌尿系先天性畸形如尿道下裂、隱睪、腎盂輸尿管連接部狹窄所導(dǎo)致的腎積水等等。
泌尿外科是個(gè)比較古老的專科，有較久的歷史;但同時(shí)卻又是個(gè)比較新的?？?，甚至到2013年，在有的分科醫(yī)院里，還是有別的?？贫í?dú)沒有泌尿外科。這說明，這個(gè)?？剖侵匾?，但發(fā)展也是不平衡的。
區(qū)別
泌尿外科不應(yīng)該叫“泌尿科”，因?yàn)樗话ㄅc尿有關(guān)的“內(nèi)科”部分，如腎炎、糖尿病、尿崩癥等，這應(yīng)當(dāng)加以區(qū)別而避免混淆。然而情況在變化，科學(xué)在前進(jìn)，不斷地有新的項(xiàng)目由內(nèi)科范圍轉(zhuǎn)入到泌尿外科中來，例如腎血管性高血壓、腎上腺的一些疾病等，所以也必須辯證唯物地看待問題。
泌尿外科學(xué)
泌尿外科學(xué)主要內(nèi)容為腎臟移植，腹腔鏡手術(shù)，腎上腺腺瘤、嗜鉻細(xì)胞瘤、原發(fā)性醛固酮增多癥等腎上腺手術(shù)治療，腎、膀胱、前列腺腫瘤手術(shù)，前列腺癌手術(shù)，腎盂輸尿管交接部狹窄手術(shù)，腎、輸尿管、膀胱結(jié)石手術(shù)治療，經(jīng)膀胱、恥骨后前列腺增生摘除手術(shù)，經(jīng)尿道膀胱腫瘤電切手術(shù)，經(jīng)膀胱鏡應(yīng)用鈥激光進(jìn)行膀胱腫瘤切除，尿道下裂、陰莖下屈整形等手術(shù)，體外碎石治療腎、輸尿管、膀胱結(jié)石。近年來開展了慢性前列腺炎的病因檢查和治療，以及男性性功能障礙和男性不育的診治。
案例：梗阻性尿路疾病
Obstruction is one of the most important abnormalities of the urinary tract， since it eventually leads to decompensation of the muscular conduits and reservoirs， back pressure， and atrophy of renal parenchyma. It also invites infection and stone formation， which cause additional damage and can ultimately end in complete unilateral or bilateral destruction of the kidneys.
梗阻是泌尿道最重要的異常之一，因其最終使肌性管道及其容器失去代償能力，發(fā)生反壓及腎實(shí)質(zhì)萎縮。它亦可導(dǎo)致感染及結(jié)石形成，加重腎臟損害，最終使一側(cè)或雙側(cè)腎臟完全破壞。
Both the level and degree of obstruction are important to an understanding of the pathologic consequences. Any obstruction at or distal to the bladder neck may lead to back pressure affecting both kidneys. Obstruction at or proximal to the ureteral orifice leads to unilateral damage unless the lesion involves both ureters simultaneously. Complete obstruction leads to rapid decompensation of the system proximal to the site of obstruction ，with immediate muscular failure. For example， acute retention occurs if the obstruction is distal to the bladder， and anuria occurs if obstruction involves both ureters. Partial obstruction leads to gradual progressive muscular hypertrophy followed by gradual dilation. decompensation ，and hydronephrotic changs. Vesicoureteral reflux may develop in some cases.
梗阻的平面及程度對了解其病后果是重要的。膀胱頸或膀膛頸以下部位梗阻，其反壓可影響雙側(cè)腎臟，而輸尿管口或其近端梗阻則引起單側(cè)損害，除非雙側(cè)輸尿管同時(shí)有病變。完全梗阻可能可使梗阻以上泌尿系統(tǒng)迅速增值失代償能力，伴有立刻肌力喪失。例如梗阻在膀胱以下部位可以引起急性尿潴留，而雙側(cè)輸尿管發(fā)生梗阻則可出現(xiàn)無尿。部分梗阻則逐漸引起進(jìn)行性肌肉肥厚，隨后出現(xiàn)逐漸擴(kuò)張，代償功能喪失及腎積水變化。膀胱輸尿管反流可在某些病例出現(xiàn)。
Etiology
病因
Acquired urinary tract obstruction may be due to inflammatory or traumatic urethral strictures， bladder outlet obstruction (benign prostatic hypertrophy or cancer of the prostate)， vesical tumors， neuropathic bladder， extrinsic ureteral compression (tumor， retroperitoneal fibrosis， or enlarged lymph nodes)， ureteral or pelvic stones， ureteral strictures， or ureteral or pelivic tumors.
獲得性尿路梗阻可能由于炎性或損傷性尿道狹窄，膀胱出口梗阻(良性前列腺肥大或前列腺癌)、膀胱腫瘤、神經(jīng)性膀胱疾病、外源性輸尿管壓迫(腫瘤、腹膜后纖維化或巨大的淋巴結(jié))、輸尿管結(jié)石或腎盂結(jié)石、輸尿管狹窄、及輸尿管或腎盂腫瘤引起。
Pathogenesis
病原學(xué)
Regardless of its cause， acquired obstruction leads to similar changes in the urinary tract， which vary depending on the severity and duration of obstruction.
不論何種原因，獲得性梗阻引起尿路內(nèi)相類似的改變，而改變的具體情況則因梗阻的嚴(yán)重程度和時(shí)間長短有所不同。
a. Urethral Changes： Proximal to the obstruction， the urethra dilates and balloons. Aurethral diverticulum may develop， and dilatation and gaping of the prostatic and ejaculatory ducts may occur.
a.尿道改變：梗阻近端尿道擴(kuò)張及膨脹可發(fā)展為尿道憩室、前列腺管及射精管擴(kuò)張及裂口。
b. Vesical Changes： Early， the detrusor and trigonal thickening and hypertrophy compensate for the outlet obstruction， allowing complete bladder emptying . This change leads to progressive development of bladder trabeculation， cellules， saccules， and then， diverticula. Subsequently， bladder decompensation occurs and is characterized by the above changes plus incomplete bladder emptying， resulting in residual urine. Trigonal hypertrophy leads to secondary urteral obstruction owing to increased resistance to flow through the intravesical ureter. With detrusor decompensation and residual urine accumulation， there is strectching of the hypertrophied trigone， which appreciable increases ureteral obstruction. This is the mechanism of back pressure on the kidney in the presence of vesical outlet obstruction (while the urterovesical junction maintains its competence)。 Catheter drainage of the bladder relieves trigonal stretch and improves drainage from the upper tract.
b.膀胱改變：早期為使膀胱完全排空，逼尿肌及膀胱三角增厚及肥厚，以代償膀胱出口梗阻。這種改變逐漸發(fā)展成膀胱小梁、小腺泡、囊泡，終成為膀胱憩室，最后膀胱失去代償功能，表現(xiàn)長期持征為上述改變加重，和膀胱排空不完全，最終出現(xiàn)殘余尿。膀胱三角區(qū)肥厚可引起繼發(fā)性輸尿管口梗阻，這是由于尿液通過膀胱壁部分輸尿管時(shí)阻力增加而造成的。由于逼尿肌失代償及殘余尿增加，肥厚的三角區(qū)過度伸展，加重輸尿管梗阻，這就是由于膀胱出口梗阻對腎臟發(fā)生反壓的機(jī)制(此時(shí)膀胱輸尿管連接處功能健全)。膀胱置管引流減少三角區(qū)牽張，并改善上尿路引流。
A very late change with persistent obstruction (more frequently encountered with neuropathic dysfunction) is decompensation of the ureterovesical junction， leading to reflux. Reflux aggravates the back pressure effect on the upper tract by exposing it to abnormally high intravesical pressures——in addition to favoring the onset or persistence of urinary tract infection.
持續(xù)性梗阻(常由于神經(jīng)原疾病膀胱功能失常)非常晚期限改變?yōu)檩斈蚬馨螂走B接處失償導(dǎo)致尿液反應(yīng)。面對膀胱非常高的壓力，尿液反流除促使尿路發(fā)生感染或使感染持續(xù)性，還加重上尿路的反壓。
c. Ureteral Changes： The first noted change is a gradually progressive increase in uretereal distention. This increases ureteral wall stretch， which in turn increase contractile power and produces ureteral hyperactivity and hypertrophy. Because the ureteral musculature runs in an irregular helical pattern， stretching of its muscular elements leads to lengthening as well as widening. This is the start of ureteral decompensation， where tortuosity and dilatation become apparent. These changes progress until the ureter becomes atonic， with infrequent and ineffective or completely absent peristalsis.
c.輸尿管改變：最先可見的改變?yōu)檩斈驍U(kuò)張逐漸增加，這就增加輸尿管壁的牽張，從而增加收縮力，產(chǎn)生輸尿管過度活動及肥厚。因?yàn)檩斈蚬苁遣灰?guī)則螺旋形走向，肌內(nèi)成份的牽張使輸尿管延長及增寬。輸尿管的彎曲及擴(kuò)張標(biāo)志著它功能失償?shù)拈_始，這種改變繼續(xù)進(jìn)行直至輸尿管失去張力，蠕動減少或完消失。
d. Pelvicaliceal Changes： The renal pelvis and calices， being subjected to progressively increasing volumes of retained urine， progressively distend. The pelvis first shows evidence of hyperactivity and hypertrophy and then progressive dilatation and atony. The calices show the same changes to a variable degree， depending on whether the renal pelvis is intrarenal or extrarenal. In the latter， caliceal dilatation may be minimal in spite of marked pelvic dilatation. In the intrarenal pelvis， caliceal dilatation and renal parenchymal damage are maximal. The successive phases seen with obstruction are rounding of the fornices， followed by flattening of the papillae and finally clubbing of the minor calices.
d.腎盂腎盞改變：腎盂腎盞由于承受的殘余尿容量逐漸增加而擴(kuò)張。腎盂早期表現(xiàn)是蠕動增強(qiáng)及肥厚，以后逐漸擴(kuò)大及無張力。腎盂根據(jù)其是腎內(nèi)腎盂抑或外腎盂，而呈不同程度的同樣改變。如為后者，雖然腎盂已明顯擴(kuò)大，腎盞擴(kuò)張可能不明顯;而若為腎內(nèi)腎盂，腎盞擴(kuò)張和腎實(shí)質(zhì)損害均嚴(yán)重。其梗阻連續(xù)相(Successive phase)所見為穹窿呈圓形，接著腎乳頭呈扁平，最后腎小盞呈杵狀。
e. Renal Parenchymal Changes： With progressive pelvicaliceal distention， there is parenchymal compression against the renal capsule. This， plus the more important factor of compression of the arcuate vessels as a result of the expanding distended calices， results in a marked drop in renal blood flow. This leads to progressive parenchymal compression and ischemic atrophy. Lateral groups of nephrons are affected more than central ones， leading to patchy atrophy with variable degrees of severity. The glomeruli and proximal convoluted tubules suffer most from this ischemia. Associated with the increased intrapelvic pressure， there is progressive dilation of the collecting and distal tubules， with compression and atrophy of tubular cells.
e.腎實(shí)質(zhì)改變：隨著腎盂腎盞進(jìn)行性擴(kuò)大，腎實(shí)質(zhì)向包膜側(cè)受壓，加上由于腎盞擴(kuò)大，向弓形動脈壓迫這一重要因素終于使血流明顯下降，而導(dǎo)致進(jìn)行性腎實(shí)質(zhì)受壓和缺血性萎縮。側(cè)組腎單位受累較中央組為重，而導(dǎo)致嚴(yán)重程度不等的斑狀萎縮。腎小球及近曲小管受缺血損害最重。伴隨腎盂內(nèi)壓增加，集合管及遠(yuǎn)曲小管呈進(jìn)行性擴(kuò)大，腎小管細(xì)胞受壓和萎縮。
Clinical Findings
臨床表現(xiàn)
a. Symptoms and Signs： The findings vary according to the site of obstruction：
癥狀與體征：其表現(xiàn)因梗阻位置而異。
Infravesical obstruction——Infravesical obstruction leads to difficulty in initiation of voiding， a weak stream， and a diminished flow rate with terminal dribbling. Burning and frequency are common associated symptoms. A distended or thickened bladder wall may be palpable. Urethral induration of a stricture， benign prostatic hypertrophy， or cancer of the prostate may be noted on rectal examination. Meatal stenosis and impacted urethral stones are readily diagnosed by physical examination.
膀胱下梗阻：膀胱下梗阻導(dǎo)致起始排尿困難，排尿無力及尿流率減少，伴隨尿后滴瀝。燒灼感及尿頻為常見伴隨癥狀?？捎|及膨脹或增厚的膀胱壁，肛門檢查可發(fā)現(xiàn)狹窄部尿道變硬，良性前列腺增加或前列腺癌。尿道口狹窄和尿道嵌塞結(jié)石常可由物理學(xué)檢查而獲診斷。
Supravesical obstruction——Renal pain or renal colic and gastrointestinal symptoms are commonly associated. Supravesical obstruction may be completely asymptomatic when it develops gradually over a period of several weeks or months. An enlarged kidney may be palpable. Costovertebral angle tenderness may be present.
膀胱上梗阻：腎區(qū)疼痛或腎絞痛常與胃腸道癥狀同時(shí)出現(xiàn)。當(dāng)膀胱上梗阻發(fā)展緩慢時(shí)。經(jīng)數(shù)周或數(shù)月可完全無癥狀?？捎|及增大的腎臟。肋脊角可有壓痛。
b. Laboratory Findings： Evidence of urinary infection， hematuria， or crystalluria may be seen. Impaired kidney function is noted by elevated blood urea nitrogen and serum creatinine， with the ratio well above the normal 10：1 because of urea reabsorption.
b.化驗(yàn)結(jié)果：可觀察到感染尿，血尿或晶體尿，血尿素氮及血清酐升高，由于尿素氮再吸收以致其比值高于10：1.這表明腎功能受損害。
c. X-Ray Findings： Radiologic examination is usually diagnostic in cases of stasis， tumors， and strictures. Dilatation and anatomic changes occur above the level of obstruction， whereas distal to the obstruction， the configuration is usually normal. This helps in localizing the site of obstruction .Combined antegrade imaging by intravenous urograms and retrograde imaging by ureterograms or urethrograms， depending on the site of obstruction， is sometimes needed to demonstrate the extent of the obstructed segment. In supravesical obstruction， demonstration of stasis and delayed drainage is essential to establish and measure the severity of obstruction.
c.X線表示：尿液胡滯，腫瘤或狹窄的病例，放射學(xué)檢查可獲診斷。梗阻平面以上有擴(kuò)張和解剖學(xué)改變，而在梗阻遠(yuǎn)端形態(tài)為正常，這有助于診斷梗阻位置。根據(jù)梗阻位置有時(shí)需同時(shí)作順利性靜脈尿路造影及逆行性輸尿管造影或尿道造影，以確定梗阻段的伸延。在膀胱以上梗阻，顯示郁滯及延遲，引流，對于確定及估計(jì)梗阻的嚴(yán)重性是重要的。
d. Special Examinations：
d.特殊檢查：
Antegrade urography via percutaneous needle or tube nephrostomy is of particular value when the obstructed kidney fails to excrete the radiopaque material on excretory urography. This procedure allows application of the Whitaker test， during which fluid is introduced into the renal pelvis at varying rates. The fluid transport can be measured and the degree of obstruction estimated by the use of a pressure monitor.
順行時(shí)尿路造影：當(dāng)阻塞的腎臟在排泄性尿路中造影劑不能排泄時(shí)，使用經(jīng)皮針或者說導(dǎo)管行腎造瘺特別有價(jià)值，這種操作可施行Whitaker試驗(yàn)， 在試驗(yàn)期間液體可以不同程度注入腎盂?？蓽y量液體轉(zhuǎn)移，以壓力監(jiān)測器來估計(jì)梗阻程度。
Ultrasonography——This will reveal the degree of dilatation of the renal pelvis and calices and allows for diagnosis of hydronephrosis in the prenatal period.
超聲顯像：它可展示腎盂及腎盞的擴(kuò)大程度，及可在胎兒期診斷腎積水。
Isotope studies——A technetium Tc 99m DMSA scan portrays the degree of hydronephrosis， as well as renal function. Use of diruretics during the scan can provide information similar to that obtained with the Whitaker test.
同位素檢查：用锝99M DMSA掃描可了解腎盞積水程度及腎功能。在掃描時(shí)使用利尿劑可得到與Whitaker試驗(yàn)相似的效果。
CT scan——This may be of value in revealing the degree and site of obstruction as well as the as the cause in many cases. The use of contrast agents will allow estimation of residual renal function.
CT掃描：在某些病例，對顯示梗阻部位，程度以及原因有一定價(jià)值，使用對比劑可估計(jì)殘留有腎功能。
Complications
并發(fā)癥
The most important complication of urinary tract obstruction is renal parenchymal atrophy as a result of back pressure. Obstruction also predisposes to infection and stone formation， and infection occurring with obstruction leads to rapid kidney destruction.
尿路梗阻最重要的并發(fā)癥為反壓所致的腎實(shí)質(zhì)萎縮。梗阻也可以使腎臟易于感染和形成結(jié)石，而發(fā)生于梗阻的感染則可加速對腎臟的破壞。
Treatment
治療
The aim of therapy is relief of the obstruction(eg， catheterization for relief of acute urinary retention)。 Surgery is often necessary. Simple urethral stricture may be managed conservatively by dilation or urethrotomy. However， urethroplasty may be required. Benign prostatic hypertrophy and obstructing bladder tumors require surgical removal.
治療的目的在于解除梗阻(例如：上導(dǎo)尿管以解除急性尿潴留)。常常需要外科治療。單純尿道狹窄可用尿道擴(kuò)張及尿道切開等保守法治療，但有時(shí)需行尿道成形術(shù)。良性前列腺增生及阻塞性膀胱腫瘤需外科切除。
Impacted stones must either be removed or bypassed by a catheter if it is thought that they may pass spontaneously. If they do not pass spontaneously， the stones must be removed surgically later.
嵌頓性結(jié)石必須取石;如認(rèn)為結(jié)石可能自行排出，亦可經(jīng)旁道置管。如不能自行排出，以后必須手術(shù)取石。
Ureteral or ureteropelvic junction obstruction requires surgical revision and plastic repair， either by ureterovesicoplasty， ureteroureteral anastomosis， bladder flaps to bridge a gap in the lower ureter， transureteroureteral anastomosis or ureteropyeloplasty. Penal stones may be removed instrumentally via percutaneous nephrostomy or by irrigation through a tube placed directly into the kidney.
輸尿道或腎盂輸尿管交界梗阻需行手術(shù)矯正或行整形修補(bǔ);輸尿管膀胱成形術(shù)，輸尿管輸尿管吻合術(shù)，或輸尿管腎盂成形術(shù)。在下段輸尿管則可用膀胱瓣作搭橋填補(bǔ)缺損。腎結(jié)石可通過皮穿器械摘除，或者經(jīng)皮穿刺腎造瘺或經(jīng)腎直接置管進(jìn)行沖洗。
Preliminary drainage above the obstruction is sometimes needed to improve kidney function. Occasionally， permanent drainage and diversion by cutaneous ureterostomy， ileal or colonic loop diversion， or permanent nephrostomy is required. If damage is advanced， nephrectomy may be indieated.
有時(shí)為改善腎功能可先在梗阻上方置管引流，有時(shí)需作永久性引流，輸尿管皮膚造口尿流改道術(shù)，回腸或結(jié)腸改道或永久性腎造口等。如損害加重，可通適用腎切除。
Prognosis
預(yù)后
The prognosis depends on the cause， site， duration， and degree of kidney damage and renal decompensation. In general， relief of obstruction leads to improvement in kidney function except in seriously damaged kidneys， especially those destroyed by inflammatory scarring.
預(yù)后取決于原因，位置，病程及腎臟損害和腎臟失償程度。一般來說，解除梗阻可使腎功能改善，除非腎臟嚴(yán)重受損，尤其是炎性疤痕所破壞的。
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